NURSES' ROLE IN MILIEU THERAPY

INTRODUCTION

Milieu is the French word for “middle” – in English translation, the word milieu means “surroundings, or
environment.”

Milieu therapy is the treatment of mental disorder or maladjustment by making substantial changes in a
patient's immediate life circumstances and environment in a way that will enhance the effectiveness of
other forms of therapy.

The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital
experience are considered therapeutic.

Within this therapeutic community setting the client is expected to learn adaptive coping, interaction
and relationship skills that can be generalized to other aspects of his or her life.

MEANING

The word milieu is French for “middle”. The English translation of the word is surroundings or
environment. Milieu therapy is the scientific planning of an environment for therapeutic pu poses.

DEFINITION

A scientific structuring of the environment in order to effect behavioral changes and to improve the
psychological health and functioning of the individual (Skinner, 1979).

HISTORY

Late 1700 s: Pinel (in France) coined the term “moral treatment” to describe his new approach to
psychiatric care, which included removing chains, using attitudes, and setting examples of appropriate
behavior and humanitarianism.

Early 1800s: Tuke (in England) established the York retreat based on atmosphere of kindness,
meaningful employment of time, regular exercise, family environment, and the treatment of clients as
guests.

Late 1800s: the service pattern in psychiatric institutions was the domestic service pattern in which care
was custodial and the staff performed essentially house keeping tasks.

Early 1900s: attention to hospital atmosphere declined, resulting in the development of environments
that were benignly custodial or more destructively controlling, much like a prison.

1930: Sullivan began to experiment again with varying the treatment milieu by selecting the staff
members who were sympathetic and interacted well with the patient.
1939: Menninger and others developed prescribed attitudes based on psychoanalytical principles that
determined staff interaction patterns.

1940s: the predominant service patterns was the medical intervention pattern in which staff, including
nurses, served as the physicians agents in providing care.

1946: Main ‘coined the term “therapeutic community” to describe the approach of resocialization of
neurotic individuals through social interactions.

1948: Bettleheim’ coined the term Milieu therapy to describe his use of the total environment for
treatment of disturbed children.

1953: Max Well Jones used the therapeutic community approach in two experimental units for the
treatment of antisocial personality disorders in which the social environment was seen as the primary
treatment modality.

1990s: the development of milieu therapy based on research to identify the milieu structure most
effective for specific treatment groups.

Future: Better integration of hospital and community psychiatry will provide for more efficient and
more effective care for the mentally ill in the community.

BASIC ASSUMPTIONS

Skinner outlined seven basic assumptions on which a therapeutic community is based:

The health in each individual is to be realized and encouraged to grow: all individuals are considered to
have strengths as well as limitations. These healthy aspects of the individual are identified and serve as a
foundation for growth in the personality and in the ability to function more adaptively and productively
in all aspects of life.

Every interaction is an opportunity for therapeutic intervention: within this structured setting, it is
virtually impossible to avoid interpersonal interaction. The ideal situation exists for clients to improve
communication and development relationship skills. Learning occurs from immediate feedback of
personal perceptions.

The client owns his or her own environment: client makes decisions and solves problems related to
government of the unit. In this way personal needs for autonomy as well as needs that pertains to the
group as a whole are fulfilled.

Each client owns his or her behavior: Each individual within the therapeutic community is expected to
take responsibility for his or her own behavior.
Peer pressure is a useful and a powerful tool: Behavioral group norms are established through peer
pressure. Feedback is direct and frequent, so that behaving in a manner acceptable to the other
members of the community becomes essential.

Inappropriate behaviors are dealt with as they occur: Individuals examine the significance of their
behavior, look at how it affects other people, and discuss more appropriate ways of behaving in certain
situations.

Restrictions and punishment are to be avoided: Destructive behaviors can usually be controlled with
group discussion. However, if an individual requires external controls, temporary isolation is preferred
over lengthy restriction or other harsh punishment.

GOALS OF MILIEU THERAPY

Manipulate the environment so that all aspects of client’s hospital experience are considered
therapeutic.

