1) Milieu therapy, also known as therapeutic community, was developed in the 1940s independently by T. Main in Birmingham and Maxwell Jones in the UK. It focuses on manipulating the patient's social environment and involving them in community activities and decision making. 2) Milieu therapy aims to use a patient's social environment to provide therapeutic experiences. It enables patients to actively participate in their own care and the daily problems of their community. 3) There are three main types of milieu therapy: genuine therapeutic community, therapeutic milieu of institution, and social therapy or concept-based therapy. The therapeutic community respects individuals and shares decision making with patients.

1. MILIEU THERAPY
PRESENTED BY,
Subarna Neogi
M.Sc Nursing 1st year
C.O.N.,JIPMER

2. CONCEPT:
• Developed by MAXWELL in 1953
• 1st published in ENGLAND book name is “SOCIAL PSYCHIATRY”
• Later on it was published in United States & name changes to
“THERAPEUTIC COMMUNITY”

3. BACKGROUND:
• Two persons, namely T. Main in Bermingham and Maxwell Jones of
UK during 2nd world war worked simultaneously on this concept
without the knowledge of each other.

4. WHAT IS MILIEU THERAPY:
• A small cohesive communities where patients have a significant
involvement in decision making & the practicalities of the running
unit.
• the emphasis is on manipulation of the environment to bring about
changes in the patients behavior.

5. DEFINITION:
• According to Kraft,
“the therapeutic community is a very special type of milieu therapy in
which the total structure of the treatment unit is involved as a part of
the helping process.”
• Stuart and Sundeen defined milieu therapy 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 and the daily problems of his
community."

6. OBJECTIVES:
• 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 and
become involved in daily activities of his community.
• To help patients to solve problems, plan activities and to develop the
necessary rules and regulations for the community.
• To increase their independence and gain control over many of their
own personal activities.
• To enable the patients become aware of how their behaviour affects
others.

8. TYPES:
1. GENUINE THERAPEUTIC COMMUNITY OF DEMOCRATIC / ANALYTIC
2. THERAPEUTIC MILIEU OF INSTITUTIONAL
3. SOCIAL THERAPY OR CONCEPT BASED THERAPY

10. The therapeutic community attempts to:
• Respect the individual client as a citizen having capacity for
autonomous action
• Share decision making with residents about day to day life of the
community
• Use the mechanism of meetings and groups to develop openness of
the communication about problems, feelings and conflicts.
• Stress an ordinary domestic environment, in which, clients can enjoy
in meaningful, purposeful activity.

11. BASIC ASSUMPTIONS:
• The Health in Each Individual Is to Be Realized and Encouraged to Grow
• Every Interaction Is an Opportunity for Therapeutic Intervention
• The Client Owns His or Her Own Environment
• Each Client Owns His or Her Behavior
• Restrictions and Punishment Are to Be Avoided
• Peer pressure
• Appropriate behavior

12. PRINCIPLES:
1. Responsibility for treatment belongs to the staff and client
2. Roles of staff and clients are equalized – may discuss either staff behavior
or client’s behavior.
3. Democratic environment is fostered
4. Open communication is encouraged
5. Focus is on client assets
6. Peer pressure is utilized to reinforce rules and regulations
7. Interpersonal interactions are utilized to improve communication skills
8. Inappropriate behavior is dealt with as they occur

13. CONTINUE….
9. Group discussion and temporary seclusion are favoured approaches for
acting out behavior
10. Team approach is used
11. Clients are treated as part of team and share in the responsibility and
process of making decisions.
12. Clients are involved in all phases of treatment
13. Community government is set up – use meetings to teach standards,
values and behavior, explore behavior, make decision, use problem solving
14. Two main goals for clients – learn to set limits, learn psychosocial skills

14. LIMIT SETTING:
Behaviours that requires setting limits:
Destructive: suicide, homicide, harm to person or property
Disorganisation: psychotic behaviour- hallucinations, delusions,
disoriented, dissociative episodes of post-traumatic stress disorders
Deviants: acting out, breaking rules, illegal activities
Dysphoric: depressed, withdrawn, elated, phobic, obsessive-
compulsive
Dependent: avoids responsibility for thoughts and behaviours

15. CONTINUE…
• Psycho social skill development:
Leadership: client government
Self-assertion: expressing feelings and attitudes is encouraged, focus
is on taking it out.
Occupational activities: basic skills for managing life, activities of daily
living, vocational counselling, training
Recreational activities: leisure activities, co-operation with others,
conversation within social context
Independence: focus on decision making, problem solving, self-care

16. SPECIFIC ROLES OF INTERDISCIPLINARY TEAM
IN MAINTENANCE OF THERAPEUTIC MILIEU
• Psychiatrist.
• Clinical psychologist.
• Psychiatric clinical nurse specialists.
• Mental health technician/psychiatric technician.
• Psychiatric social worker.
• Occupational therapist.
• Recreational therapist.

