4. The concept of therapeutic community
was first developed by Maxwell Jones
in 1953 . He wrote a book entitled
“Social Psychiatric” which was first
published in England. Later on when it
was published in the United States, its
title was changed to “Therapeutic
Community.”
JAYESH PATIDAR 4/24/2013 4
5. Stuart & Sundeen defined therapeutic
community as “a therapy in which
patient‟s social environment would be
used to provide a therapeutic
experience for the patient by involving
him as an active participant in his own
care & the daily problems of his
community.”
JAYESH PATIDAR 4/24/2013 5
6. To use patient‟s social environment to provide a
therapeutic experience for him.
To enable the patient to be an active participant
in his own care & become involved in daily
activities of his community.
To help patients to solve problems, plan activities
& to develop the necessary rules & regulations
for the community.
To increase their independence & gain control
over many of their own personal activities.
To enable the patients become aware of how
their behavior affects others.
JAYESH PATIDAR 4/24/2013 6
7. Free communication
Shared responsibilities
Active participation
Involvement in decision making
Understanding of roles,
responsibilities, limitations &
authorities.
JAYESH PATIDAR 4/24/2013 7
8. Responsibility for treatment belong to the staff
& client.
Roles of staff & clients are equalized- may
discuss either staff behavior or clients
behavior.
Democratic environment is fostered.
Open communication is encouraged
Focus is on client assets.
Peer pressure is utilized to reinforce rules &
regulations.
JAYESH PATIDAR 4/24/2013 8
9. Interpersonal interactions are utilized to improve
communication skills.
Inappropriate behavior are dealt with as they
occur.
Team approach is used.
Clients are involved in all phases of treatment
Community government is set up – Use meetings
to teach standards, values & behavior, explore
behavior, make decision, use problem solving.
Two main goals for clients – Learn to set limits,
Learn psychosocial skills
JAYESH PATIDAR 4/24/2013 9
10. 1. Daily community Meetings
2. Patient Government or Ward Council
3. Staff Meeting or Review
4. Living & Learning Opportunities
JAYESH PATIDAR 4/24/2013 10
11. These meetings are composed of 60-90
patients. All levels of unit staff are involved,
including administrative personnel. Acute
patients are involved in the meetings.
Meetings should be held regularly for 60
minutes.
Discussion should focus mainly on day-to-day
life in the unit.
During discussion patients‟ feelings & behaviors
are examined by other members.
Frank discussion are encouraged, these may take
place with much outpouring of emotions &
anger.
JAYESH PATIDAR 4/24/2013 11
12. The purpose of patient government is to deal
with practical unit details such as house-keeping
functions, activity planning & privileges.
A group of 5-6 patient will have specific
responsibilities, such as house keeping, physical
exercise, personal hygiene, meal distribution, a
group to observe suicidal patients, etc. staff
members should be available always.
All decisions should be feedback to the
community through the community meetings.
JAYESH PATIDAR 4/24/2013 12
13. A staff meeting should be held following each
community meeting (patient are excluded & only
staff are present). In this meeting the staff would
examine their own responses, expectations, &
prejudices.
4. Living & Learning Opportunities:
Learning opportunities are to be
provided within the social milieu, which should
provide realistic learning experiences for the
patients.
JAYESH PATIDAR 4/24/2013 13
15. Free communication both within & between staff
& patient group.
Communication are directed towards the
modification of patient‟s attitude, behavior & role
performance.
Atmosphere in the community will be democratic
as opposed to hierarchical, rehabilitative rather
than custodial, permissive instead of limited &
controlled.
Nurses will be more communal with the patient
instead of displaying all the time therapeutic role.
JAYESH PATIDAR 4/24/2013 15
16. Environment will be essentially permissive &
flexible.
Patient‟s activities are individualized & the role of
patients are unspecified & their participation is
completely voluntary.
A compulsory daily community meeting that all
staff members have to attend & all patients are
encouraged to attend.
The primary role of staff is to help the patients
gain new insights & test new behavioral patterns.
Problems of the patients are discussed & the
solutions are sought in the small group therapy
session following each community meeting.
JAYESH PATIDAR 4/24/2013 16
17. Patient government or ward council is to deal
with practical unit details such as privileges &
house keeping rosters. Staff member is available
to the patient government, & all decisions are
fed back to the community through the
community meetings.
Staff meeting or review is essential to on-the-
ward training. It gives opportunity for the staff
members to examine their own responses,
expectations & prejudices.
Feedback is one of the fundamental concepts in
therapeutic community practice.
JAYESH PATIDAR 4/24/2013 17
18. Patient develops harmonious
relationship with other members of the
community.
