MILIEU MANAGEMENT

Chapters 24, 25, 26

Key Terms
Therapeutic milieu
The context in which treatment occurs

Therapeutic community
In-patient setting with a patient-led government to establish and enforce community rules

Milieu Management
Purposeful manipulation of the environment to promote a therapeutic atmosphere

Essential Features of the Therapeutic Environment

Share responsibility and decisionmaking High levels of interaction between patients and staff Clarity of the programs role and leadership

Milieu Elements
Safety Structure Norms Limit-setting Balance Environmental modification

Psychotherapeutic Manager Roles

Working with patients Leading groups Participating in community meetings Coordination medical care Dispensing medications Making discharge arrangements Working with families Leading interdisciplinary team meetings Teaching patients and families

Variables affecting the Therapeutic Environment

Unit model of care Staff relationships Management practices Organizational structures Staff burnout Physical layout of unit

Variables affecting the Therapeutic Environment

JCAHO standards Dealing with aggression/violence Dealing with suicidal behavior Consumer movement Clinical supervision

JCAHO Environment of Care Standards

Ongoing assessment and maintenance of equipment Hazard surveillance Reporting and investigating safety issues Monitoring safety management technique/procedures Orientation programs that address safety

JCAHO Environment of Care Standards

Security is ensured through:
Mechanisms to address security issues Appropriate identification of staff, patients, visitors Mechanisms for handling emergencies Mechanisms for interacting with media

JCAHO Environment of Care Standards

The social environment must provide:
Storage space for grooming and hygiene articles Closet and drawer space for personal property Suitable clothing

JCAHO Environment of Care Standards

The physical setting must provide:
Adequate privacy Door locks consistent with program goals Telephones for private conversations Sleeping rooms with doors Suitable furnishing Access to outdoors, unless contraindicated

De-escalation Interventions
Separate the patient from others Listen, empathize Calm voice, appropriate body language Set clear, specific limits Allow patient to verbalize concerns Show respect and interest in well-being Stay connected with patient Point out problematic behavior

De-escalation Interventions
State what will happen if behavior continues Offer alternatives; avoid ultimatums Dont argue Use show of force judiciously

Inpatient Therapeutic Activities

Occupational therapy Recreational therapy Exercise therapy Patient education Group psychotherapy Spirituality groups Living skills groups

Therapeutic Community
Fundamental Themes:
Reality confrontation Learning social skills Group cohesion/community

Utilize:
Community meetings Step systems

Inpatient Settings
Open adult unit Intensive/acute care Child-adolescent unit Medical-psychiatric unit Substance abuse unit Dual diagnosis unit Psychogeriatric unit

Community Treatment Settings

Day treatment Partial hospitalization Residential treatment homes