Manipal College of Nursing, Manipal

University, Manipal

Presentation on Milieu Therapy

SUBMITTD BY SUBMITTED TO
Mr. Ashish R Badnapurkar Mrs. Tessy Tressa Jose
MSc (N) 1st year Professor
MCON, Manipal Department of Mental health Nursing
MCON, Manipal

SUBMITTED ON

04/09/09
 Milieu Therapy
Introduction:-

Florace Nightingle founder of modern nursing says “Organise environment to allow body to heal”, the
same principle is hold true in Psychiatric Nursing . The purpose of The Psychiatric inpatient is to help the
client recognise and recover from psychiatric problem that led to their hospitalization . Milieu Therapy can
be a powerful therapeutic tool when individual dynamics and the social system can be combined in a
planned and meaningful way to manage and change behaviour and relationships.

Definition:-

• The term therapeutic milieu and therapeutic environment are used to describe such an atmosphere
providing a therapeutic environment is a fundamental activity of psychiatric nursing.
– (ANA1994, Banfer 1980)
• Milieu therapy is a design in which physical surroundings, structure of patient activities, and
promotion of stable social structure and cultural settings enhance the setting’s therapeutic potential.
– Kelther Schwecke Bostrom.
• Milieu therapy is a treatment environment in which every day events and interactions are
therapeutically designed for the purpose of enhancing social skills and building confidence.
– Encyclopaedia.

Development of Therapeutic milieu:-

Therapeutic milieu is developed as a result of Henry Stack Sullivan’s belief that interactions among clients
are beneficial because clients have the opportunity to practice interpersonal relationship skills, provide
feedback to peers about behavior and work together to develop problem solving skill (Sullivan 1968).

Sullivan develops the first therapeutic community or milieu therapy with young men with schizophrenia in
1929 (although that term was not used extensively until Maxwell Jones published The Therapeutic
Community in 1953).

Goal of Therapeutic milieu:-

 To recognize all interpersonal and environmental forces to develop an atmosphere that facilitates
client’s growth, rehabilitation, and restoration of health.

Objectives of Therapeutic milieu:-

• A group therapy approach to living experience with the following objectives:

• To minimize the anti therapeutic environment for the patient in the ward
• To minimize prolongation of hospitalization by helping early recovery
• To minimize maladaptive behavior.
• To provide free and favorable climate. In which patient can talk and gain awareness of his own
feelings, impulses and behaviour Correct or redefine perception of stressors
• Correct maladaptive behaviour
• Develop adaptive coping
• Acquire interpersonal & stress-management skills
• Apply all of this in a social content

To maintain & create a therapeutic milieu by providing individualized treatment plans, promoting self-
governance, progressive levels of responsibility, variety of activities, links with family & community &
effective interaction among health team who are humanistic.

Essential features of Therapeutic milieu:-

Gundeson (1978) identifies three essential features of therapeutic milieu
➢ Distribution of responsibility and decision making.
➢ High level of interaction between patient and staff.
➢ Clarity of the role and leadership of programme.
Milieu therapy achieves these characteristics by establishing community meetings, activity groups, social
skills group, Physical exercise programmes psycho educational programmes, transition groups, work
programmes. Nurse must be active member of the milieu. Patient will be no more active than Nurse ( Kahn
and White, 1978)
Elements of therapeutic Milieu:-
For the milieu to be effectively managed six elements must be present in the environment: safety, unit
structure, unit norms, limit settings, balance and unit modification.
 Safety: - safety or being safe implies freedom from danger or harm. It is an important concern in any
therapeutic environment and encompasses freedom from both physiological and physical harm.
Protection from psychological harm is provided by unit norms that do not permit undue
confrontation of one patient by another or excessive confrontation of patent by staff members.
Patient may be protected also by restricting the visitors, including family members who are known to
be disparage to the patients.
Patients who experience severe anxiety may suffer unnecessarily if staff member do not
intervene. Interventions to decrease anxiety and promote a feeling of psychological safety may
include giving psychotropic, assuring patient that a staff member will stay them, and providing such
a nonstimulating environment. .
Freedom from physical harm also is important safety is assured by developing unit norms
that do not permit physical violence by any community member. Policies and procedures for control
of aggression are necessary. (E.g. Time out, restrains or seclusion room

