The Therapeutic Milieu
The therapeutic milieu is an environment that is structured and maintained as an ideal, dynamic setting in which to work with clients. This milieu includes safe physical surroundings, all treatment team members, and other clients.
Learning objectives
After studying this chapter, you should be able to:
Define milieu therapy.
Articulate the standards for a therapeutic milieu or environment as set forth by Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Identify participants in the therapeutic milieu or environment.
Discuss the role of the psychiatric–mental health nurse in the therapeutic milieu or environment.
Describe the components of the therapeutic milieu or environment.
Formulate a list of educational strategies to promote client education.
Explain the importance of providing interventions to meet a client’s spiritual needs.
Develop a list of nursing interventions to promote an optimal balance of rest and activity.
Articulate the rationale for pain management in the therapeutic milieu or environment.
Explain the rationale for the use of seclusion and restraints.
Describe examples of behavior therapy techniques.
Identify clients who would benefit from participation in occupational, educational, art, music, or recreational therapy.
Key Terms
Activities of daily living
Assertiveness training
Aversion therapy
Behavior therapy
Cognitive behavior therapy
Flooding
Implosive therapy
Limit-setting
Milieu therapy
Pavlov’s Theory of Conditioning
Protective nursing care
Skinner’s Theory of Operant Conditioning
Sleep pattern disturbance
Systematic desensitization
Therapeutic lifestyle change counseling (TLC)
Therapeutic milieu
Ward Atmosphere Scale (WAS)
Milieu therapy refers to socioenvironmental therapy in which the attitudes and behavior of the staff in a treatment service and the activities prescribed for the client are determined by the client’s emotional and interpersonal needs (Shahrokh & Hales, 2003). The environment in which the treatment service is delivered is referred to as the therapeutic milieu. It is structured to control, stabilize, and improve problematic emotions and behavior and enables the client to use problem-solving skills to cope with self, others, and environmental stressors. Milieu therapy promotes personal growth and client interactions. The focus is on social relationships as well as occupational and recreational activities. Deinstitutionalization, the use of psychotropic agents, respect for client rights, creation of the multidisciplinary treatment team, and the use of therapeutic groups have contributed to the development of a therapeutic milieu or environment for individuals with psychiatric–mental health disorders.
This chapter describes the development of the therapeutic milieu, including the criteria for establishing it. It also highlights the components involved including the participants and specific interventions used in a therapeutic milieu. Finally, the chapter discusses the need for evaluating the therapeutic milieu to determine its effectiveness for psychiatric–mental health disorders.
Development of the Therapeutic Milieu
As noted in the opening quote for this chapter, therapeutic milieu refers to an environment that is structured to provide clients with the opportunity to interact with staff and other clients. It developed as a result of Henry Stack Sullivan’s belief that interactions among clients are beneficial because clients have the opportunity to practice interpersonal relationship skills, provide feedback to peers about behavior, and work together to develop problem-solving skills (Sullivan, 1968).
A therapeutic milieu can exist in a variety of settings. Clients with psychiatric–mental health disorders may be treated in the hospital, the community, at home, or in private practice of a counselor or therapist.
The term therapeutic milieu has often been used interchangeably with therapeutic environment. It has also been used to describe contemporary treatment settings in which the biopsychosocial needs of individuals such as the terminally or chronically ill, victims of abuse, children with medical problems, and elderly clients are met. Examples include hospice programs, safe houses, Ronald McDonald Houses, halfway houses, geriatric residential treatment centers, and respite programs. Each of these programs provide individualized milieu therapy for clients and their families and/or significant others.
Regardless of the therapeutic milieu setting, certain criteria must be met to help clients develop a sense of self-esteem and personal worth, feel secure, establish trust, improve their ability to relate to others, and return to the community. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has set forth a comprehensive list of standards as a guide in the development of a therapeutic milieu. These standards serve as criteria for JCAHO accreditation surveys. These standards are reflected in the criteria listed in Box 12-1.
Components of a Therapeutic Milieu
Today, as noted earlier in the text, inpatient stays are often limited to crisis stabilization unless a client has a diagnosis of serious and persistent mental illness (Chapter 35) and do not allow clients time to develop meaningful relationships. As a result of this change in the health care environment and health care delivery system, psychiatric nursing is moving toward noninstitutional care with an emphasis on outpatient functions and small treatment units. The components of a therapeutic milieu that were originally provided in psychiatric institutions have been incorporated into community mental health settings (Chapter 8). This movement has resulted in nurses working collaboratively and cooperatively with clients, clients’ families, each other, and other health care providers in order to provide safe, competent, ethical care that will benefit clients. Collaboration is also needed to ensure the client’s need for accessible, affordable health care is met.
Box 12.1: Criteria for Establishing a Therapeutic Milieu
The therapeutic milieu should:
be purposeful and planned to provide safety from physical danger and emotional trauma. It should have furniture to facilitate a homelike atmosphere. Provisions for privacy and physical needs are necessary.
promote interaction and communication among clients and personnel and provide safety from emotional trauma.
provide a testing ground for new patterns of behavior while clients take responsibility for their actions. Behavioral expectations—including the existing rules, regulations, and policies—should be explained to clients.
provide for consistent limit-setting. This criterion reflects aspects of a democratic society. All clients are treated as equally as possible with respect to restrictions, rules, and policies.
encourage participation in group activities and free-flowing communication in which clients are free to express themselves in a socially acceptable manner.
provide for client respect and dignity. Adult–adult interactions should prevail when appropriate, promoting equal status among the parties involved, exchange of interpersonal information, and avoidance of any “power plays.” Clients should be encouraged to use personal resources to resolve problems or conflicts.
convey an attitude of overall acceptance and optimism. Conflict among staff members must be handled and resolved in some manner to maintain a therapeutic milieu. Clients are perceptive of such reactions and may feel that they are the cause of conflicts among personnel.
allow for continual assessment and evaluation of clients’ progress, with modifications in treatment and nursing interventions as needed.
