Milieu Therapy

Hannah Pershall, Mandy Woodard, Jennifer Patton, & Lara Kim

What is Milieu Therapy?

Milieu is the French word for middle in
English translation, the word milieu means surroundings, or environment. Also called therapeutic community, or therapeutic environment, this type of therapy consists of a scientific structuring of the environment in order to effect behavioral changes and to improve the individuals psychological health and functioning.

The Goal of Milieu Therapy

Manipulate the environment so that all aspects
of the clients hospital experience are considered therapeutic. Within the therapeutic environment, patients are expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of their life. The community environment itself is the primary tool of therapy
Factors such as social interactions, the physical structure of the setting, and scheduled activities may generate stress and resistance for some patients these stressful experiences are used to help them learn to manage stress adaptively in the real world

Milieu Therapy emphasizes

Group and social interaction Rules and expectations that are mediated by
Example: Patient teaching

peer pressure for normalization of adaptation Viewing patients as responsible human beings

Patients rights to goals Patients rights to freedom of movement and

informal relationships with staff
Example: Games engaging staff and patients

Interdisciplinary participation and goal-oriented,

clear communication

Other Important Aspects of the Milieu

Clients must be encouraged to perform as
independently as possible
Patients should accept responsibility and request their medication at the appropriate time Nurses should encourage patients to be self-reliant Nurses must work with patients to ensure achievement and

Reality orientation for patients with disorganized

thinking, disorientation, or confusion is important
Calendars, activity schedules, and name badges help keep patients oriented to reality Example: Schedule of daily events each morning

provide positive feedback for success Example: Medication administration in a challenging situation

Milieu Cont
One-to-one relationships should be fostered
Trust established between patient and nurse may carry over to the patient establishing trust in others in their life for the first time. Developing trust means
Keeping promises Total acceptance of the patient as a person Responding to the patient with concrete behaviors they understand (i.e., if you are cold, I will bring you a blanket) Encouraging patient to express feelings and emotions and discuss unresolved issues which cause them problems

More Milieu
Limits should be set on unacceptable
behavior
State clearly the unacceptable behaviors and what the consequences are should the limits be violated Limits must be established, written and carried out by all staff members. Consistency is essential if leaning is to be reinforced! Example: Limitations of different schedule groups

The Seven Basic Assumptions of a Therapeutic Community

1. The health in each individual is to be realized and 2.
encouraged to grow Identify the patients strengths they serve as a foundation for growth Every interaction is an opportunity for therapeutic intervention Structured setting makes it impossible to avoid interpersonal interaction Patients improve communication and relationship development skills The client owns his or her own environment Patients solve problems and make decisions Autonomy is fostered, group needs fulfilled Each client owns his or her behavior Patients are expected to take responsibility for their behavior

3. 4.

Assumptions Cont
5.
Peer pressure is a useful and powerful tool Peer pressure establishes behavioral group norms Feedback is direct and frequent, so behaving in ways acceptable to the group becomes essential 6. Inappropriate behaviors are dealt with as they occur Patients examine their own behavior, see how it affects others, and discuss more appropriate ways to behave in situations Example: Tipping back in chairs, encouraging patients to walk away to cool off, redirecting patients during skills groups 7. Restrictions and punishment are to be avoided Destructive behaviors can usually be controlled with group discussion Temporary isolation is preferred over lengthy restriction or harsh punishments

Conditions that Promote a Therapeutic Community

The conditions that promote a therapeutic community in
the hospital setting are similar to the types of conditions that exist in real-life situations

Basic physiological needs are fulfilled Physical facilities are conducive to achievement of the
goals of therapy
Maslow = higher levels of functioning cannot be met until basic needs are fulfilled Example: Assistance with grooming needs

Space provided for privacy as well as interaction Furnishings arranged in atmosphere that provides for facilitation of interpersonal interaction and communication

Conditions Cont
A Democratic form of self-government exists
Patients participate in decision-making and problemsolving that affect the management of the treatment setting Community meetings are scheduled regularly
attended by staff and patients all individuals have equal input into the discussions, all are required to attend Patient norms, rules, and behavioral limits are set here and expectations affect all patients equally Disagreements are discussed as a group and decisions are made by all Voting is used and both patients and staff agree to abide by the majoritys preferences

Conditions Cont
Responsibilities are assigned according to patient capabilities
Assign patients responsibilities that will promote achievement and enhance self-esteem - dont set them up for failure. If patients regress, adjustments to responsibilities are made in a way that preserves self-esteem and allows them to achieve greater responsibilities as level of functioning returns

A structured program of social and work-related activities is

scheduled as part of the treatment program Patient therapy includes group activities to enhance interpersonal interaction and communication, as well as time to work on personal problems. A structured schedule is the focus of a therapeutic community. Activities facilitate change in personality and behavior New coping strategies are learned and social skills are developed Patients can practice in group settings what they have learned to prepare for discharge

Conditions Cont.
Community & family are included in the program of
therapy in an effort to facilitate discharge from treatment Goal is to keep as many links to the patients life outside of therapy as possible to prevent dependence on therapy and ease discharge Family members can participate in therapy sessions, eat meals with the patient, etc. Connection with the community is maintained through activities: Shopping, picnics, movies, bowling, visiting the zoo Passes to visit family on the weekend

Recent Research Articles

Acknowledging communication: A milieutherapeutic approach in mental health care (2008)

Theoretical Framework Therapeutic relationship in challenging encounters Acknowledging communication Self-delimitation and self- reflection Aim Core conditions for acknowledging communication Example

Recent Research: Acknowledging Communication Contd.

competent From a culture of conformity to appreciating diversity Self- delimitation and self-reflection in practice

The process of change in staff From knowing best to acknowledging patients as

Misunderstanding of acknowledgement in Example Passive approach

A Credo for Support

Other Recent Research Articles

The Neurobiology of PTSD (2005)
Nursing implications

Ward atmosphere (2007)

Importance of Relationships

The Role of Diversional Activities (2005)

Acitivity companions Volunteer services Diversional supplies Humor Nature