The Therapeutic Milieu

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.

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.

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).

Table 12.1 Multidisciplinary Treatment Team

Psychiatric nurse A registered nurse specializing in psychiatric nursing by employing theories of human behavior and the therapeutic use of self. Gives holistic nursing care by assessing the client’s mental, psychological, and social status. Provides a safe environment, works with clients dealing with everyday problems, provides leadership, and assumes the role of client advocate.
Nurses with master’s degree, clinical specialty, or certification in psychiatric–mental health nursing; conducts individual, family, or group therapy. In certain states, the nurse practitioner is granted prescriptive privileges.
Psychiatric nurse assistant or technician High school graduate who receives in-service education pertaining to the job description. Assists the mental health team in maintaining a therapeutic environment, providing care, and supervising client activities.
Psychiatrist Licensed physician with at least 3 years of residency training in psychiatry, including 2 years of clinical psychiatric practice. Conducts therapy sessions and serves as leader of the multidisciplinary treatment team. Prescribes medication and somatic treatment. Specializes in the diagnosis, treatment, and prevention of mental and emotional disorders.
Clinical psychologist Person with doctoral degree in clinical psychology, who is licensed by state law and a psychology internship (supervised work experience). Provides a wide range of services, from diagnostic testing, interpretation, evaluation, and consultation to research. May treat clients individually or in a group therapy setting.
Psychiatric social worker College graduate with a baccalaureate, master’s, or doctoral degree. Uses community resources and adaptive capacities of individuals and groups to facilitate positive interactions with the environment. Conducts the intake interview; family assessment; individual, family, and group therapy; discharge planning; and community referrals.
Occupational therapist College graduate with a baccalaureate or master’s degree in occupational therapy. Uses creative techniques and purposeful activities, as well as therapeutic relationship, to alter the course of an illness. Assists with discharge planning and rehabilitation, focusing on vocational skills and activities of daily living to raise self-esteem and promote independence.
Educational therapist College graduate who specializes in educational therapy. Determines effective instructional methods, assessing the person’s capabilities and selecting specialized programs to promote these capabilities. May include remedial classes, special education for “maladjusted” children, or continuing education for hospitalized students with emotional or behavioral problems (eg, anorexia nervosa, depression, or substance abuse).
Art therapist College graduate with a master’s degree and specialized training in art therapy. Encourages spontaneous creative artwork to express feelings of emotional conflicts. Assists the client in analyzing expressive work. Uses basic child psychiatry to diagnose and treat emotional or behavioral problems. Attention is paid to the use of colors as well as symbolic or real-life figures and settings.
Musical therapist College graduate with a master’s degree and training in music therapy. Focuses on the expression of self through music such as singing, dancing, playing an instrument, or composing songs and writing lyrics. Music therapy promotes improvement in memory, attention span, and concentration and provides an opportunity for one to take pride in one’s achievement.
Psychodrama therapist College graduate with advanced degree and training in group therapy. This therapy is also referred to as role-playing therapy. People are encouraged to act out their emotional problems through dramatization and role playing. This type of therapy is excellent for children, adolescents, and people with marital or family problems. The therapist helps the people to explore past, present, and potential experiences through role play and assists group members in developing spontaneity and successful interactional tools. The audience may participate by making comments about and interpretations of the people acting.
Recreational or activity therapist College graduate with a baccalaureate or master’s degree and training in recreational or activity therapy. Focuses on remotivation of clients by directing their attention outside themselves to relieve preoccupation with personal thoughts, feelings, and attitudes. Clients learn to cope with stress through activity. Activities are planned to meet specific needs and encourage the development of leisure-time activities or hobbies. Recreational therapy is especially useful with those people who have difficulty relating to others (eg, the regressed, withdrawn, or immobilized person). Examples of recreational activities include group bowling, picnics, sing-alongs, and bingo.
Play therapist A psychiatrist, licensed psychologist, psychiatric nurse, psychiatric social worker, or other person trained in counseling. A play therapist observes the behavior, affect, and conversation of a child who plays in a protected environment with minimal distractions, using games or toys provided by the therapist. The therapist tries to gain insight into the child’s thoughts, feelings, or fantasies and helps the child to understand and work through emotional conflicts.
Pet therapist Also referred to as an animal-assisted therapist. A trained practitioner with experience with animal behavior. Provides animal-assisted visitation and animal-assisted therapy. Uses certified therapy animals to visit clients and families at the bedside or in a common waiting area. Provides therapy on a one-to-one basis. The goals of animal-assisted therapy include the reduction of stress; improvement in emotional well-being, self-concept, and social interaction; and behavior modification.
Speech therapist College graduate with a master’s degree and training in speech therapy. Speech therapists assess and treat disturbed children or people who have developmental language disorders involving nonverbal comprehension, verbal comprehension, and verbal expression. Failure to develop language may occur as a result of deafness, severe mental disability, gross sensory deprivation, institutionalization (eg, an orphanage), or an abnormality of the central nervous system. The speech therapist may work with a neurologist or otologist in such cases.
Chaplain College graduate with theological or seminary education. Identifies the spiritual needs of the client and support persons and provides spiritual comfort as needed. If appropriately trained, a chaplain may act as a counselor. The chaplain may attend the intake interview and staff meetings to provide input about the client as well as to plan holistic health care.
Dietitian or clinical nutritionist Person with graduate-level education in the field of nutrition. The dietitian serves as a resource person to the multidisciplinary treatment team as well as a nutritional counselor for clients with eating disorders, such as anorexia nervosa, bulimia, pica, and rumination.
Auxiliary personnel Volunteers, housekeepers, or clerical help who come in contact with clients. Such persons receive in-service training on how to deal with psychiatric emergencies as well as how to interact therapeutically with clients.

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.

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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Jun 16, 2016 | Posted by in NURSING | Comments Off on The Therapeutic Milieu

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