would you define & describe a therapeutic milieu?
are the components of the ‘total milieu’ and what are its objectives?
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,
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
recreational, occupational, social, psychiatric, medical & nursing
protects & shelters the patient from:
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
personnel in the environment must work together to provide a caring,
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.
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:
- A group
therapy approach to living experience with the following objectives:
or redefine perception of stressors
interpersonal & stress-management skills
all of this in a social content
are the progressive levels of responsibility according to self-care capacity?
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.
– 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
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.
approach is a ‘level system’ stating what the patient must
do to earn a specific privilege, this is a type of behavior
modification is most appropriate with adolescents &
much less so with adults. (p.223)
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.
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.
in the community – include support groups such as AA. Support
groups can also help the patient develop social skills & confidence.
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.
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
is the nurse’s role & function in the therapeutic milieu?
limited self-care capacity.
I – ex: not dangerous, oriented x3, good hygiene, attends one therapy
II – ex: states names of several staff members, goes to many therapies
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
of the above terms:
- 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.
guidelines would be personally helpful to the nurse working in the therapeutic
& 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).
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.
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.
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.
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.
goal is to assist the patient to assume responsibility for taking
their medication to avert recurrence of psychiatric symptoms &
care - consumes the greatest portion of the nurses time &
effort and include the following:
stressors such as loud voices, violent TV programs or video games,
unsightly visual stimuli, unpleasant odors & crowded places.
the patient to identify problems & conflicts, and to attempt to
understand them & use new problem solving methods.
nurse performs, when needed, brief on-the-spot reality therapy &
limit setting to help the patient deal with destructive behaviors.
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.
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).
related to family as mentioned earlier under Links with Family &
Significant others is also provided.
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).
therapy includes progressive muscle relaxation, visual imagery, soothing
auditory experiences & massage.
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.
your self-awareness by evaluating yourself & evaluation by supervisors
- 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.
clearly (say what you mean) & do not hesitate to seek clarification
of what someone else is saying.
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