Milieu TherapyMilieu Therapy

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

What is Milieu Therapy?What is Milieu Therapy?

• Milieu is the French word for “middle” – in Milieu is the French word for “middle” – in English translation, the word milieu means English translation, the word milieu means “surroundings, or environment.”“surroundings, or environment.”

• Also called Also called therapeutic communitytherapeutic community, or , or therapeutic environmenttherapeutic environment, this type of , this type of therapy consists of a scientific structuring of therapy consists of a scientific structuring of the environment in order to effect the environment in order to effect behavioral changes and to improve the behavioral changes and to improve the individuals psychological health and individuals psychological health and functioning.functioning.

The Goal of Milieu TherapyThe Goal of Milieu Therapy• Manipulate the environment so that all Manipulate the environment so that all

aspects of the client’s hospital experience aspects of the client’s hospital experience are considered therapeutic. are considered therapeutic.

• Within the therapeutic environment, patients Within the therapeutic environment, patients are expected to learn adaptive coping, are expected to learn adaptive coping, interaction, and relationship skills that can be interaction, and relationship skills that can be generalized to other aspects of their life. generalized to other aspects of their life.

• The community environment itself is the The community environment itself is the primary tool of therapyprimary tool of therapy– Factors such as social interactions, the physical Factors such as social interactions, the physical

structure of the setting, and scheduled activities structure of the setting, and scheduled activities may generate stress and resistance for some may generate stress and resistance for some patients – these “stressful experiences” are used patients – these “stressful experiences” are used to help them learn to manage stress adaptively in to help them learn to manage stress adaptively in the real worldthe real world

Milieu Therapy Milieu Therapy emphasizes…emphasizes…

• Group and social interactionGroup and social interaction

• Rules and expectations that are mediated by peer Rules and expectations that are mediated by peer pressure for normalization of adaptationpressure for normalization of adaptation

• Viewing patients as responsible human beingsViewing patients as responsible human beings– Example: Patient teachingExample: Patient teaching

• Patient’s rights to goals Patient’s rights to goals

• Patient’s rights to freedom of movement and Patient’s rights to freedom of movement and informal relationships with staffinformal relationships with staff– Example: Games engaging staff and patientsExample: Games engaging staff and patients

• Interdisciplinary participation and goal-oriented, Interdisciplinary participation and goal-oriented, clear communicationclear communication

Other Important Aspects of the Other Important Aspects of the Milieu…Milieu…• Clients must be encouraged to perform as Clients must be encouraged to perform as

independently as possibleindependently as possible– Patients should accept responsibility and request Patients should accept responsibility and request

their medication at the appropriate timetheir medication at the appropriate time• Nurses should encourage patients to be self-reliantNurses should encourage patients to be self-reliant• Nurses must work with patients to ensure achievement and Nurses must work with patients to ensure achievement and

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

• Reality orientation for patient’s with Reality orientation for patient’s with disorganized thinking, disorientation, or disorganized thinking, disorientation, or confusion is importantconfusion is important– Calendars, activity schedules, and name badges help Calendars, activity schedules, and name badges help

keep patients oriented to realitykeep patients oriented to reality– Example: Schedule of daily events each morningExample: Schedule of daily events each morning

Milieu Cont…Milieu Cont…

• One-to-one relationships should be fosteredOne-to-one relationships should be fostered– Trust established between patient and nurse may Trust established between patient and nurse may

carry over to the patient establishing trust in carry over to the patient establishing trust in others in their life for the first time.others in their life for the first time.• Developing trust meansDeveloping trust means

– Keeping promisesKeeping promises– Total acceptance of the patient as a personTotal acceptance of the patient as a person– Responding to the patient with concrete behaviors they Responding to the patient with concrete behaviors they

understand (i.e., “if you are cold, I will bring you a blanket”)understand (i.e., “if you are cold, I will bring you a blanket”)– Encouraging patient to express feelings and emotions and Encouraging patient to express feelings and emotions and

discuss unresolved issues which cause them problemsdiscuss unresolved issues which cause them problems

More Milieu…More Milieu…

• Limits should be set on unacceptable Limits should be set on unacceptable behaviorbehavior– State clearly the unacceptable behaviors and State clearly the unacceptable behaviors and

what the consequences are should the limits what the consequences are should the limits be violatedbe violated

– Limits must be established, written and Limits must be established, written and carried out by all staff members. Consistency carried out by all staff members. Consistency is essential if leaning is to be reinforced!is essential if leaning is to be reinforced!

