Milieu Therapy

Vicki Notes

How would you define & describe a therapeutic milieu?

  • First milieu is French for ‘middle place’ so you might think of it as a nice safe ‘middle ground.’ Milieu refers to the people & all other social; physical factors in the environment with which the patient interacts. This may be 24 hours a day or partial (less than 24 hours, usually 4-6).
  • This environment is designed to provide a secure retreat for person’s whose capacities for coping with reality have deteriorated (people who just can’t cope anymore).
  • It offer opportunities to acquire adaptive coping skills (teaches you more effective or new ways to deal with problems) & lets the patient test them these new coping skills in a secure, comfortable physical facility.
  • Provides recreational, occupational, social, psychiatric, medical & nursing therapies.
  • Milieu protects & shelters the patient from:
  • Perceived pain, terrifying stressors, can protect a person from their own or others maladaptive behavior (i.e. attempt at suicide or abuse by spouse). This therapy supports the patient physiologically, provides pleasant attractive sensory stimulation, teach patients & family adaptive coping strategies.
  • All personnel in the environment must work together to provide a caring, healing environment.
What are the components of the ‘total milieu’ and what are its objectives?
  • A group therapy approach to living experience with the following objectives:
    • Correct or redefine perception of stressors
    • Correct maladaptive behavior
    • Develop adaptive coping
    • Acquire interpersonal & stress-management skills
    • Apply all of this in a social content
It is also very important that the milieu match the patient’s cultural background because it’s absence to match can causes greater cognitive or inner conflict. What is the overall goal of the mental health team? To maintain & create a therapeutic milieu by - providing individualized treatment plans, promoting self-governance, progressive levels of responsibility, variety of activities, links with family & community & effective interaction among health team who are humanistic. Further explanation of the above terms:
  • Individualized treatment plans – are tailored as much as possible to the needs & right of the person. Definite structure, schedule, overall guidelines & social controls are set forth.
  • Self-governance – refers to the development of self-responsibility & appropriate interdependence with peers. Patient’s participate in decision making regarding milieu issues (i.e. structured committee meetings, client-team committee meeting).
  • Progressive Levels of Responsibility – refers to the fact that patients are expected to assume a role in maintaining the environment à assignments should be according to capabilities. This works to promote feelings of self-responsibility. MH team members assign levels and peer comments about readiness for level changes are considered.
    • One approach is a ‘level system’ stating what the patient must do to earn a specific privilege, this is a type of behavior modification.
    • Behavior modification is most appropriate with adolescents & much less so with adults. (p.223)
  • A variety of meaningful activities – encourages proactive social behavior & adaptive coping skills (patients interact in activities & have a chance to ‘test’ the new communication/coping skills they have learned). Activities include exercise class, jogging, weight lifting, interpersonal skills training (such as assertiveness training, listening & communicating skills) & leisure skills classes.
  • Links with family & Significant others – family education programs may be used to help members of the family understand the patient’s problems & learn how they can help with recovery. The family may be involved in selected milieu activities (i.e. interpersonal skill's classes, MH classes, family group therapy & medication classes). In partial settings the family may learn how to care for the patient at home (i.e. s/s related to the particular problem, medication side effects & guidelines to select a psychiatric home care service.
  • Links in the community – include support groups such as AA. Support groups can also help the patient develop social skills & confidence.
  • Effective interaction between MH team members – the mental health staff must have effective interaction à we are all human so from time to time there will be conflict à in this environment it is vital that conflict are resolved effectively & promptly or the entire milieu therapy/environment may decline.
  • Humanistic mental health team members – members of this teams must posses certain attributes, they must be: optimistic, inspire hopefulness, be creative, lack fear or prejudice when confronted with bizarre unconventional behavior, provide daily contact, set limits, share control & provide effective education.
What are the progressive levels of responsibility according to self-care capacity?
  • Classification levels include:
