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MILIEU THERAPY—THE
THERAPEUTIC COMMUNITY
• The word milieu is French for “middle.” The English translation of the
word is “surroundings, or environment.” In psychi...
BASIC ASSUMPTIONS
• Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based:
• 1. The he...
• 2. Every interaction is an opportunity for therapeutic intervention.
Within this structured setting, it is virtually imp...
• 4. Each client owns his or her behavior. Each individual within the
therapeutic community is expected to take responsibi...
• 6. Inappropriate behaviors are dealt with as they occur. Individuals
examine the significance of their behavior, look at...
CONDITIONS THAT PROMOTE A THERAPEUTIC
COMMUNITY
• In a therapeutic community setting, everything that happens to the
clien...
• 1. Basic physiological needs are fulfilled. As Maslow (1968) has
suggested, individuals do not move to higher levels of ...
• 3. A democratic form of self-government exists. In the therapeutic
community, clients participate in the decision making...
• 5. A structured program of social and work-related activities is
scheduled as part of the treatment program. Each client...
• 6. Community and family are included in the program of therapy in an
effort to facilitate discharge from treatment. An a...
• The following are responsibilities of IDT team members.
• Psychiatrist
Serves as the leader of the team. Responsible for...
THE PROGRAM OF THERAPEUTIC COMMUNITY
•
• Care for clients in the therapeutic community is directed by an interdisciplinary...
• Psychiatric nurse Provides ongoing assessment of client condition, both
• mentally and physically. Manages the therapeut...
• Occupational therapist
• Works with clients to help develop (or redevelop) independence in performance of
activities of ...
• Art therapist
• Uses the client’s creative abilities to encourage expression of emotions and feelings through artwork. H...
Milieu therapy—the therapeutic community
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Milieu therapy—the therapeutic community

  1. 1. MILIEU THERAPY—THE THERAPEUTIC COMMUNITY
  2. 2. • The word milieu is French for “middle.” The English translation of the word is “surroundings, or environment.” In psychiatry, therapy involving the milieu, or environment, may be called milieu therapy, therapeutic community, or therapeutic environment. Therefore, Milieu therapy can be defined as, A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual (Skinner, 1979). • The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic.
  3. 3. BASIC ASSUMPTIONS • Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based: • 1. The health in each individual is to be realized and encouraged to grow. All individuals are considered to have strengths as well as limitations. These healthy aspects of the individual are identified and serve as a foundation for growth in the personality and in the ability to function more adaptively and productively in all aspects of life.
  4. 4. • 2. Every interaction is an opportunity for therapeutic intervention. Within this structured setting, it is virtually impossible to avoid interpersonal interaction. The ideal situation exists for clients to improve communication and relationship development skills. Learning occurs from immediate feedback of personal perceptions. • 3. The client owns his or her own environment. Clients make decisions and solve problems related to government of the unit. In this way, personal needs for autonomy as well as needs that pertain to the group as a whole are fulfilled.
  5. 5. • 4. Each client owns his or her behavior. Each individual within the therapeutic community is expected to take responsibility for his or her own behavior. • 5. Peer pressure is a useful and a powerful tool. Behavioral group norms are established through peer pressure. Feedback is direct and frequent, so that behaving in a manner acceptable to the other members of the community becomes essential.
  6. 6. • 6. Inappropriate behaviors are dealt with as they occur. Individuals examine the significance of their behavior, look at how it affects other people, and discuss more appropriate ways of behaving in certain situations. • 7. Restrictions and punishment are to be avoided. Destructive behaviors can usually be controlled with group discussion. However, if an individual requires external controls, temporary isolation is preferred over lengthy restriction or other harsh punishment.
  7. 7. CONDITIONS THAT PROMOTE A THERAPEUTIC COMMUNITY • In a therapeutic community setting, everything that happens to the client, or within the client’s environment, is considered to be part of the treatment program. The community setting is the foundation for the program of treatment • Under what conditions, then, is a hospital environment considered therapeutic? A number of criteria have been identified:
  8. 8. • 1. Basic physiological needs are fulfilled. As Maslow (1968) has suggested, individuals do not move to higher levels of functioning until the basic biological needs for food, water, air, sleep, exercise, elimination, shelter, and sexual expression have been met. • 2. The physical facilities are conducive to achievement of the goals of therapy. Space is provided so that each client has sufficient privacy, as well as physical space, for therapeutic interaction with others. Furnishings are arranged to present a homelike atmosphere—usually in spaces that accommodate communal living, dining, and activity areas—for facilitation of interpersonal interaction and communication.
  9. 9. • 3. A democratic form of self-government exists. In the therapeutic community, clients participate in the decision making and problem solving that affect the management of the treatment setting. This is accomplished through regularly scheduled community meetings. • These meetings are attended by staff and clients, and all individuals have equal input into the discussions. • 4. Responsibilities are assigned according to client capabilities. Increasing self-esteem is an ultimate goal of the therapeutic community. Therefore, a client should not be set up for failure by being assigned a responsibility that is beyond his or her level of ability. By assigning clients responsibilities that promote achievement, self-esteem is enhanced. Consideration must also be given to times during which the client will show some regression in the treatment regimen. Adjustments in assignments should be made in a way that preserves self-esteem and provides for progression to greater degrees of responsibility as the client returns to previous level of functioning.