Client is expected to learn adaptive coping, interaction and relationship skills that can be generalized to
other aspects of his or her life.

Achieving client autonomy

PRINCIPLES OF MILIEU THERAPY

To promote a fundamental respect for individuals (both clients and staff).

To use opportunities for communication between client and staff for maximum therapeutic benefit.

To encourage clients to act at a level equal to their ability and to enhance their self esteem( autonomy is
reinforced)

To promote socialization.

To provide opportunities for clients to be part of unit management.

Individuals are held responsible for own actions.

Peer pressure is utilized to reinforce rules and regulations.

Team approach is used.

Group discussions and temporary seclusions are favoured approaches for acting out behaviour.

The nurses function is to act in ways that consistently promote these goals.

Characteristics of milieu therapy:

The concept of milieu therapy developed from a desire to counteract the negative, regressive effects of
institutionalization: reduced ability to think and act independently, an adoption of institutional values
and attitudes, and loss of commitments in the outside world.

Several strategies have been developed to counter these negative effects. They include

Distribution of power

Open communication

Structured interactions

Work- related activities.

Community and family involvement in the treatment process

Adaptation of the environment to meet developmental needs.

Distribution of power

The milieu therapy approach involves “flattening” the control hierarchy so all participants have a voice in
decision making. This process may include the whole population of the treatment unit, or a governing
council may take the final decisions based on input from various smaller groups of clients and staff
members.

The ultimate goal of any treatment program is client autonomy. This may be achieved through a
stepwise progression through a number of treatment programs or by gradually increasing independence
within a given program. Consciously incorporating a plan for increasing independence is a means to
achieve client autonomy.

Open communication:

Although the importance of open communication has been widely recognized in literature, it is still not a
reality in many settings. One reason for this may be the insecurity of persons in the authority. Open
communication requires risk taking. Questioning and criticism may be threatening, where as there is
little to risk if no feedback is allowed. Cultural norms, personal defenses and established communication
patterns may block the communications.

In the therapeutic milieu, treatment decisions are often made by the clients themselves, who therefore
need information to make effective decision. It is not necessary to communicate personal information
but clients and staff need to be aware of individual treatment goals to ensure everyone is working
towards the same goal. In this atmosphere, exclusive confidentiality is replaced by mutual trust, honesty
and open communication.

Structured interactions
K.A Menninger pioneered the concept of structured interaction patterns in the form of attitude therapy.
An advantage of the structured interaction approach is that all staff members approach the client in a
consistent manner, acknowledging specific diagnostic areas, thereby shortening treatment time.

The difficulty with this approach is that once a diagnosis is made and an attitude prescribed there is little
flexibility in the interaction pattern. Day- to day fluctuations in the client’s condition may not be
accounted for, and some staff members sometimes seem stilted in their response to clients.

Work related activities:

The focus of these activities is on benefits to the client rather than to the agency. Work under realistic
circumstances and for appropriate rewards is probably the best central activity for all clients. Several
factors contribute to effective work therapy programs.

First, clients need to choose the type of work they wish to perform

Second, work activities should be geared toward developing skills that will be useful in actual job
situations. The current trend is to place clients on the job and provide funds for staff support in the work
environment.

Third, a variety of activities provides the opportunity to test different areas for future job interests.

Community and family involvement:

As a result of more effective medications and humane treatment philosophies, community mental
health centers emerged. Hospitalization is considered desirable only for acute illnesses. For easy
accessibility, mental health centers are placed conveniently within a neighborhood.

According to milieu therapy approach, clients are kept in their usual environment, for example, a day
treatment center or halfway house, and continue most of their routine activities while receiving
treatment. If one family member is hospitalized, an attempt is made to continue family involvement.
This is an effective way to improve family interaction and minimize the isolation resulting from
hospitalizing one family member.

Adaptation of the environment to meet the developmental needs:

To develop his full potential an individual must have an environment adapted to his current needs.
Adapting the environment to meet these multiple needs is challenging due to the extension of milieu
therapy to all age groups and the inclusion of family members with individuals of varying ages within the
treatment milieu.

