MILEU THERAPY

Koech Nickson
 INTRODUCTION
• Standard 5c of the Psychiatric-Mental Health Nursing: Scope and Standards of
Practice(American Nurses Association [ANA], 2007) states that “The psychiatric-mental
health nurse provides, structures, and maintains a safe and therapeutic environment in
collaboration with patients, families, and other health care clinicians". This chapter defines
and explains the goal of milieu therapy. The conditions necessary for a therapeutic
environment are discussed, and the roles of the various health-care workers within the
interdisciplinary team are delineated. An interpretation of the nurse’s role in milieu therapy
is included.
 DEFINITION
• The word milieu is French for “middle.” The English translation of the word is
“surroundings or environment.” In psychiatry, therapy involving the milieu, or environment,
may be called milieu therapy, therapeutic community, or therapeutic environment.
• The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s
hospital experience are considered therapeutic. Within this therapeutic community setting,
the client is expected to learn adaptive coping, interaction, and relationship skills that can be
generalized to other aspects of his or her life.
 INDICATIONS
 Depression
 Dependence syndrome
 Neurosis
 Somatoform disorders
 Schizophrenia
 Personality disorders
 Violent offenders
 BASIC ASSUMPTIONS
• 1. The health in each individual is to be realized and encouraged to grow: All
individuals are considered to have strengths as well as limitations. These healthy aspects of
the individual are identified and serve as a foundation for growth in the personality and in
the ability to function more adaptively and productively in all aspects of life.
• 2. Every interaction is an opportunity for therapeutic intervention: Within this
structured setting, it is virtually impossible to avoid interpersonal interaction. The ideal
situation exists for clients to improve communication and relationship development skills.
Learning occurs from immediate feedback of personal perceptions.
• 3. The client owns his or her own environment: Clients make decisions and solve
problems related to government of the unit. In this way, personal needs for autonomy
as well as needs that pertain to the group as a whole are fulfilled.
• 4. Each client owns his or her behavior: Each individual within the therapeutic
community is expected to take responsibility for his or her own behavior.
• 5. Peer pressure is a useful and a powerful tool: Behavioral group norms are
established through peer pressure. Feedback is direct and frequent, so that behaving in
a manner acceptable to the other members of the community becomes essential.
• 6. Inappropriate behaviors are dealt with as they occur: Individuals examine the
significance of their behavior, look at how it affects other people, and discuss more
appropriate ways of behaving in certain situations.
• 7.Restrictions and punishments are to be avoided: Destructive behaviors can
usually be controlled with group discussion. However, if an individual requires
external controls, temporary isolation is preferred over lengthy restriction or other
harsh punishment.
CONDITIONS THAT PROMOTE A THERAPEUTIC
COMMUNITY

1.Basic physiological needs are fulfilled: As Maslow (1968) suggested, individuals do not
move to higher levels of functioning until the basic biological needs for food, water, air, sleep,
exercise, elimination, shelter, and sexual expression have been met.
2. The physical facilities are conducive to achievement of the goals of therapy: Space is
provided so that each client has sufficient privacy, as well as physical space, for therapeutic
interaction with others. Furnishings are arranged to present a homelike atmosphere
3. A democratic form of self-government exists: In the therapeutic community, clients
participate in the decision making and problem solving that affect the management of the
treatment setting. This is accomplished through regularly scheduled community meetings.
4. Responsibilities are assigned according to client capabilities: Increasing self-esteem
is an ultimate goal of the therapeutic community. Therefore, a client should not be set up
for failure by being assigned a responsibility that is beyond his or her level of ability.
5. Community and family are included in the program of therapy in an effort to
facilitate discharge from treatment: An attempt is made to include family members, as
well as certain aspects of the community that affect the client, in the treatment program.
 INTERDISCIPLINARY TEAM IN
PSYCHIATRIC UNIT
Psychiatrist; Serves as the leader of the team Responsible for diagnosis and treatment of
mental disorders Performs psychotherapy; prescribes medication and other somatic therapies
Clinical Psychologist; Conducts individual, group, and family therapy Administers,
interprets, and evaluates psychological tests that assist in the diagnostic process
Psychiatric Clinical Nurse Specialist; Conducts individual, group, and family therapy
Presents educational programs for nursing staff Provides consultation services to nurses who
require assistance in the planning and implementation of care for individual clients
Psychiatric Nurse; Provides ongoing assessment of client condition, both mentally and
physically, Manages the therapeutic milieu on a 24-hour basis, Administers medications,
Assists
Mental Health Technician (also called psychiatric aide or assistant or psychiatric technician)
Psychiatric Social Worker-Conducts individual, group, and family therapy; Is
concerned with client’s social needs, such as placement, financial support, and
community requirements, Conducts in-depth psychosocial history on which the needs
assessment is based
Occupational Therapist-Works with clients to help develop (or redevelop)
independence in performance of activities of daily living, focus is on rehabilitation
and vocational training
Recreational Therapist-Uses recreational activities to promote clients to redirect
their thinking or to re-channel destructive energy in an appropriate manner Clients
learn skills that can be used during leisure time and during times of stress following
discharge from treatment
 ROLES OF A NURSE IN
THERAPEUTIC COMMUNITY
Environment Management: Nurses are responsible for managing the physical environment
of the therapeutic setting. They ensure that the space is safe, clean, and conducive to
promoting the desired therapeutic outcomes.