  10. 10. • 5. A structured program of social and work-related activities is scheduled as part of the treatment program. Each client’s therapeutic program consists of group activities in which interpersonal interaction and communication with other individuals are emphasized. Time is also devoted to personal problems.Various group activities may be selected for clients with specific needs . A structured schedule of activities is the major focus of a therapeutic community. Through these activities, change in the client’s personality and behavior can be achieved. New coping strategies are learned and social skills are developed. In the group situation, the client is able to practice what he or she has learned to prepare for transition to the general community.
  11. 11. • 6. Community and family are included in the program of therapy in an effort to facilitate discharge from treatment. An attempt is made to include family members, as well as certain aspects of the community that affect the client, in the treatment program. It is important to keep as many links to the client’s life outside of therapy as possible .Family members are invited to participate in specific therapy groups and, in some instances, to share meals with the client in the communal dining room. • Connection with community life may be maintained through client group activities, such as shopping, picnicking, attending movies, and visiting the zoo. These connections with family and community facilitate the discharge process and may help to prevent the client from becoming too dependent on the therapy. •
  12. 12. • The following are responsibilities of IDT team members. • Psychiatrist Serves as the leader of the team. Responsible for diagnosis and treatment of mental disorders. Performs psychotherapy; prescribes medication and other somatic therapies. • Clinical psychologist • Conducts individual, group, and family therapy.Administers, interprets, and evaluates psychological tests that assist in the diagnostic process. • Psychiatric clinical nurse Specialist • Conducts individual, group, and family therapy.Presents educational programs for nursing staff. Provides consultation services to nurses who require assistance in the planning and implementation of care for individual clients.
  13. 13. THE PROGRAM OF THERAPEUTIC COMMUNITY • • Care for clients in the therapeutic community is directed by an interdisciplinary treatment (IDT) team. An initialassessment is made by the admitting psychiatrist, nurse, or other designated admitting agent who establishes a priority of care. The IDT team determines a comprehensive treatment plan and goals of therapy and assigns intervention responsibilities. All members sign the treatment plan and meet regularly to update the plan as needed. Depending on the size of the treatment facility and scope of the therapy program, members representing a variety of disciplines may participate in the promotion of a therapeutic community. For example, an IDT team may include a psychiatrist, clinical psychologist, psychiatric clinical nurse specialist, psychiatric nurse, mental health technician, psychiatric social worker, occupational therapist, recreational therapist, art therapist, music therapist, psychodramatist, dietitian, and chaplain.
  14. 14. • Psychiatric nurse Provides ongoing assessment of client condition, both • mentally and physically. Manages the therapeutic milieu on a 24-hour basis.Administers medications. Assists clients with all therapeutic activities as required. Focus is on one-to- one relationship development. • Mental health technician Functions under the supervision of the psychiatric nurse. Provides assistance to clients in the fulfillment of their activities of daily living. Assists activity therapists as required in conducting their groups. May also participate in one-to-one relationship development. • Psychiatric social worker • Conducts individual, group, and family therapy. Is • concerned with client’s social needs, such as placement, financial support, and community requirements. Conducts in-depth psychosocial history on which the needs assessment is based. Works with client and family to ensure that requirements for discharge are fulfilled and needs can be met by appropriate community resources.
  15. 15. • Occupational therapist • Works with clients to help develop (or redevelop) independence in performance of activities of daily living. Focus is on rehabilitation and vocational training in which clients learn to be productive, thereby enhancing self-esteem. Creative activities and therapeutic relationship skills are used. • Recreational therapist • Uses recreational activities to promote clients to redirect their thinking or to rechannel destructive energy in an appropriate manner. Clients learn skills that can be used during leisure time and during times of stress following discharge from treatment. Examples include bowling, volleyball, exercises, and jogging. Some programs include activities such as picnics, swimming, and even group attendance at the state fair when it is in session. • Music therapist • Encourages clients in self-expression through music. Clients listen to music, play instruments, sing, dance, and compose songs that help them get in touch with feelings and emotions that they may not be able to experience in any other way.
  16. 16. • Art therapist • Uses the client’s creative abilities to encourage expression of emotions and feelings through artwork. Helps clients to analyze their own work in an effort to recognize and resolve underlying conflict. • Psychodramatist • Directs clients in the creation of a “drama” that portrays real-life situations. Individuals select problems they wish to enact, and other clients play the roles of significant others in the situations. Some clients are able to “act out” problems that they are unable to work through in a more traditional manner. All members benefit through intensive discussion that follows. • Dietitian • Plans nutritious meals for all clients. Works on consulting basis for clients with specific eating disorders, such as anorexia nervosa, bulimia nervosa, obesity, & pica. • Chaplain • Assesses, identifies, and attends to the spiritual needs of clients and their family members. Provides spiritual support and comfort as requested by client or family. • May provide counseling if educational background includes this type of preparation. •
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