MILIEU THERAPY

INTRODUCTION The term milieu is a French word meaning middle place. In English language, milieu means environment or settings. As used in psychiatry mental health nursing , milieu refers to the people & all other social & physical factors in the environment with which the client interacts. Historically milieu therapy referred to a 24-hour therapeutic experience lasting several days or even weeks. As a result of shrinking financial resources for mental health care, milieu therapy is provided in 24 hours & partial hospitalization settings. This trend has challenged nurses and other mental health professionals to adapt milieu therapy approaches to brief or partial hospitalization treatments to ensure quality psychiatric care without diluting the effectiveness of this therapeutic modality. Offering secure comfortable physical facilities & providing recreational, occupational, social, psychiatric, medical and nursing therapies the therapeutic milieu can do the following: Shelter clients physically from perceived painful, terrifying stressors. Protect clients physically from discharges of their own & others maladaptive behaviors. Support the physiological existence of the clients.

Provide pleasant, attractive sensory stimulation.

Teach clients & families about adaptive coping strategies. To accomplish these goals the therapeutic milieu must consist of caring, concerned , intelligent health care providers who can work together effectively as mental health team .Psychiatry mental health nurses & other mental health & medical personnel working together create a therapeutic milieu- a healing environment. DEFINITION Milieu therapy, or therapeutic community, is defined as a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual. CHARACTERISTICS OF A THERAPEUTIC MILIEU The overall goal of the mental health team is to maintain & create a therapeutic milieu characterized by following elements: Individualized treatment plans. Self-governance Progressive levels of responsibility. Variety of meaningful activities. Links with the clients family & significant others. Effective interaction among mental health team members Links with the community. Humanistic mental health team members Individualized treatment plans A therapeutic milieu is tailored to the clients individualized needs as much as possible without infringing on the needs & rights of other clients and mental health team members. Nevertheless to provide organization and predictability within the environment, a definite structure, schedule, overall guidelines and social controls are set forth. Self governance To assist the clients to develop self responsibility & appropriate interdependence with peers, a therapeutic milieu must provide some formal mechanism whereby clients participate in decision making regarding milieu issues. Such

mechanism might include structured community meetings & client-team committee meetings held at regularly scheduled intervals. Progressive levels of responsibility In a therapeutic milieu, clients are expected to assume responsible role in maintaining the environment. A clients degree of responsibility should be commensurate with his/her capabilities at any point during the treatment process. Matching expected responsibilities with capabilities promotes feelings of self responsibility in the client. Variety of Meaningful activities: To encourage proactive social behavior & adaptive coping skills, a therapeutic milieu should provide each client with an individualized activity schedule. Such as activities may include structured exercises classes, jogging, weight lifting, interpersonal skills training (e.g. assertiveness training, listening and communication skills), leisure skills classes and work and occupational therapies. Links with the clients family & significant others Therapeutic milieu should provide opportunities for the client to reenter the main stream of family life at the end or her own pace. One way is through family education programs. Led by a mental health professional preferably a psychiatric mental health clinical specialist nurse. Family education programs aims to help the family members & significant others understand the client problems and learn how they can contribute to the clients recovery. Family assessment & brief family therapy may help a client or family members to identify maladaptive relationship patterns. With 24 hours hospitalization, visitation programs for family members & significant others can incorporated into the overall therapeutic milieu by involving them in selected milieu activities interpersonal skill classes, mental health classes, family group therapy, and psychotropic medication classes. In partial hospitalization psychiatric settings, family members and significant others may participate in education programs instructing them how to provide appropriate home care for the client. Home care issues, such as recognition of signs & symptoms indicating exacerbations of the clients psychiatry illness, administration of psychotropic medication in the home & provision of a facilitative home environment to assist the clients recovery. Links with the community Activities outside the structured milieu such as an attending support groups such as alcoholics Anonymous, emotion anonymous and overeaters anonymous & others link clients with community life. Participating in these activities with mental heath team members can help a client develop the social skills & confidence needed to reenter the community. Such activities also can provide the with opportunities to acquire enjoyable leisure time interests. Effective Interaction among Mental health team members Interpersonal conflicts occur periodically in any group including a mental health team. Consequently team members must be able to resolve interpersonal conflicts effectively & promptly. If they cannot do so , the effectiveness of the therapeutic milieu can decline the point at which clients are placed in jeopardy. When mental health team members engage in effective conflict resolution, they are more apt to trust each other & act and interact as a team & not as lone therapists. Further mental health team members who can resolve interpersonal conflicts are effective role models for clients. Humanistic Mental Health team members For a therapeutic milieu program to be effective, mental health team members need to possess high degrees of the following: Optimistic attitude toward people in general. Ability to inspire hopefulness in clients & their families and team members. Creativity in working toward more effective ways of involving clients in their own recovery process.

Lack of fear or prejudice when confronted with people exhibiting unconventional bizarre, or aberrant behavior.

Willingness to maintain frequent daily personal contact with the client. Ability to set limits on personal behavior & the behavior of others in a nonpunitive manner. Willingness to share control & decision making with team members & clients. Belief that controls & limits should be provided by therapeutic relationships with the clients to the greatest extent possible rather than by physical or chemical restraints.