Clients who are regressed or who are overwhelmed need more structure and support; other clients
benefit from a program that promotes autonomy and responsibility. A program that provides stepwise
increase in responsibility would be an effective solution.
Progressive levels of responsibility according to client’s self care capacity:

Level I: Displays a destructive behavior to self, others, or the environment.

Disoriented to time, place and person.

Unable to function in group therapy.

Exhibits poor personal hygiene.

Level II: Does not display destructive behavior.

Knows the current time, date and place.

Attends at least one therapeutic group daily.

Attempts to maintain good personal hygiene

Level III: Attends All Therapeutic Activities.

Participates actively in the Community Meetings and serves on at least one client committee.

Develops a self-directed behavior plans to change or resolve a personal problem.

Knows the names of all medications and the times they are to be taken.

Participates in a family session.

Level IV: Takes an active role in assisting other clients to gain level changes.

Demonstrates willingness to serve as an officer on the client committee.

Assumes a leadership role in the community, acts as a positive role model, and ensures that other
clients are prompt in their attendance of regularly scheduled activities and group meetings.

Initiates discussions with the mental health team concerning discharge planning.

One approach to differing levels of responsibilities is to divide the clients into small groups according to
their developmental needs. More regressed clients focus on physical and safety needs, and more
advanced individuals concentrate on social, esteem and self- actualizing needs. Individuals progress to
more advanced levels as their needs indicate.

Key concepts of milieu therapy:

Containment

Validation

Structured interaction
Open communication

Containment:

is the process of providing safety and security and involves the patient’s access to food and shelter. In a
well contained milieu, patient feels safe from their illnesses and protected against social stigma. Most
facilities encourage patients and nursing staff to wear street clothes, which helps decrease the
formalized nature of hospital settings and promotes nurse- patient relationships. Therapeutic milieu
emphasises patient involvement in treatment decisions and operations of the unit. Families are viewed
as a part of patient’s life, and ties are maintained.

Validation:

it is another process that affirms patient individuality. Safe- patient interactions should constantly
reaffirm the patient’s humanity and human rights. Any interaction a staff member initiates with a
patient should reflect his or her respect for that patient.

Structured interaction:

purposeful interactions that allows patients to interact with others in a useful way. The daily community
meeting provides structure to explain unit rules and consequences of violations.

Open communication:

in this staff and patient willingly share information. Staff members invite the patient’s self disclosure
within the support of a nurse- patient relationship. In addition, they provide a model of effective
communication when interacting with one another as well as with patients. Support, attention, praise
and reassurance given to patients improve self esteem and increase confidence.

Programs within the milieu:

Client government

Structured meeting

Clients have inputs into all unit activities.

May make decisions related to privileges for other clients.

Discussion of the problems of everyday living

Usually meets once per week.

Work related activities:

Work therapy

Monetary reward
Client should choose the type of work.

Offer a variety of activities

Characteristics of the milieu therapist:

A productive therapist

Shares problems within a context that will benefit others.

Recognizes the risks involved in honest communication and works to minimize these risks.

Communicates an empathetic understanding of others problems.

Is warm and supportive without excessive attachment.

Accepts responsibilities for own actions and admits mistakes.

Works to solve problems independently, asks for assistance when problems exceed own scope or
resources.

Is self- directed in selecting activities that contribute to organizational goals.

Believes that others enjoy work and responsibility when given the opportunity to participate in goal
setting.

Sees their contribution in terms of the whole, not only on the task.

Works with others to achieve consensus in decision making.

Shares information at the appropriate time and with the appropriate people.

Acknowledges anxiety and uses resources to cope effectively.

Seeks feedback about abilities and performance.

Has a sense of self- worth and self- respect.

Readily adapts to change.

Functions comfortably in various roles, acts as either a leader or a follower as the situation dictates.

Accepts conflicts and confrontation as normal aspects of life and handles them effectively.

Believes that all people can change, grow and function more effectively.