Participants in the Therapeutic Milieu
Members of several disciplines collaborate in the promotion of a therapeutic milieu. Referred to as the psychiatric multidisciplinary treatment team, members include psychiatric–mental health nurses; psychiatric nurse assistants or technicians; psychiatrists; clinical psychologists; psychiatric social workers; occupational, educational, art, musical, psychodrama, recreational, play, pet, and speech therapists; chaplains; dietitians; and auxiliary personnel. Table 12-1 presents a summary of these roles. The psychiatric–mental health nurse assumes responsibility for the management and coordination of activities in the milieu. Due to budgetary constraints, the occupational therapist or the recreational therapist often may serve as the music and art therapist, especially in smaller, privately owned, or community-based hospitals.
The multidisciplinary treatment team participates in regularly scheduled meetings to allow team members to discuss the client’s progress and to review the client’s individualized plan of care. Clients and their family members, significant others, and support persons are invited to participate in these meetings (Fig. 12-1). Treatment methods have evolved from passive, isolated ones to methods that emphasize interaction and cooperation. Clients and their families or significant others who attend the meetings are able to participate in planning and problem-solving. Their input is encouraged as clients develop positive coping skills and are empowered to demonstrate accountability and responsibility in interdependent relationships.
Interventions Used in the Therapeutic Milieu
Various interventions can be used in the therapeutic milieu in either the inpatient or outpatient setting. Interventions that meet the basic needs of the client in the psychiatric–mental health setting are addressed here. Interactive therapies such as crisis intervention, individual and group therapy, and family therapy, as well as special treatment modalities such as psychopharmacology, electroconvulsive therapy, and alternative therapies, are discussed in Chapters 13,14,15,16,17,18 of this text.
Client Education
Client education, also referred to as sharing information, promotes self-care and independence, prevents complications, and reduces recidivism and hospital readmissions. As Gallagher and Zeind (1998, p.16aaa)
assert, “Today’s patients want to be well-informed consumers of health care.” The nurse is often challenged in the role of teacher or educator by barriers such as lack of educational resources, limited time spent with the client, the client’s lack of education to comprehend information, language or cultural differences between the client and nurse, and the client’s physical or emotional disabilities (Katz, 1997).
assert, “Today’s patients want to be well-informed consumers of health care.” The nurse is often challenged in the role of teacher or educator by barriers such as lack of educational resources, limited time spent with the client, the client’s lack of education to comprehend information, language or cultural differences between the client and nurse, and the client’s physical or emotional disabilities (Katz, 1997).
 Table 12.1 Multidisciplinary Treatment Team | ||||||||||||||||||||||||||||||||||||
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According to the 1992 National Adult Literacy Survey conducted by the Department of Education’s National Center for Education Statistics, approximately 40 million adults in the United States can’t understand written materials because of limited or low literacy. Older adults and members of inner-city minority groups are twice as likely to have poor reading abilities compared with the general population. However, despite these statistics, written patient education materials provided by health care facilities continue to be a primary source of information for many clients. Therefore, educational material should contain familiar
words and short sentences, and define any essential medical or psychiatric terminology in simple language (Winslow, 2001). The nurse should also consider the client’s cultural and ethnic identity when developing educational material.
words and short sentences, and define any essential medical or psychiatric terminology in simple language (Winslow, 2001). The nurse should also consider the client’s cultural and ethnic identity when developing educational material.
 Figure 12.1 Multidisciplinary team meeting. |
Before initiating client education, the nurse assesses what the client already knows and what his or her knowledge deficits are. The nurse also assesses whether the client is accessible and amenable to teaching before initiating a learning/teaching/information session. If the patient is not ready or open at the time, then the nurse is wasting his or her time.
The following is a list of educational strategies the nurse can use to promote client education after the client is ready to learn or to share information.
Prioritize the client’s needs and focus on everyday issues (eg, safety vs. nutritional needs).
Present specific information (eg, “Let’s discuss what you should do when you experience what you describe as panic attacks.”).
Use simple language and avoid speaking in a monotone.
Utilize different educational approaches depending on the client’s ability to relate to the written word, video or audio presentations, or ability to use the Internet.
Involve the client’s family members and support persons in the educational process.
Educate and reinforce information while providing care.
Client educational group sessions are also an important intervention for clients who are typically admitted to a psychiatric facility to stabilize their symptoms until they are cleared for outpatient treatment. Nurses can address issues such as medication management, drug and alcohol abuse, stress, diet and exercise, and smoking (Sherman, 2003). Topics such as anger management, interventions for hallucinations or delusions, and the benefits of attending rehabilitation meetings are also included in client education. (Nursing interventions including client education regarding these various topics are discussed in the various disorder chapters in Units VI and VII.)
Sherman (2003) describes a unique group approach to client education, the News Hour. Clients are encouraged to talk about whatever interests them within a certain timeframe or allotted time period. Each client takes a turn, and this allows for exchange and sharing of thoughts. The purpose of this therapeutic intervention is to help clients improve their social skills, focus on others, and realize that they can effect change themselves if they stay informed.
Spiritual Interventions
Criteria for establishing a therapeutic milieu state that the staff should convey an overall acceptance of clients. According to the American Nurses Association’s (ANA) Code of Ethics for Nurses—Provisions (2001), nurses must ensure human dignity for all clients regardless of differences in religion or spiritual beliefs. Because the nurse provides care for clients of different cultural and ethnic backgrounds, issues related to spirituality may be overlooked or misunderstood. As noted in Chapter 4
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