  • Severely limited self-care capacity.
  • Level I – ex: not dangerous, oriented x3, good hygiene, attends one therapy daily.
  • Level II – ex: states names of several staff members, goes to many therapies
  • Level III – meets requirements for all other levels plus takes active role with other patients, assumes leadership role & initiates discussion with MH team about discharge. (for more detailed example see chart – p.223)
What is the nurse’s role & function in the therapeutic milieu?
  • To manage & coordinate from a holistic view rather than a fragmented perspective of other MH team members à this allows nursing to ensure continuity of care. Nurse’s also assess physiological & psychological status continually, influence of the milieu therapy, provide physical & safety care, medication administration & education, psychosocial care, mental health & health education.
Further explanation of the above terms:
  • Physical & safety care – assess the patient’s ability to perform ADLs, signs of physical illness or adverse reactions to psychotropic drugs or reactions to withdrawal/detoxification when indicated. Assess self-destructive or other-destructive behaviors. Perform periodic safety checks (be sure to do it in a way as to not violate patient rights).
  • Frequently patients with destructive tendencies are treated in Partial Programs, here safety contracts are used (a type of behavior approach). Contracts can be formed between patients and peers as well.
  • Adequate staffing is very important, usually there is one RN per five patients, at least one activity therapist available 12hrs/day & two other paraprofessionals or MH workers.
  • In Partial Programs a ratio of one RN to ten patients is considered safe, with again one activity therapist & two other professionals.
  • Medication administration & education – in milieu therapy the nurse may be expected to gain informed consent before giving psychotropic drugs, this includes explaining desired & undesired effects. Encourage the patient to ask questions & respect that they had the right to decline the drug à this shows respect for the patient, begins education & this active involvement encourages compliance.
  • The patient is expected to approach the nurse for medications at the specific times & places.
  • A responsible patient may be given a 24-hour supply of their medication to take independently à this demonstrates readiness to assume self-care.
  • The goal is to assist the patient to assume responsibility for taking their medication to avert recurrence of psychiatric symptoms & rehospitalization.
  • Psychosocial care - consumes the greatest portion of the nurses time & effort and include the following:
  • Reducing stressors such as loud voices, violent TV programs or video games, unsightly visual stimuli, unpleasant odors & crowded places.
  • Encouraging the patient to identify problems & conflicts, and to attempt to understand them & use new problem solving methods.
  • The nurse performs, when needed, brief on-the-spot reality therapy & limit setting to help the patient deal with destructive behaviors.
  • Therapy by the nurse aims to increase self-awareness by helping the patient clarify & correct perceptions of current stressors, identify their thoughts & feelings toward the stressors and how they effect their behavior, evaluate which coping methods are effective and test the methods in the therapeutic milieu.
  • Mental Health education – is provided by the nurse who teaches the patient & family all aspects of psychotropic medications or coping strategies for psychiatric illness (this improves compliance).
  • Teaching related to family as mentioned earlier under Links with Family & Significant others is also provided.
  • Stress management techniques taught to aid in coping include exercise, relaxation therapy & pursuit of leisure activities (fosters a sense of well being, self-confidence, self-control & increased self-esteem).
  • Relaxation therapy includes progressive muscle relaxation, visual imagery, soothing auditory experiences & massage.
  • Health education – the nurse provides education on physical health as well, some patients may be at risk related the self-neglect associated with many psychiatric disorders.
What guidelines would be personally helpful to the nurse working in the therapeutic milieu?
  • Cultivate your self-awareness by evaluating yourself & evaluation by supervisors & peers.
  • Be objective when interacting with clients, teams members & the milieu’s social atmosphere without becoming overly involved & don not take sides!
  • Be sensitive to all but recognize personal limits as well.
  • Communicate clearly (say what you mean) & do not hesitate to seek clarification of what someone else is saying.
  • Always expect the unexpected not matter how well it was planned!
  • Be clear at all times in what your values, principals & beliefs are regarding what is and what is not clinically appropriate for adequate patient care.

Nursing… where science meets humanity