Gains self-confidence.
Develop leadership skills.
Learns to understand & solve problems
of self & others.
Become socio-centric.
JAYESH PATIDAR 4/24/2013 18
19. Learns to live & think collectively with
the members of the community.
Lastly therapeutic community provides
opportunities to participate in the
formulation of hospital rules &
regulations that affect patient‟s personal
liberties like bedtime, meal time,
weekend permission, control of radio or
TV, social activities, late night privileges
etc.
JAYESH PATIDAR 4/24/2013 19
20. Role blurring between staff & patient.
Group responsibility can easily
become nobody‟s responsibility.
Individual needs & concerns may not
be met.
Patient may find the transition to
community difficulty.
JAYESH PATIDAR 4/24/2013 20
21. Providing & maintaining a safe & conflict free
environment through role modeling & group
leadership.
Sharing of responsibilities with patients.
Encouraging patient to participate in decision-
making functions.
Assisting patients to assume leadership roles.
Giving feedback.
Carrying out supervisory functions.
JAYESH PATIDAR 4/24/2013 21
23. „Milieu‟ is a French word meaning
“Middle Place”.
In English language, milieu means
“environment” or “setting”, as used in
psychiatric mental health nursing, it
refers to the people & all other social
& physical factors in the environment
with which the client interacts.
JAYESH PATIDAR 4/24/2013 23
24. A therapeutic milieu is a 24 – hour environment
designed to provide a secure retreat for
individuals whose capacities for coping with
reality have deteriorated.
The therapeutic milieu gives them opportunities
to acquire adaptive coping skills. By offering
secure, comfortable physical facilities for
sleeping, dining, bathing & engaging in
recreational, occupational, social, psychiatric &
medical therapies, the therapeutic milieu does
many advantages.
JAYESH PATIDAR 4/24/2013 24
25. A therapeutic milieu is a “safe space,” a non-punitive
atmosphere in which caring is a basic factor.
In this environment, confrontation may be a positive
therapeutic tool that can be tolerated by the client.
Nurses & treatment team members should be aware
of their own roles in this environment, maintaining
stability & safety, but minimizing authoritarian
behavior
Clients are expected to assume responsibility for
themselves within the structure of the milieu as much
as possible.
Feedback from other clients & the sharing of tasks or
duties within the treatment program facilitate the
client‟s growth.
JAYESH PATIDAR 4/24/2013 25
26. Shelters clients physically from what they
perceive as painful, terrifying stressors.
Protects clients physically from discharges of
their own & other‟s maladaptive behaviors.
Supports the physiological existence of clients.
Provides pleasant, attractive, sensory
stimulation of clients.
Educates clients & their families about adaptive,
effective coping.
JAYESH PATIDAR 4/24/2013 26
27. 1. Maintaining Safe Environment
2. The Trust Relationship
3. Building Self-esteem
4. Limit-setting
JAYESH PATIDAR 4/24/2013 27
28. The nursing staff should follow the facility‟s
policies with regard to prevention of routine
safety hazards & supplement these policies as
necessary.
For Example;
Dispose of all needles safety & out of reach of
client.
Restrict or monitor the use of matches &
lighters.
Do not allow smoking.
JAYESH PATIDAR 4/24/2013 28
29. Remove mouthwash, aftershave lotions & so
forth, if substance abuse is suspected.
Keep sharp objects out of reach of client
Identify potential weapons & dangerous
equipment.
Do not leave medicines unattended or unlocked.
Keep keys (to unit door, medicines) on your
person at all times.
Search packages brought in by visitors, explain
the reason for such rules briefly, & do not make
any exceptions.
JAYESH PATIDAR 4/24/2013 29
30. one of the keys to a therapeutic
environment is the establishment of trust.
Both the client & the nurse must trust that
treatment is desirable & productive. Trust is
the foundation of a therapeutic relationship,
& limit-setting & consistency are its
building blocks.
JAYESH PATIDAR 4/24/2013 30
31. Strategies to help build or enhance
self-esteem must be individualized &
built on honesty & on the client‟s
strengths.
Some general suggestions are:
Set & maintain limits.
Accept the client as a person.
Be non-judgmental at all times.
Structure the client‟s time & activities.
JAYESH PATIDAR 4/24/2013 31
32. Have realistic expectations of the
client & make them clear to the client.
Initially provide the client with tasks,
responsibilities & activities that can be
easily accomplished.
Never flatter the client.
Allow the client to make his own
decisions whenever possible.