 Unit norms: - Unit norms are those aspects of a unit that pervade the setting. They are intended to
promote community living through the behaviour that is socially acceptable. Promote community
living through behaviours that are socially acceptable. For instance a common behaviour unit norm
that violent behaviour in not permitted. A norm of non violence provides physical and emotional
security

 Unit structure: - Unit structure is identified as physical environment, the unit regulations, and the
daily schedule of classes and groups. it provided by establishing community meetings, activity
groups social skills group, living skill group, self esteem group, physical excises programmes,
transitional groups, both formal and informal, in which patient share problems and triumphs are also
part of the therapeutic environment. Structure denotes the design of the unit, space, areas for
socializing, and areas for privacy required. Telephones must be available and visiting rooms are
often necessary seculism room are also necessary their design, location and furnishing must maintain
both safety and dignity.
One of the interesting milieu concepts is structured interaction. Purpose full interactions,
that allow patient to interact with others in a useful way. For instance the daily community meetings
provide structure to explain unit rules and consequences of violation. Ideally, patients who are either
elected or volunteer for the responsibility assume leadership for these meetings. In the meetings the
group discusses behavioural expectations such as making beds daily, appropriate dress, and rules for
the unit. Usually there are other rules such as no fighting or name calling. In some instance the
treatment team assigns the structured interaction to specific patients as part of their treatment.
Specific attitudes or approaches are directed toward individual patients who benefit from particular
 type of interaction. Nurse consistently assumes indulgence, flexibility, passive or active friendliness,
matter of fact attitude, casualness, watchfulness, or kind of firmness when interacting with specific
patient.

 Limit setting: - Limit setting is important on the unit and is related to unit norms. Limit should be
set on acting out behaviour, such as self destructive behaviour, physical aggressiveness, lack of
compliance use of alcohol or illicit drugs, use of over the counter drugs and elopement ( running
away).if patient is likely to engage in any of these behaviours it is important to discuss the behaviour
with the patient in an anticipatory fashion, rather than to wait until after the fact.

 Balance:- balance is also important concept, but difficult to describe and does not lent itself to
concrete list of rules. Balance is the process of gradually allowing independent environment.
Independence is gained in increatements because too much independence may overwhelm the
patient.

 Unit modification:- Though unit modification the nurse can facilitate the development of a
therapeutic environment and communicate patients worth. Physical arrangement, safety issues, and
orientation features these thing can create an atmosphere in which patient are enabled to maximize
their strengths. Ongoing unit norms, rules and regulations are also important aspect in unit
modification. Flexibility in maintaining a therapeutic environment is important.

 Validation: - In a therapuitic environment, validation is another process that affirms patients

individuality. Staff-patient interactions should constantly reaffirm the patient’s humanity and human
rights. Any interaction a staff member initiates with a patient should reflect his or her respect for that
patient. Patient must believe that staff members truly like and respect them.

 Open communication: - In open communication staff and patient willingly share information. Staff
members invite patient self disclosure within the support of a Nurse- Patient relationship. In addition,
they provide a model of effective communication when they interacting with one another as well as
with patients. They arrange environment to facilitate optimal interaction and re socialization.
Support, attention, praise, and reassurance given to the patients improve self esteem and increase
confidence. Patient education is also part of this support, as they are directions to foster coping skills.

 De-escalation:- is an interactive process of calming and redirecting a patient who has an immediate
potential for violence directed towards self or others. This intervention involves assessing the
situation and preventing it from escalating to one in which injury occurs to the patient or staff, or
other patients. Once the nurse has assessed the situation he or she calmly calls to the patient and asks
the individual to leave the situation. The nurse must avoid rushing towards the patients or giving
orders. Nurse can use various interventions in this situation, including distraction, conflict resolution,
and cognitive interventions.