The inter disciplinary treatment team

Care of the clients in the milieu therapy is directed by an interdisciplinary treatment team. They include:
Psychiatrist, Clinical psychologist, Psychiatric clinical nurse specialist, Psychiatric nurse, Mental health
technician (psychiatric aide or assistant or psychiatric technician), Psychiatric social worker,
Occupational therapist, Recreational therapist, Music therapist, Art therapist, Psyhcodramatist, Dietitian
and Chaplain.

NURSING PROCESS

The physical, intellectual and social aspects of the environment all contribute to the emotional
atmosphere.

Physical dimension:

the physical aspects of the treatment environment include all concrete features of the external world.
These features include the organization, structure and interaction of many spatial components. The
study of this interrelationship, called proxemics, is subdivided into three aspects: fixed feature space,
semi fixed feature space and informal space.

Fixed feature space:

the internal and external design of a building and its relationship to other buildings and environmental
factors constitute the fixed or permanent elements in space. The arrangements of these elements
strongly affect interactions that strongly affect interactions that influence therapeutic outcomes.

Semi fixed feature space:

objects that have some degree of mobility are regarded as semi fixed. These are the props that promote
a certain degree of freedom within the environment such as furniture, partitions, folding doors, and
planters.

Certain furniture arrangements (long bunches found in railway stations), while others (tables at a side
walk café) tend to pull people together. Those who sit at the corners of a table at right angles to each
other tend to speak more than those sitting next to each other and more than those sitting across the
table from each other.

Informal space:

informal space, or personal distances maintained in interpersonal encounters, is probably the most
significant use of space for the individual. The proper distance between persons varies by culture.

Nurse’s role:

A nurse participating in the design or renovation of the setting can greatly affect the therapeutic physical
environment. A nurses input concerning the number of activities and interactions that occur in a
dayroom can determine if the design is functional. Shower curtains, lockers for personal items, bulletin
boards to display personal art work and pictures, and bed side lamps can be added at little costs.
Intellectual dimension:

the intellectual aspects of the environment are an extension of the physical properties. They include
color, sound, texture, temperature, odor and taste. The clarity of the intellectual environment is
determined by the amount and clarity of sensory stimulation. The number of stimuli becomes a problem
at either end of the continuum- excessive stimuli (sensory overload) or lack of stimulation (sensory
deprivation).

Design features:

several design features can be used to promote orientation. Patterns in floor coverings and furnishings
may be used to identify personal space. These can serve as orientation supports to assist confused
individuals in identifying their special relationship to others. Perceptual clarity is especially important for
stairways to prevent accidents resulting from confusion.

Nurse’s role: the nurse may interpret the needs of the client population for design experts with
knowledge of color, texture and lighting. All these factors combine to promote perceptual clarity and
orientation. The nurse is often responsible for making referrals, encouraging client participation and
coordinating the team members involved.

Social dimension:

the social system of a treatment milieu includes the roles of individual members, the organization of
these roles into a social system based on leadership style, communication patterns that develop, and
staff/ client ratio. The function of the care giver is to respond to the needs of the client who is seeking
assistance. Although each of the care giver roles described has separate functions, many of them
overlap. The delegation of specific functions is largely determined by the social structure and leadership
style of the treatment setting.

Communication patterns:

several patterns have been identified: fan, chain, ring, wheel, and all- channel.

In the fan pattern messages originates at one source and are directed downward to several receivers
who do not interact with each other. They may only respond to the central message sender.

In the chain pattern messages are initiated at one point and are passed from one receiver to the next
until the messages reaches the end of the chain. Feedback must receive through the reverse sequence
of receiving.

The ring pattern is similar to the chain pattern except that the last receiver reports to the sender.
Messages and feedback follow a cyclical pattern
In the wheel pattern messages originates at a central position. Interaction may occur between the
message sender ad any one of the receivers positioned next to each other.

In the all channel patterns, messages may originate at any point and all members may interact.

The fan network is most likely to develop in groups with autocratic leadership, chain and ring networks
are common with laissez-faire leadership and wheel and all- channel communications are most common
in demographic groups.

The network communications also affects the roles within a group. Group morale is affected by
communication networks. As part of communication process it is important to distinguish between
constructive and destructive conflicts and to intervene to promote to promote constructive conflict
resolution.