JAYESH PATIDAR 4/24/2013 32
33. Setting & maintaining limits are integral
to a trust relationship & to a
therapeutic milieu. Before stating a
limit explain the reason for limit-
setting.
Some basic guidelines for effective
using limits are:
State the expectations or the limit as
clearly, directly & simply as possible.
JAYESH PATIDAR 4/24/2013 33
34. The consequence that will follow the client‟s
exceeding the limit also must be clearly stated
at the outset.
The consequences should immediately follow
the client‟s exceeding the limit & must be
consistent, both over time (each time the limit
is exceeded) & among staff (each staff
member must enforce the limit).
Consequences are essential to setting &
maintaining limits, they are not an opportunity
to be punitive to a client.
JAYESH PATIDAR 4/24/2013 34
35. In conclusion, the nurse works with
other health professionals in an
interdisciplinary team; The
interdisciplinary team works within a
milieu that is constructed as a
therapeutic environment, with the aim
of developing a holistic view of the
client & providing effective treatment.
JAYESH PATIDAR 4/24/2013 35
36. Use nursing process to provide comprehensive
care.
Provide direct client care
Manages the day-to-day care of individual clients.
Assists the client for re-entry into the community.
Give indirect client care
Maintains on going communication with other
mental health team members.
Enforces rules, policies & regulations of therapeutic
milieu.
A schedule, assigns, manages, & evaluates clinical
work
JAYESH PATIDAR 4/24/2013 36
37. Administer medication & give medication teaching
Provide psychosocial care
Uses informal group interventions such as
community meetings & structured or unstructured
group therapy sessions to assist client with
problems in their current life situations.
Conducts brief, “on-the-spot” counseling with
clients & families.
Set limits to deal with behaviors destructive to the
self, others, or the environment.
Helps the clients use their time productively for
leisure & work.
Involves withdrawn clients in the milieu.
JAYESH PATIDAR 4/24/2013 37
38. Encourages clients who have low self-esteem to value
themselves.
Serves as a role model by demonstrating inter personal
effectiveness in relating to clients & other mental
health team members.
Conducts one-to-one therapy sessions daily with
selective clients.
Conducts group therapy on a daily basis to help clients
to gain self-awareness about how they behave in
groups
Provide mental health teaching
Psychotropic medications, methods of coping, inter
personal effectiveness (eg; assertiveness training,
communication, problem-solving skills, parenting
skills & so forth) stress management, relaxation &
physical exercise etc.
JAYESH PATIDAR 4/24/2013 38
39. Encourage clients to help & support each
other individually & as a group.
Assist clients to understand each other‟s
feelings & problems.
Conduct community meetings.
Participate freely in milieu activities (i.e,
exercise, art, craft classes, social function)
JAYESH PATIDAR 4/24/2013 39
41. Occupational therapy is the
application of goal-oriented,
purposeful activity in the assessment
& treatment of individuals with
psychological, physical or
developmental disabilities.
JAYESH PATIDAR 4/24/2013 41
42. “Any activity, which engages a
person‟s resources of time & energy &
is composed of skills & values” (Reed
& Sanderson, 1980).
“Any goal-directed activity meaningful
to the individual & providing feedback
to him about his worth & value as an
individual & about his inter-
relatedness to others”.
JAYESH PATIDAR 4/24/2013 42
43. The aim of the occupational therapist‟s
intervention is the alleviation of dysfunction &
the development of maximum functional
independence in all aspects of living. Specific
aims of occupational therapy are:
I. Promotion of recovery
II. Mobilization of total assets of the patient
III. Prevention of hospitalization.
IV. Creation of good habits of work & leisure.
V. Rehabilitation with return of self-confidence.
JAYESH PATIDAR 4/24/2013 43
44. The main goal is to enable the
patient to achieve a healthy
balance of occupations through
the development of skills that will
allow him to function at a level
satisfactory to himself & others.
JAYESH PATIDAR 4/24/2013 44
45. Occupational therapy is provided to
children, adolescents, adults & elderly
patients.
These programs are offered in psychiatric
hospitals, nursing homes, rehabilitation
centers, special schools, community group
homes, community mental health centers,
day care centers, halfway homes &
addiction centers.
JAYESH PATIDAR 4/24/2013 45
46. Helps to develop social skills &
provide an outlet for self-expression.
Strengthens ego defenses.
Develops a more realistic view of the
self in relation to other.
JAYESH PATIDAR 4/24/2013 46
47. The client should be involved as much as
possible in selecting the activity.
Select an activity that interests or has the
potential to interest him.
The activity should utilize the client‟s strengths
& abilities.
The activity should be of short duration to foster
a feeling of accomplishment.