 Seclusion:- is the involuntary confinement of a person in a room or an area where the person is
physically prevented from leaving – ( Centre for Medicare & services 2007)
A patient is placed in seclusion m for purposes of safety or behavioural management. The seclusion
room has no furniture expect mattress and a blanket. The walls usually padded. The room is
environmentally safe with no hanging devises, electrical outlets or windows from which patient
could jump. Once the patient is placed in seclusion, he or she is observed at all times.
 There are several types of seclusion arrangements. Some facilities place seclusion room next to the
nurses’ station. This seclusion room has an observation window. Other facilities use a modified
patient room and assign a staff member to view the patient all the times. Facilities place
 Restraints: - the most restrictive safety is restrains, which are used only in the most extreme
circumstances. All other methods used for maintaining safety and control must be employed before
and documented prior to the use restraints.

 Chemical restraints: - is the use of medications to control patients or manage their behaviour.
Chemical restraints are added to the patients or manage their behaviour.

 Physical restraints:- is any manual method or physical or mechanical device attached or adjacent to
the patient’s body that restrict freedom of movement or normal access to one’s body, material or
equipment and con not be easily removed.

Research Study result: - research conducted in oxford university:-

How effective is seclusion, restraints or alternative controls for people with serious mental health
problem.

Finding: - No controlled studies exist that evaluate the value of seclusion or restraints in those with serious
mental illness. There are reports of serious adverse effects for these techniques in qualitative reviews.

Implication to nursing: - alternative ways of dealing with unwanted or harmful behaviours need to be
developed. Continuing use seclusion or restraints must therefore be questioned from within well designed
studies.

The Nurse’s role & function in the therapeutic milieu

Jones (1968) saw the psychiatric setting as providing a living laboratory situation for experimenting or
learning new way of problem solving conflict and crisis. The psychiatric setting is essence becomes
microcosm of larger society. The various roles of the nurse in promoting psychiatric nurse are as follows.
 To manage & coordinate from a holistic view rather than a fragmented perspective of other
MH team members
This allows nursing to ensure continuity of care. Nurse’s also assessing physiological &
psychological status continually, influence of the milieu therapy; provide physical & safety care,
medication administration & education, psychosocial care, mental health & health education.
Further explanation of the above terms:
 Physical & safety care –
Assess the patient’s ability to perform ADLs, signs of physical illness or adverse reactions to
psychotropic drugs or reactions to withdrawal/detoxification when indicated. Assess self-destructive
or other-destructive behaviours. Perform periodic safety checks (be sure to do it in a way as to not
violate patient rights).
• Frequently patients with destructive tendencies are treated in Partial Programs, here safety contracts
are used (a type of behaviour approach). Contracts can be formed between patients and peers as well.
• Adequate staffing is very important, usually there is one RN per five patients, at least one activity
therapist available 12hrs/day & two other paraprofessionals or MH workers.
• In Partial Programs a ratio of one RN to ten patients is considered safe, with again one activity
therapist & two other professionals.
 Medication administration & education –
In milieu therapy the nurse may be expected to gain informed consent before giving psychotropic
 drugs, this includes explaining desired & undesired effects. Encourage the patient to ask questions &
respect that they had the right to decline the drug  this shows respect for the patient, begins
education & this active involvement encourages compliance.
• The patient is expected to approach the nurse for medications at the specific times & places.
• A responsible patient may be given a 24-hour supply of their medication to take independently 
this demonstrates readiness to assume self-care.
• The goal is to assist the patient to assume responsibility for taking their medication to avert
recurrence of psychiatric symptoms & re hospitalisation.
 Psychosocial care –
• Consumes the greatest portion of the nurses time & effort and include the following:
• Reducing stressors such as loud voices, violent TV programs or video games, unsightly visual
stimuli, unpleasant odours & crowded places.
• Encouraging the patient to identify problems & conflicts, and to attempt to understand them & use
new problem solving methods.
• The nurse performs, when needed, brief on-the-spot reality therapy & limit setting to help the patient
deal with destructive behaviours.
• Therapy by the nurse aims to increase self-awareness by helping the patient clarify & correct
perceptions of current stressors, identify their thoughts & feelings toward the stressors and how they
affect their behavior, evaluate which coping methods are effective and test the methods in the
therapeutic milieu.
 Mental Health education –
• Is provided by the nurse who teaches the patient & family all aspects of psychotropic medications or
coping strategies for psychiatric illness (this improves compliance).
• Teaching related to family as mentioned earlier under Links with Family & Significant others is also
provided.
• Stress management techniques taught to aid in coping include exercise, relaxation therapy & pursuit
of leisure activities (fosters a sense of well being, self-confidence, self-control & increased self-
esteem).
• Relaxation therapy includes progressive muscle relaxation, visual imagery, soothing auditory
experiences & massage.

