Deblina Roy M.Sc Nursing 1st year K.G.M.U. Institute of Nursing

MILIEU THERAPY / THERAPEUTIC COMMUNITY

Objective of the session•Define milieu therapy. •Explain the goal of therapeutic community/milieu therapy. • Identify seven basic assumptions of a therapeutic community. • Discuss conditions that characterize a therapeutic community.• Identify the various therapies that may be included within the program of the therapeutic community and the health-care workers that make up the interdisciplinary treatment team. •Describe the role of the nurse on the interdisciplinary treatment team.

Standards of psychiatric nursing (standard 5C)• “The psychiatric-mental health nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health care clinicians”

Meaning • 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 the therapeutic environment.

Goal of the therapy• 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 • relationship skills that can be generalized to other aspects of his or her life.

Definition

•Milieu Therapy :A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual (Skinner, 1979).

Historical aspects •Milieu therapy came into its own during the 1960s through the early 1980s. • During this period, psychiatric inpatient treatment provided sufficient time to implement programs of therapy that were aimed at social rehabilitation.• Nursing’s focus of establishing interpersonal relationships with clients fit well within this concept of therapy. • Patients were encouraged to be active participants in their therapy, and individual autonomy was emphasized.

Basic assumptions of the therapeutic community• Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

• Assumption 1• 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.

Assumption 2• 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.

•Assumption 3

• 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. • Assumption 4• 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.

•Assumption 5• 5. Peer pressure is a useful and 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.

•Assumpti0n 6• 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.

Assumption 7• 7. Restrictions and punishment 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 consequences.

Conditions that promote a therapeutic community• 1. Basic physiological needs are fulfilled:

• 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— usually in spaces that accommodate communal living, dining, and activity areas—for facilitation of interpersonal interaction and communication.

Cont.• 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.

Cont.

• 5. A structured program of social and work related activities is scheduled as part of the treatment program: Each client’s therapeutic program consists of group activities in which interpersonal interaction and communication with other individuals are emphasized. Time is also devoted to personal problems.

• 6. 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.

Program of therapeutic community

The IDT team determines a comprehensive treatment plan and goals of therapy and assigns

An initial assessment is made by the admitting psychiatrist, nurse, or other designated admitting agent

who establishes a priority of care.

Care for clients in the therapeutic community is directed by an interdisciplinary treatment (IDT) team.

Cont..

Depending on the size of the treatment facility and scope of the therapy program, members representing a variety of

disciplines may participate in the promotion of a therapeutic community

All members sign the treatment plan and meet regularly to update the plan as needed.

Intervention responsibilities

Members of the Inter Disciplinary teamIDT team may include• psychiatrist • clinical psychologist• psychiatric clinical nurse specialist • psychiatric nurse • mental health technician• psychiatric social worker• occupational therapist• recreational therapist• art therapist• music therapist• Psycho dramatist• Dietitian.• chaplain.

Roles of the Interdisciplinary team members

Role of nurse in milieu therapy• Milieu therapy can take place in a variety of inpatient and outpatient settings. • In the hospital, nurses are generally the only members of the IDT team who spend time with the clients on a 24-hour basis• Assume responsibility for management of the therapeutic milieu. In all settings, the nursing process is used for the delivery of nursing care. • Ongoing assessment, diagnosis, outcome identification, planning, implementation, and evaluation of the environment are necessary for the successful management of a therapeutic milieu. • In the therapeutic milieu, nurses are responsible for ensuring that clients’ physiological needs are met.

• Nurses are involved in all day-to-day activities that pertain to client care. • Suggestions and opinions of nursing staff are given serious consideration in the planning of care for individual clients. • Information from the initial nursing assessment is used to create the IDT plan. • Nurses have input into therapy goals and participate in the regular updates and modification of treatment plans. • In some treatment facilities, a separate nursing care plan is required in addition to the IDT plan. •When this is the case, the nursing care plan must reflect diagnoses that are specific to nursing and include problems and interventions from the IDT plan that have been assigned specifically to the discipline of nursing.

• Clients must be encouraged to perform as independently as possible in fulfilling activities of daily living. • ongoing assessments to provide assistance for those who require . • Assessing physical status is an important nursing responsibility that

must not be overlooked in a psychiatric setting that emphasizes holistic care. • Reality orientation for clients who have disorganized thinking or who

are disoriented or confused is important in the therapeutic milieu.• Clocks with large hands and numbers, calendars that give the day

and date in large print, and orientation boards that discuss daily activities and news happenings can help keep clients oriented to reality.• Nurses should ensure that clients have written schedules of activities

to which they are assigned and that they arrive at those activities on schedule.• Some clients may require an identification sign on their door to

remind them which room is theirs. • On short-term units, nurses who are dealing with psychotic clients

usually rely on a basic activity or topic that helps keep people oriented.

• management of medication administration on inpatient psychiatric units. • In some treatment programs, clients are expected to accept the

responsibility and request their medication at the appropriate time. • encourage clients to be self-reliant. • Nurses must work with the clients to determine methods that

result in achievement and provide positive feedback for successes. • nursing in the therapeutic milieu is the one-to-one relationship

that grows out of a developing trust between client and nurse. • Many clients with psychiatric disorders have never achieved the

ability to trust. • If this can be accomplished in a relationship with the nurse, the

trust may be generalized to other relationships in the client’s life. • Within an atmosphere of trust, the client is encouraged to express

feelings and emotions and to discuss unresolved issues that are creating problems in his or her life.

• setting limits on unacceptable behavior in the therapeutic milieu. • This requires stating to the client in understandable terminology what behaviors are not acceptable and what the consequences will be should the limits be violated. • These limits must be established, written, and carried out by all staff. • The role of client teacher is important in the psychiatric area, as it is in all areas of nursing. • Nurses must be able to assess learning readiness in individual clients. • Some topics must be individualized for specific clients, whereas others may be taught in group situations.

Patient education points • Ways to improve self esteem• Ways to manage anger appropriately• Stress management • Identify the increasing anxiety and reduce its progression.• normal stages of grieving and behaviors associated with grieving.• Assertiveness techniques • Relaxation techniques • Medications • Effects of substance on the body• Problem solving skills • Thought stopping and thought switching skills • Sex education• Good nutrition• Parental guidelines

• Milieu therapy interventions are recognized as one of the basic-level functions of psychiatric-mental health nurses as addressed [in the Psychiatric-Mental Health Nursing: Scope and Standards of Practice, (ANA, 2007)].

Summary • ticks

Discussion

Conclusion • Milieu therapy has been described as an excellent framework for operationalizing [Hildegard] Peplau’s interpretation and extension of Harry Stack Sullivan’s Interpersonal Theory for use in nursing practice.• therapeutic milieu concept and to reclaim nursing’s traditional milieu intervention functions. • Nurses need to identify the number of registered nurses necessary to carry out structured and unstructured milieu functions consistent with their Standards of Practice.

References • Vyas A. Ahuja N . post graduate text book of psychiatry .15th ed .jaypee brothers , New Delhi ; Pp-428-91• Saddock . Kaplan . Synopsis of psychiatry . 11th Ed Jaypee brothers . New York .Pp 647• Townsend MC. Essentials of psychiatric nursing . 7th ed . Moseby , New York .Pp- 165-74