If possible, the selected activity should provide
some new experience for the client.
JAYESH PATIDAR 4/24/2013 47
48. It consists of six stages:
1. Initial evaluation of what patient can do &
cannot do in a variety of situations over a
period of time.
2. Development of immediate & long-term goals
by the patient & therapist together. Goals
should be concrete & measurable so that it is
easy to see when they have been attained.
3. Development of therapy plan with planned
intervention.
JAYESH PATIDAR 4/24/2013 48
49. 4. Implementation of the plan &
monitoring the progress. The plan is
followed until the first evaluation. If
found satisfactory it is continued &
altered, it not.
5. Review meetings with patient & all the
staff involved in treatment.
6. Setting further goals when immediate
goals have been achieved; modifying
the treatment program as relevant.
JAYESH PATIDAR 4/24/2013 49
50. 1. Diversional activity: These activities are
used to divert one‟s thoughts from life
stresses or to fill time. For example,
organized games.
2. Therapeutic activities: These activities are
used to attain a specific care plan or goal.
For example, basket making, carpentry etc.
JAYESH PATIDAR 4/24/2013 50
51. Anxiety disorder: Simple concrete tasks with
no more than 3 or 4 steps that can be learnt
quickly. For example, kitchen tasks, washing,
sweeping, mopping, mowing lawn & wedding
gardens.
Depressive disorder: Simple concrete tasks
which are achievable; it is important for the
patient to experience success. Provide positive
reinforcement after each achievement. For
example, craft, mowing lawn, wedding
gardens.
JAYESH PATIDAR 4/24/2013 51
52. Manic disorder: Non-competitive activities that
allow to use of energy & expression of
feelings. Activities should be limited &
changed frequently. Patient needs to work in
an area away from distraction. For example,
raking, grass, sweeping, etc.
Schizophrenia (paranoid): Non- competitive,
solitary meaningful tasks that require some
degree of concentration so that less time is
available for focus on delusions. For example,
puzzles, scrabble.
JAYESH PATIDAR 4/24/2013 52
53. Schizophrenia (catatonic): Simple concrete
tasks in which patient is actively involved.
Patient needs continuous supervision & at
first works best on a one-to-one basis. For
example, metal work, molding clay, etc.
Antisocial personality: Activities that
enhance self-esteem & are expressive &
creative, but not too complicated. Patient
needs supervision to makes sure each tasks
is completed. For example, leather works,
painting, etc.
JAYESH PATIDAR 4/24/2013 53
54. Dementia: Group activities to increase feeling
of belonging & self-worth. Provide those
activities which promote familiar individual
hobbies. Activities need to be structured
requiring little time for completion & not much
concentration. Explain & demonstrate each
task, then have patient repeat the
demonstration. For example, cover making,
packing goods.
Substance abuse: Group activities in which
patient uses his talent. For example, involving
patient in planning social activities,
encouraging interaction with others etc.
JAYESH PATIDAR 4/24/2013 54
55. Childhood & Adolescent disorders:
Children: Playing, story telling, painting,
poetry, music etc
Adolescent: Creative activities such as leather
works, drawing, painting
Mental retardation: Repetitive work
assignments are ideal; positive reinforcement
after each achievement. For example, cover
making, candle making packaging goods etc.
JAYESH PATIDAR 4/24/2013 55
57. Play is a natural mode of growth &
development in children. Through play a child
learns to express his emotions & it serves as
a tool in the development of the child.
JAYESH PATIDAR 4/24/2013 57
58. It releases tension & pent-up emotions.
It allows compensation for loss & failures.
It improves emotional growth through his
relationship with other children.
It provides an opportunity to the child to act
out his fantasies & conflict, to get rid of
aggression & to learn positive qualities from
other children.
JAYESH PATIDAR 4/24/2013 58
59. Play therapy gives the therapist a chance to
explore family relationships of the child &
discover what difficulties are contributing to
the child‟s problem.
Play therapy allows studying hidden aspects
of the child‟s problems.
It is possible to obtain a good ideas of the
intelligence level of the child.
Through play inter-sibling relationships can
be adequately studied.
JAYESH PATIDAR 4/24/2013 59
60. Individual vs group play therapy: In individual
therapy the child is allowed to play by himself &
the therapist‟s attention is focused on this one
child alone. In group play therapy other children
are involved.
Free play vs controlled play therapy: In free play
the child is given freedom in deciding with what
toys he wants to play. In controlled play
therapy, the child is introduced into a scene
where the situation or setting is already
established.