 Health education –
• The nurse provides education on physical health as well, some patients may be at risk related the
self-neglect associated with many psychiatric disorders.

➢ Guidelines would be personally helpful to the nurse working in the therapeutic milieu
• Cultivate your self-awareness by evaluating yourself & evaluation by supervisors & peers.
• Be objective when interacting with clients, team members & the milieu’s social atmosphere without
becoming overly involved & don not take sides!
• Be sensitive to all but recognize personal limits as well.
• Communicate clearly (say what you mean) & do not hesitate to seek clarification of what someone
else is saying.
• Always expect the unexpected not matter how well it was planned!
• Be clear at all times in what your values, principals & beliefs are regarding what is and what is not
clinically appropriate for adequate patient care.

➢ Evaluation of the therapeutic Milieu: - Therapeutic milieu requires periodic evaluation to

determine effectiveness. The Ward Atmosphere Scale (WAS) is an instrument that can be used to
evaluate the effectiveness of therapeutic milieu (Moos-1997). It consists of ten subscales. Each
 subscale is rated by staff and client to provide information regarding what actually exist and should
exist in a therapuitic milieu. Subscale items focus on-
1. Staff control of rules, schedules, and client behaviour.
2. Programme clarity of day-to-day routine.
3. Measurement of client involvement in social functioning, attitudes and general enthusiasm.
4. Practical preparation of the client for discharge and transition into community.
5. Supportive atmosphere of staff, Doctors, and peers towards client.
6. Degree of spontaneity in the environment that allow the client to express feelings freely.
7. Promotion of responsibility, self- direction, and independence, as well as staff response to the
client’s suggestions or cretinism.
8. Order and organization of the unit, including staff and client responses.
9. Encouragement of verbalization of personal problem by clients.
10. Encouragement of verbalization of feelings such as anger, and the channeling of feelings into
appropriate behaviour. \
This instrument is appropriate for evaluating therapeutic milieus in inpatients settings, partial
hospitalization programmes, Day-care centre and community based mental health programmes.

Oxford university research study:-The effects of a milieu therapy program were observed in 80 male
psychiatric-medically infirm patients assigned to open, semi-closed, and closed wards. Ratings by nursing
aides indicated that the functioning of the men in the closed and semi-closed wards improved significantly
over 3 mo., whereas the functioning of those in the open wards remained the same. It was concluded that the
milieu therapy program had been most beneficial for the patients who had been much regressed and socially
deprived.

Conclusion: - Nursing has an investment in developing the “Healthy community life” described by Jones
and Hofing (1974) astutely observed the interpersonal environment or non therapeutic or non therapeutic
depending almost entirely on the interest and ability of the nursing staff”. Milieu therapy gives chance to
client and Nurse to interact with the environment.

Bibliography:-

Ann Boyd, Psychiatric Nursing contemporary Practice, Fourth Edition(2008) Wolters klwer, Lippincot
Williams & Wilkins, New Delhi, P-175-179.

Kelther Schwecke Bostorm, psychiacteric Nursing, second Edition (1995), Mosbys, New York, P-313-325.

Katherene m. Fortinash, A. Holody Worret, psychiatric Mental Health Nursing, Fourth Edition(2008),

Gail W. Sruart, Michel T. Laraia, Principles and Practice of Psychiatric Nursing, 8th edition 2005), Mosby Elsevier,
Kundi, P-701-703