17. HANDOUTS ON MILEU THERAPY TEAM MEMBER:

18. CONDITIONS THAT PROMOTE A
THERAPEUTIC COMMUNITY:
• Basic Physiological Needs Are Fulfilled
• The Physical Facilities Are Conducive to Achievement of the Goals of
Therapy
• A Democratic Form of Self-Government Exists
• Responsibilities Are Assigned According to Client Capabilities
• Community and Family Are Included in the Program of Therapy in an
Effort to Facilitate Discharge from Treatment.
• A structured program of social & work.

19. THERAPEUTIC COMMUNITY ELEMENTS
• Free communication
• Shared responsibilities
• Active participation
• Involvement in decision making
• Understanding of roles, responsibilities, limitations and authorities

20. Components of Therapeutic
Community
• Daily Community Meetings
• Patient Government or Ward Council
• Staff Meetings or Review
• Living and Learning Opportunities

21. PATIENTS FOR WHOM THERAPEUTIC COMMUNITY IS USEFUL
• Schizophrenia
• Substance abuse disorder
• Antisocial disorder
• Children's care taking environment

22. PERSONAL ATTRIBUTES REQUIRED BY NURSES
• Sensitive observation of patients and social relationships in order to
form care plan
• Individualized care planning, using imaginative ways of enhancing
patient’s co-operation and implementation
• Articulate and clear report writing and structuring of case notes
• Clarity of oral reporting
• Listening and counselling
• Group techniques as leader, co-worker and participants
• Managerial, administrative, and educational skills appropriate to own
position and role in the community

23. SALIENT FEATURES:
• Free communication both within and between staff and patient group
• Communications are directed towards the modification of patient’s
attitude, behavior and role performance
• Atmosphere in the community will be democratic as opposed to
hierarchical, rehabilitative rather than custodial, permissive instead of
limited and controlled
• Nurses will be more communal with the patient instead of displaying
all the time therapeutic role
• Environment will be essentially permissive and flexible

24. CONTINUE….
• Patients activities are individualized and the role of patients are
unspecified and their participation is completely voluntary
• Group responsibility is emphasized and opportunities for corrective
learning experience are deliberatively provided
• A compulsory daily community meeting that all staff members have
to attend and all patients are encouraged to attend
• The primary role of staff is to help the patients gain new insights and
test new behavioural pattern
• Problems of the patients are discussed and the solutions are sought
in the small group therapy sessions following each community
meeting

25. CONTINUE….
• Patient government or ward council is to deal with practical unit details
such as privileges and housekeeping rosters. Staff member is available to
the patient government, and 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
opportunities for the staff members to examine their own responses,
expectations and prejudices
• Living – learning opportunities are provided to the patient within the social
milieu. Thus, the therapeutic community is like a school for living in which
the patient learns to meet the demands of everyday life.
• Feedback is one of the fundamental concepts in therapeutic community
practice.

26. ADVANTAGES OF TC
• Patient develops harmonious relationships
with other members of the community.
• Gains self-confidence.
• Develops leadership skills.
• Learns to understand and solve problems
of self and others.
• Become socio-centric.
• Learns to live and think collectively with
the members of the community.
• provides opportunities to participate in the
formulation of hospital rules and
regulations
DISADVANTAGES
OF TC
• Role blurring between staff and
patient.
• Group responsibility can easily
become nobody's responsibility.
• Individual needs and concerns
may not be met.
• Patient may find the transition
to community difficult

29. QUESTIONS:
1. Who 1st
gave the concept of milieu therapy?
a. Lazarus
b. Dutchman
c. Maxwell Jones
d. Freud
2. What is not a technique of milieu therapy?
a. Institutional
b. Social
c. Genuine
d. group therapy
3. How many steps are there in milieu therapy?
a. 3
b. 5
c. 4
d. 2

30. ASSIGNMENT:
• Write an assignment on different types of milieu therapy and
nurse role.