– Example: Limitations of different schedule Example: Limitations of different schedule groupsgroups

The Seven Basic Assumptions The Seven Basic Assumptions of a Therapeutic Communityof a Therapeutic Community

1.1. The health in each individual is to be realized and The health in each individual is to be realized and encouraged to growencouraged to grow

• Identify the patient’s strengths – they serve as a Identify the patient’s strengths – they serve as a foundation for growthfoundation for growth

2.2. Every interaction is an opportunity for therapeutic Every interaction is an opportunity for therapeutic interventionintervention

• Structured setting makes it impossible to avoid Structured setting makes it impossible to avoid interpersonal interactioninterpersonal interaction

• Patients improve communication and relationship Patients improve communication and relationship development skillsdevelopment skills

3.3. The client owns his or her own environmentThe client owns his or her own environment• Patients solve problems and make decisions Patients solve problems and make decisions • Autonomy is fostered, group needs fulfilledAutonomy is fostered, group needs fulfilled

4.4. Each client owns his or her behaviorEach client owns his or her behavior• Patients are expected to take responsibility for their Patients are expected to take responsibility for their

behaviorbehavior

Assumptions Cont…Assumptions Cont…

55.. Peer pressure is a useful and powerful tool Peer pressure is a useful and powerful tool• Peer pressure establishes behavioral group normsPeer pressure establishes behavioral group norms• Feedback is direct and frequent, so behaving in ways Feedback is direct and frequent, so behaving in ways

acceptable to the group becomes essentialacceptable to the group becomes essential6.6. Inappropriate behaviors are dealt with as they occur Inappropriate behaviors are dealt with as they occur

• Patients examine their own behavior, see how it affects Patients examine their own behavior, see how it affects others, and discuss more appropriate ways to behave in others, and discuss more appropriate ways to behave in situationssituations

• Example: Tipping back in chairs, encouraging patients to Example: Tipping back in chairs, encouraging patients to walk away to “cool off,” redirecting patients during skills walk away to “cool off,” redirecting patients during skills groupsgroups

7.7. Restrictions and punishment are to be avoided Restrictions and punishment are to be avoided• Destructive behaviors can usually be controlled with group Destructive behaviors can usually be controlled with group

discussiondiscussion• Temporary isolation is preferred over lengthy restriction or Temporary isolation is preferred over lengthy restriction or

harsh punishmentsharsh punishments

Conditions that Promote a Conditions that Promote a Therapeutic CommunityTherapeutic Community

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

• Basic physiological needs are fulfilledBasic physiological needs are fulfilled– Maslow = higher levels of functioning cannot be met until Maslow = higher levels of functioning cannot be met until

basic needs are fulfilledbasic needs are fulfilled– Example: Assistance with grooming needsExample: Assistance with grooming needs

• Physical facilities are conducive to achievement of Physical facilities are conducive to achievement of the goals of therapythe goals of therapy– Space provided for privacy as well as interactionSpace provided for privacy as well as interaction– Furnishings arranged in atmosphere that provides for Furnishings arranged in atmosphere that provides for

facilitation of interpersonal interaction and facilitation of interpersonal interaction and communicationcommunication

Conditions Cont…Conditions Cont…

• A Democratic form of self-government A Democratic form of self-government existsexists– Patients participate in decision-making and Patients participate in decision-making and

problem-solving that affect the management of problem-solving that affect the management of the treatment settingthe treatment setting• Community meetings are scheduled regularly Community meetings are scheduled regularly

