Therapeutic community or milieu in psychiatry is a very important and ans a standard in professional psychiatric nursing

1. Deblina Roy
M.Sc Nursing 1st year
K.G.M.U. Institute of Nursing
MILIEU THERAPY /
THERAPEUTIC
COMMUNITY

2. Objective of the session
• Define milieu therapy.
• Explain the goal of therapeutic community/milieu
therapy.
• Identify seven basic assumptions of a therapeutic
community.
• Discuss conditions that characterize a therapeutic
community.
• Identify the various therapies that may be included
within the program of the therapeutic community and
the health-care workers that make up the
interdisciplinary treatment team.
• Describe the role of the nurse on the interdisciplinary
treatment team.

3. Standards of psychiatric nursing (standard 5C)
• “The psychiatric-mental health nurse provides, structures, and
maintains a safe and therapeutic environment in collaboration
with patients, families, and other health care clinicians”

4. Meaning
• 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 the therapeutic environment.

5. Goal of the therapy
• The goal of milieu therapy is to manipulate the environment so
that all aspects of the client’s hospital experience are considered
therapeutic.
• Within this therapeutic community setting the client is expected
to learn :
• adaptive coping,
• interaction
• relationship skills
that can be generalized to other aspects of his or her life.

6. Definition
• Milieu Therapy :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).

7. Historical aspects
• Milieu therapy came into its own during the 1960s through the
early 1980s.
• During this period, psychiatric inpatient treatment provided
sufficient time to implement programs of therapy that were aimed
at social rehabilitation.
• Nursing’s focus of establishing interpersonal relationships with
clients fit well within this concept of therapy.
• Patients were encouraged to be active participants in their
therapy, and individual autonomy was emphasized.

8. Basic assumptions of the therapeutic community
• Skinner (1979) outlined seven basic assumptions on which a
therapeutic community is based:
• Assumption 1
• 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.

9. Assumption 2
• 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.

10. •Assumption 3
• 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.
• Assumption 4
• 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.

11. •Assumption 5
• 5. Peer pressure is a useful and 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.
•Assumpti0n 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.

12. Assumption 7
• 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
consequences.

13. Conditions that promote a therapeutic
community
• 1. Basic physiological needs are fulfilled:
• 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.

14. Cont.
• 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.
• 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.

15. Cont.
• 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.
• 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.

16. Program of therapeutic community
The IDT team determines a comprehensive treatment plan and goals
of therapy and assigns
An initial assessment is made by the admitting psychiatrist, nurse, or
other designated admitting agent who establishes a priority of care.
Care for clients in the therapeutic community is directed by an
interdisciplinary treatment (IDT) team.

17. Cont..
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
All members sign the treatment plan and meet regularly to update the
plan as needed.
Intervention responsibilities

18. Members of the Inter Disciplinary team
IDT team may include
• psychiatrist
• clinical psychologist
• psychiatric clinical nurse specialist
• psychiatric nurse
• mental health technician
• psychiatric social worker
• occupational therapist
• recreational therapist
• art therapist
• music therapist
• Psycho dramatist
• Dietitian.
• chaplain.

19. Roles of the Interdisciplinary team members

20. Role of nurse in milieu therapy
• Milieu therapy can take place in a variety of inpatient and
outpatient settings.
• In the hospital, nurses are generally the only members of the IDT
team who spend time with the clients on a 24-hour basis
• Assume responsibility for management of the therapeutic milieu. In
all settings, the nursing process is used for the delivery of nursing
care.
• Ongoing assessment, diagnosis, outcome identification, planning,
implementation, and evaluation of the environment are necessary
for the successful management of a therapeutic milieu.
• In the therapeutic milieu, nurses are responsible for ensuring that
clients’ physiological needs are met.