JAYESH PATIDAR 4/24/2013 60
61. Structured vs unstructured play therapy:
Structured play therapy involves organizing the
situation in such a way so as to obtain more
information. In unstructured play therapy no
situation is set & no plans are followed.
Directive vs non-directive play therapy: In
directive play therapy, the therapist totally sets
the direction, whereas in non-directive play
therapy, the child receives no direction. Play
therapy is generally conducted in a playroom.
The playroom should be suitably stocked with
adequate play material, depending upon the
problems of the child.
JAYESH PATIDAR 4/24/2013 61
63. Recreation is a form of activity therapy
used in most psychiatric setting.
It is planned therapeutic activity that
enables people with limitations to
engage in recreational experiences.
JAYESH PATIDAR 4/24/2013 63
64. To encourage social interaction.
To decrease withdrawal tendencies
To provide outlet for feelings.
To promote socially acceptable
behavior
To develop skills, talents & abilities
To increase physical confidence & a
feeling of self worth.
JAYESH PATIDAR 4/24/2013 64
65. Provide a non-threatening & non-
demanding environment.
Provide activities that are relaxing &
without rigid guidelines & time-
frames.
Provide activities that are enjoyable &
self-satisfying.
JAYESH PATIDAR 4/24/2013 65
66. Motor forms: These can be further divided into
fundamental & accessory; among the
fundamental forms are such games as hockey
& football, while the accessory forms are
exemplified by play activity & dancing.
Sensory forms: These can be either visual for
example, looking at motion pictures, play, etc.,
or auditory such as listening to a concert.
Intellectual forms: These include reading,
debating & so on.
JAYESH PATIDAR 4/24/2013 66
67. Anxiety disorder: Aerobic activities like
walking, jogging, etc.
Depressive disorder: Non-competitive sports,
which provide outlet for anger, like jogging,
walking , running, etc.
Manic disorder: One-to-one basis individual
games like shuttle badminton, ball badminton,
etc.
Schizophrenia (paranoid): Activities requiring
concentration like chess, puzzles.
JAYESH PATIDAR 4/24/2013 67
68. Schizophrenia (catatonic): Social activities to give
patient contact with reality like dancing, athletics.
Dementia: Concrete, repetitious craft & projects
that breed familiarization & comfort.
Childhood & adolescent disorders: It is better to
work with the child on a one-to-one basis & give
him a feeling of importance. Employ activities
such as playing, story telling & painting.
Adolescents fare better in groups; provide gross
motor activities like sports & games to use up
excess energy.
Mental Retardation: Activities should be
according to the patient‟s level of functioning
such as walking, dancing, swimming, ball
playing. Etc.
68
JAYESH PATIDAR 4/24/2013
70. Attitude therapy is a form of milieu
therapy in which all staff members
assume a consistent, prescribed
attitude designed to be therapeutic
towards patients.
JAYESH PATIDAR 4/24/2013 70
71. i. When the patient is in the hospital for a long
time:
• The patient is interviewed to assess his
emotional state & activity level.
• Family members are interviewed to acquaint
them with the attitude therapy which will be
used for the patient.
ii. After this, a staff meeting is held in which all the
team members are present.
JAYESH PATIDAR 4/24/2013 71
72. iii. A clinical diagnosis is made by the
psychiatrist.
iv. A plan of attitude to be adopted for a
particular patient is discussed with purpose.
v. One Principal Line of Approach at a time by
all the team members.
The attitude therapy is
basically meaning to change the attitude of
the patient in specific situations. A general
attitude which the nurse needs to adopt for
psychiatric patients is kept in mind.
JAYESH PATIDAR 4/24/2013 72
73. The patient starts feeling that an
organized approach is being used for
his/her treatment.
Guesswork & haphazard plans by
individual members of the team are
reduced.
The patient‟s problems or conflict are
solved in less time.
JAYESH PATIDAR 4/24/2013 73
74. This approach also provides an
opportunity for the members to explore,
test & change the therapeutic attitude
which will bring best results in patient.
It brings members of the team together
to plan, work & evaluate each other‟s
efforts & to discover new ways of
helping the patient.
JAYESH PATIDAR 4/24/2013 74
79. It is a psychotherapeutic use of
movement, which furthers the
emotional & physical integration of
the individual.
JAYESH PATIDAR 4/24/2013 79
80. Helps to develop body awareness.
Facilitates expression of feelings.
Improves interaction & communication
Fosters integration of physical, emotional
& social experiences that results in a
sense of increased self-confidence &
contentment.
Exercise through body movement
maintains good circulation & muscle
tone.
JAYESH PATIDAR 4/24/2013 80