Safety and Security: Nurses play a vital role in maintaining a safe and secure milieu. They
assess potential risks and implement safety measures to prevent harm to patients and
stations.
Observation and Documentation: Nurses closely observe and document patient behaviors,
interactions, and responses to the therapeutic environment. They monitor changes in mood,
behavior, and overall well-being, providing valuable information for the treatment team.
Therapeutic Relationships: Nurses build therapeutic relationships with patients in
the milieu. They provide emotional support, actively listen to patients' concerns, and
engage in therapeutic communication.
Collaboration with the Treatment Team: Nurses collaborate with other members of
the treatment team, including psychiatrists, therapists, and social workers, to develop
and implement individualized care plans.
Group Facilitation: Nurses often facilitate therapeutic groups within the milieu.
They may lead psychoeducational sessions, support groups, or recreational activities
that promote social interaction, skill development, and self-expression.
Medication Administration and Management: In certain therapeutic settings,
nurses may be responsible for administering and managing medications.
Crisis Intervention: Nurses are trained in crisis intervention techniques and play a
critical role in managing crises within the therapeutic community.
 CONTRAINDICATIONS
Acute attacks of Mania
Paranoid personality
Severe depression
Paranoid delusions
 QUESTIONS
1.John tells the nurse, “I think lights out at 10 o’clock on a weekend is stupid. We should be
able to watch TV until midnight!” Which of the following is the most appropriate response
from the nurse on the milieu unit?
a. “John, you were told the rules when you were admitted.”
b. “You may bring it up before the others at the community meeting, John.”
c. “Some people want to go to bed early, John.”.
d. “You are not the only person on this unit, John. You must think of the others.”
2.In prioritizing care within the therapeutic environment, which of the following
nursing interventions would receive the highest priority?
a. Ensuring that the physical facilities are conducive to achievement of the goals of
therapy.
b. Scheduling a community meeting for 8:30 each morning.
c. Attending to the nutritional and comfort needs of all clients.
d. Establishing contacts with community resources
3. In the community meeting, which of the following actions is most important for
reinforcing the democratic posture of the therapy setting?
a. Allowing each person a specific c and equal amount of time to talk
b. Reviewing group rules and behavioral limits that apply to all clients
c. Reading the minutes from yesterday’s meeting
d. Waiting until all clients are present before initiating the meeting
4.One of the goals of therapeutic community is for clients to become more independent
and accept self-responsibility. Which of the following approaches by staff best
encourages fulfillment of this goal?
a. Including client input and decisions into the treatment plan
b. Insisting that each client take a turn as “president” of the community meeting
c. Making decisions for the client regarding plans for treatment
d. Requiring that the client be bathed, dressed, and attend breakfast on time each morning
5. Which of the following are basic assumptions of milieu therapy? (Select all that
apply).
a. The client owns his or her own environment.
b. Each client owns his or her behavior.
c. Peer pressure is a useful and powerful tool.
d. Inappropriate behaviors are punished immediately.
6. One of the goals of therapeutic community is for clients to become more
independent and accept self-responsibility. Which of the following approaches by staff
best encourages fulfillment of this goal?
a. Including client input and decisions into the treatment plan.
b. Insisting that each client take a turn as "president" of the community meeting.
c. Making decisions for the client regarding plans for treatment.
d. Requiring that the client be bathed, dressed and attend breakfast on time each morning.
7.Which of the following activities would be a responsibility of the psychiatric clinical
nurse specialist on the IDT team?
a. Manages the therapeutic milieu on a 24-hour basis.
b. Conducts group therapies and provides consultation and education to staff nurses.
c. Directs a group of clients in acting out a situation that is otherwise too painful for a client
to discuss openly.
d. Locates halfway house and arranges living conditions for client being discharged from the
hospital.