21. • Nurses are involved in all day-to-day activities that pertain to client
care.
• Suggestions and opinions of nursing staff are given serious
consideration in the planning of care for individual clients.
• Information from the initial nursing assessment is used to create
the IDT plan.
• Nurses have input into therapy goals and participate in the regular
updates and modification of treatment plans.
• In some treatment facilities, a separate nursing care plan is required
in addition to the IDT plan.
• When this is the case, the nursing care plan must reflect diagnoses
that are specific to nursing and include problems and interventions
from the IDT plan that have been assigned specifically to the
discipline of nursing.

22. • Clients must be encouraged to perform as independently as possible in
fulfilling activities of daily living.
• ongoing assessments to provide assistance for those who require .
• Assessing physical status is an important nursing responsibility that
must not be overlooked in a psychiatric setting that emphasizes
holistic care.
• Reality orientation for clients who have disorganized thinking or who
are disoriented or confused is important in the therapeutic milieu.
• Clocks with large hands and numbers, calendars that give the day and
date in large print, and orientation boards that discuss daily activities
and news happenings can help keep clients oriented to reality.
• Nurses should ensure that clients have written schedules of activities
to which they are assigned and that they arrive at those activities on
schedule.
• Some clients may require an identification sign on their door to
remind them which room is theirs.
• On short-term units, nurses who are dealing with psychotic clients
usually rely on a basic activity or topic that helps keep people oriented.

23. • management of medication administration on inpatient psychiatric
units.
• In some treatment programs, clients are expected to accept the
responsibility and request their medication at the appropriate time.
• encourage clients to be self-reliant.
• Nurses must work with the clients to determine methods that result in
achievement and provide positive feedback for successes.
• nursing in the therapeutic milieu is the one-to-one relationship that
grows out of a developing trust between client and nurse.
• Many clients with psychiatric disorders have never achieved the ability
to trust.
• If this can be accomplished in a relationship with the nurse, the trust
may be generalized to other relationships in the client’s life.
• Within an atmosphere of trust, the client is encouraged to express
feelings and emotions and to discuss unresolved issues that are
creating problems in his or her life.

24. • setting limits on unacceptable behavior in the therapeutic milieu.
• This requires stating to the client in understandable terminology
what behaviors are not acceptable and what the consequences will
be should the limits be violated.
• These limits must be established, written, and carried out by all
staff.
• The role of client teacher is important in the psychiatric area, as it is
in all areas of nursing.
• Nurses must be able to assess learning readiness in individual
clients.
• Some topics must be individualized for specific clients, whereas
others may be taught in group situations.

25. Patient education points
• Ways to improve self esteem
• Ways to manage anger appropriately
• Stress management
• Identify the increasing anxiety and reduce its progression.
• normal stages of grieving and behaviors associated with
grieving.
• Assertiveness techniques
• Relaxation techniques
• Medications
• Effects of substance on the body
• Problem solving skills
• Thought stopping and thought switching skills
• Sex education
• Good nutrition
• Parental guidelines

26. • Milieu therapy interventions are recognized as one
of the basic-level functions of psychiatric-mental
health nurses as addressed [in the Psychiatric-
Mental Health Nursing: Scope and Standards of
Practice, (ANA, 2007)].

27. Summary
• ticks

28. Discussion

29. Conclusion
• Milieu therapy has been described as an excellent framework for
operationalizing [Hildegard] Peplau’s interpretation and extension
of Harry Stack Sullivan’s Interpersonal Theory for use in nursing
practice.
• therapeutic milieu concept and to reclaim nursing’s traditional
milieu intervention functions.
• Nurses need to identify the number of registered nurses necessary
to carry out structured and unstructured milieu functions consistent
with their Standards of Practice.

30. References
• Vyas A. Ahuja N . post graduate text book of psychiatry .15th ed
.jaypee brothers , New Delhi ; Pp-428-91
• Saddock . Kaplan . Synopsis of psychiatry . 11th Ed Jaypee brothers .
New York .Pp 647
• Townsend MC. Essentials of psychiatric nursing . 7th ed . Moseby ,
New York .Pp- 165-74