MR. JAYESH PATIDAR
• Therapeutic community
• Millieu therapy
• Occupational therapy
• Play therapy
• Recreational therapy
• Attitude therapy
• Music therapy
• Dance therapy
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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
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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
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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.
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Involvement in decision making
Understanding of roles,
responsibilities, limitations &
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Responsibility for treatment belong to the staff
Roles of staff & clients are equalized- may
discuss either staff behavior or clients
Democratic environment is fostered.
Open communication is encouraged
Focus is on client assets.
Peer pressure is utilized to reinforce rules &
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Interpersonal interactions are utilized to improve
Inappropriate behavior are dealt with as they
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
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1. Daily community Meetings
2. Patient Government or Ward Council
3. Staff Meeting or Review
4. Living & Learning Opportunities
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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
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 &
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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.
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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, &
4. Living & Learning Opportunities:
Learning opportunities are to be
provided within the social milieu, which should
provide realistic learning experiences for the
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Free communication both within & between staff
& patient group.
Communication are directed towards the
modification of patient‟s attitude, behavior & role
Atmosphere in the community will be democratic
as opposed to hierarchical, rehabilitative rather
than custodial, permissive instead of limited &
Nurses will be more communal with the patient
instead of displaying all the time therapeutic role.
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Environment will be essentially permissive &
Patient‟s activities are individualized & the role of
patients are unspecified & their participation is
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.
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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
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.
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Patient develops harmonious
relationship with other members of the
Develop leadership skills.
Learns to understand & solve problems
of self & others.
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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
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Role blurring between staff & patient.
Group responsibility can easily
become nobody‟s responsibility.
Individual needs & concerns may not
Patient may find the transition to
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Providing & maintaining a safe & conflict free
environment through role modeling & group
Sharing of responsibilities with patients.
Encouraging patient to participate in decision-
Assisting patients to assume leadership roles.
Carrying out supervisory functions.
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„Milieu‟ is a French word meaning
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.
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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
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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
Clients are expected to assume responsibility for
themselves within the structure of the milieu as much
Feedback from other clients & the sharing of tasks or
duties within the treatment program facilitate the
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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,
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1. Maintaining Safe Environment
2. The Trust Relationship
3. Building Self-esteem
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The nursing staff should follow the facility‟s
policies with regard to prevention of routine
safety hazards & supplement these policies as
Dispose of all needles safety & out of reach of
Restrict or monitor the use of matches &
Do not allow smoking.
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Remove mouthwash, aftershave lotions & so
forth, if substance abuse is suspected.
Keep sharp objects out of reach of client
Identify potential weapons & dangerous
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
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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
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Strategies to help build or enhance
self-esteem must be individualized &
built on honesty & on the client‟s
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.
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Have realistic expectations of the
client & make them clear to the client.
Initially provide the client with tasks,
responsibilities & activities that can be
Never flatter the client.
Allow the client to make his own
decisions whenever possible.
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Setting & maintaining limits are integral
to a trust relationship & to a
therapeutic milieu. Before stating a
limit explain the reason for limit-
Some basic guidelines for effective
using limits are:
State the expectations or the limit as
clearly, directly & simply as possible.
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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.
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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.
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Use nursing process to provide comprehensive
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
A schedule, assigns, manages, & evaluates clinical
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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.
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Encourages clients who have low self-esteem to value
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
Conducts group therapy on a daily basis to help clients
to gain self-awareness about how they behave in
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.
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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)
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Occupational therapy is the
application of goal-oriented,
purposeful activity in the assessment
& treatment of individuals with
psychological, physical or
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“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”.
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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.
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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.
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Occupational therapy is provided to
children, adolescents, adults & elderly
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 &
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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.
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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
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.
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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
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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.
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1. Diversional activity: These activities are
used to divert one‟s thoughts from life
stresses or to fill time. For example,
2. Therapeutic activities: These activities are
used to attain a specific care plan or goal.
For example, basket making, carpentry etc.
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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
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
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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,
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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,
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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,
Substance abuse: Group activities in which
patient uses his talent. For example, involving
patient in planning social activities,
encouraging interaction with others etc.
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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.
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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.
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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
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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.
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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
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
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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.
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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.
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To encourage social interaction.
To decrease withdrawal tendencies
To provide outlet for feelings.
To promote socially acceptable
To develop skills, talents & abilities
To increase physical confidence & a
feeling of self worth.
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Provide a non-threatening & non-
Provide activities that are relaxing &
without rigid guidelines & time-
Provide activities that are enjoyable &
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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.
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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,
Schizophrenia (paranoid): Activities requiring
concentration like chess, puzzles.
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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
Mental Retardation: Activities should be
according to the patient‟s level of functioning
such as walking, dancing, swimming, ball
Attitude therapy is a form of milieu
therapy in which all staff members
assume a consistent, prescribed
attitude designed to be therapeutic
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i. When the patient is in the hospital for a long
• 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.
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iii. A clinical diagnosis is made by the
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.
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The patient starts feeling that an
organized approach is being used for
Guesswork & haphazard plans by
individual members of the team are
The patient‟s problems or conflict are
solved in less time.
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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.
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It is a psychotherapeutic use of
movement, which furthers the
emotional & physical integration of
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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 &
Exercise through body movement
maintains good circulation & muscle
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