– attended by staff and patients attended by staff and patients – all individuals have equal input into the discussions, all all individuals have equal input into the discussions, all

are required to attendare required to attend– Patient norms, rules, and behavioral limits are set here Patient norms, rules, and behavioral limits are set here

and expectations affect all patients equallyand expectations affect all patients equally– Disagreements are discussed as a group and decisions Disagreements are discussed as a group and decisions

are made by allare made by all Voting is used and both patients and staff agree to Voting is used and both patients and staff agree to

abide by the majority’s preferencesabide by the majority’s preferences

Conditions Cont…Conditions Cont…• Responsibilities are assigned according to patient capabilitiesResponsibilities are assigned according to patient capabilities

– Assign patients responsibilities that will promote achievement Assign patients responsibilities that will promote achievement and enhance self-esteem - don’t set them up for failure. and enhance self-esteem - don’t set them up for failure.

– If patients regress, adjustments to responsibilities are made in If patients regress, adjustments to responsibilities are made in a way that preserves self-esteem and allows them to achieve a way that preserves self-esteem and allows them to achieve greater responsibilities as level of functioning returnsgreater responsibilities as level of functioning returns

• A structured program of social and work-related activities is A structured program of social and work-related activities is scheduled as part of the treatment programscheduled as part of the treatment program– Patient therapy includes group activities to enhance Patient therapy includes group activities to enhance

interpersonal interaction and communication, as well as time interpersonal interaction and communication, as well as time to work on personal problems. to work on personal problems.

– A structured schedule is the focus of a therapeutic A structured schedule is the focus of a therapeutic community. community. • Activities facilitate change in personality and behaviorActivities facilitate change in personality and behavior

– New coping strategies are learned and social skills are New coping strategies are learned and social skills are developeddeveloped

– Patients can practice in group settings what they have Patients can practice in group settings what they have learned to prepare for dischargelearned to prepare for discharge

Conditions Cont….Conditions Cont….

• Community & family are included in the program Community & family are included in the program of therapy in an effort to facilitate discharge from of therapy in an effort to facilitate discharge from treatmenttreatment– Goal is to keep as many links to the patient’s Goal is to keep as many links to the patient’s

life outside of therapy as possible to prevent life outside of therapy as possible to prevent dependence on therapy and ease dischargedependence on therapy and ease discharge

– Family members can participate in therapy Family members can participate in therapy sessions, eat meals with the patient, etc.sessions, eat meals with the patient, etc.

– Connection with the community is maintained Connection with the community is maintained through activities:through activities:•Shopping, picnics, movies, bowling, visiting Shopping, picnics, movies, bowling, visiting

the zoothe zoo•Passes to visit family on the weekendPasses to visit family on the weekend

Recent Research Articles Recent Research Articles • Acknowledging communication: A milieu-Acknowledging communication: A milieu-

therapeutic approach in mental health care therapeutic approach in mental health care (2008)(2008)– Theoretical FrameworkTheoretical Framework

•Therapeutic relationship in challenging encountersTherapeutic relationship in challenging encounters

•Acknowledging communicationAcknowledging communication

•Self-delimitation and self- reflectionSelf-delimitation and self- reflection

•AimAim

– Core conditions for acknowledging communication Core conditions for acknowledging communication •ExampleExample

Recent Research: Recent Research: Acknowledging Acknowledging Communication Cont’d….Communication Cont’d….

– The process of change in staffThe process of change in staff•From knowing best to acknowledging patients From knowing best to acknowledging patients

as competentas competent

•From a culture of conformity to appreciating From a culture of conformity to appreciating diversitydiversity

•Self- delimitation and self-reflection in Self- delimitation and self-reflection in practicepractice

– Misunderstanding of acknowledgement inMisunderstanding of acknowledgement in•ExampleExample

•Passive approachPassive approach

A Credo for SupportA Credo for Support

Other Recent Research Other Recent Research ArticlesArticles• The Neurobiology of PTSD (2005)The Neurobiology of PTSD (2005)

– Nursing implicationsNursing implications

• Ward atmosphere (2007)Ward atmosphere (2007)– Importance of RelationshipsImportance of Relationships

• The Role of Diversional Activities (2005)The Role of Diversional Activities (2005)– Acitivity companionsAcitivity companions– Volunteer servicesVolunteer services– Diversional suppliesDiversional supplies– HumorHumor– NatureNature