Facilitating of a therapeutic milieu Comfortable, secure physical facilities, qualified mental health team & an effective therapeutic milieu programs are essential components of a therapeutic milieu. The total milieu acting as the primary therapeutic agent-milieu therapy-is a group therapy approach that uses a total living experience to accomplish therapeutic objectives. These therapeutic objectives in the broadest sense include assisting clients to do the following: Correct or redefine perception of stressors. Correct maladaptive coping behavioral patterns Develop adaptive coping behavioral patterns

Acquire interpersonal & stress management skills to conduct themselves more effectively & strengthen or correct their coping strategies. Generalize what they learn about themselves, other people & adaptive coping behavior to a variety of social contexts.

NURSES ROLE IN THERAPEUTIC MILIEU Psychiatric mental health nurses have assumed responsibility for managing & coordinating milieu activities. Viewing clients from a holistic rather than fragmented perspective enables nurses to fulfill these responsibilities. Unlike other mental health team members, nurses possess knowledge and skills to help the clients meet their physiological, psychological, social and spiritual needs. To manage & coordinate a therapeutic milieu effectively, nurses use the nursing process to assess clients within the therapeutic milieu, to plan and implement client and milieu strategies and to evaluate client & milieu activities. More specifically nurses assess the physiological or psychological status of each client within the milieu. Making these assessments continually enables nurses to play a major role in individualizing each clients treatment plan & activity schedule. Other ways in which nurses contribute to the management & coordination of the therapeutic milieu included the following: 1. Physical & safety care. 2. Medication administration & education 3. Psychosocial care 4. Mental Health education 5. Health education Physical & safety care: To meet the clients physical care needs, the nurse must assess the clients ability to perform activities of daily living- eating, eliminating, ambulating, bathing, dressing, etc. This allows nurse to plan & implement directly or indirectly, an individualized plan designed to reinforce or promote clients independence in performance of activities of daily living. Assessing the clients physical status for the signs of physical illness or adverse reactions to psychotropic medications. To meet safety care needs, the nurses assess the extent to which the client displays selfdestructive or other destructive behavior. The nurse also must ensure that the physical environment is safe for a client with such frequencies. To ensure safety, the nurse & mental health team members should conduct periodic safety checks of the entire milieu. These checks include not only community areas within milieu, but also the surrounding external areas. These safety checks must, however be conducted in a manner that doesnt violate clients rights.

Medication administration & education: In the therapeutic milieu, in hospital settings, nurses manage medication administration. In the therapeutic milieu nurses often are expected to gain the clients informed consent before administering psychotropic medications. This process involves explaining in general terms the desired & undesired effects of the drugs to be administered. The client is encouraged to ask questions about any aspect of medication administration & may decline to take the prescribe drug. Approaching medication administration in this manner shows respect for the client & provides a realistic point for beginning medication education Psychosocial Care: Providing psychosocial care consumes the greatest proportion of nursing time & effort in a therapeutic environment. To provide such care nurses engages in various helping behaviors. One helping behavior involves reducing stressors within the milieu that the client perceives as psychonoxious, such as loud voices, violent television programs or video games, unsightly visual stimuli, unpleasant odors, & crowded spaces. Encouraging the client to identify his/her problems & conflicts, to attempt to understand them & to experiment with two ways of handling problems & conflicts constitutes another form of psychosocial care offered by the nurse in therapeutic milieu. Conducting brief on-the-spot reality therapy with the clients to help them to deal with problems Arising in the therapeutic milieu is another important aspect of the nurses role. The nurse provides brief on spot individual therapy. A client in a therapeutic milieu may have one or more such sessions daily with the nurse assigned to his or her care. This therapy aims to assist the client in the following ways: 1. Clarifying or correcting perceptions of current stressors. 2. Identifying thoughts & feelings evoked by stressors. 3. Examining how thoughts & feelings influence behavior. 4. Evaluating the extent to which coping behaviors are adaptive or effective. 5. Identifying alternative adaptive coping strategies in the therapeutic milieu. 6. Test identified alternative coping strategies in the therapeutic milieu. By working with a client in this manner, the nurse can help increase the clients self awareness, thereby enabling the client to acquire the adaptive coping skills needed to reenter family & community. Mental Health Education: The nurse commonly provides client & family teaching centering around psychotropic medications or coping strategies for psychiatric illness. Effective teaching can increase a clients understanding of treatment plans & thereby improve compliance. Mental health education also focuses on interpersonal effectiveness which can help the clients relate to others in milieu more effectively and help them prepare for return to family, friends, community on full-time basis. Another area of mental health teaching offered by nurses & other mental health team members deals with stress management. In the therapeutic milieu, this focuses on helping the client learn to cope with stress through physical exercise, relaxation therapy, & enjoyable leisure pursuits. The nurse can teach relaxation therapy techniques in individual or group sessions. Audio or video training cassettes help teach these techniques & allow clients to participate them as needed.