Staff/client ratio:

a concrete factor that affects social interaction in a treatment setting is the staff/ client ratio. Moos
“found that more clients per staff member on a psychiatric ward, the more emphasis that was placed on
staff control and less on support and spontaneous communication. He concludes that a decreased
number of staff members and an increased number of clients will have several negative effects:

1. There is greater pressure to develop a more rigid structure.

2. Staff members need to control and manage is increased.

3. The degree of client independence and responsibility, the amount of support given, and the
involvement of staff members with clients are decreased.

4. There are fewer spontaneous interactions between clients and staff.

5. There is decreased understanding of client’s personal problems and less open handling of angry
feelings.

Thus the staff/ client ratio is extremely significant in developing positive social interactions.

Nurse’s role: intervening communication pattern effectively is the most significant role of a nurse.

Emotional dimension:

the emotional atmosphere can be sensed almost immediately when one enters a treatment setting.

Types and characteristics of emotional atmosphere.

Rewarding: when members have worked together well on the task they set for themselves, they feel
that they have gained from the experience. The members may feel rewarded if they have accomplished
something; even though the task is still incomplete.
Sluggish: often members try hard to deal with the tasks at hand but ‘just can’t get going.

Cooperative: members work together harmoniously. Members seem to share goals and support one
another in attaining goals.

Competitive: several members seem out to win their own points, with the result that the action can only
proceed out of a win- lose approach.

Play: play is the opposite of being task oriented. It exists when the members avoids the tasks and cannot
seem to shake off a light hearted, non-serious attitude long enough to get anything done.

Work: when the members devote themselves to task in a purposeful manner, the atmosphere is one of
work. This may be true regardless of what other impressions results as well; for example it is possible to
fight or not accomplish the task and still work hard.

Fight: often members find themselves in a complete disagreement regarding the topic to be discussed,
decision to be made or action to be taken.

Flight: members pursue inappropriate or outside topics, horseplay, or a bull session as means of
avoiding the real task at hand., which may be threatening or at hand.

Tense: members feel pressures from limited time, conflict between members, or personally threatening
topics.

Relaxed: members work together in a harmonious manner with little tension or conflicts.

Cold: insensitivity to emotional needs is apparent. Defense mechanisms are used to avoid contact.

Warm: an emotionally support climate that promotes appropriate expression of feelings and the
development of mutual trust.

Nurse’s role: in the treatment setting all the group members can be motivated to work toward the
common goal of improved mental health.

Spiritual dimension:

although providing a specific place for worship is important, the entire treatment environment can
provide the background for meeting the spiritual needs. Important in this assessment is the provision of
quiet spaces and opportunities relating to nature and other people.

Nurse’s role: The nurse must make sure that physical environment is structured to provide both private
places for contemplation and reflection and larger areas for group interaction.

EVALUATION OF A THERAPEUTIC MILIEU

Evaluation of a therapeutic milieu is based on observation of observation of desired outcomes. Several

scales have been developed to objectify observations. These can be effective in both assessment and
evaluation. Some of the scales for evaluation of therapeutic environment includes: behavioral mapping
by Ittleson, Rivlin, and Proshansky, which consists of eighteen categories of observable behavior.

Ward atmosphere scale by Moos. (Order and organization, clarity of expectations, staff control,
autonomy, practical orientation, personal problem orientation, involvement support, spontaneity,
anger, aggression.)

ADVANTAGES AND DISADVANTAGES OF MILIEU THERAPY

The therapeutic and anti therapeutic effect of milieu therapy will depend on the hospital setting. If the
hospital organization believes in this type of approach for mentally ill patients, the effect can be
achieved. Otherwise it is difficult for a unit to achieve these goals. In our country it may be difficult for a
unit to achieve these goals. In our country it may be difficult initially but once the hospital gets to know
the advantages for the patients, such an approach will be practical.

ADVANTAGES

Milieu therapy creates a different type of attitude and behaviour in the patient because the
environment is like home.

Instead of adopting a sick role, the patient makes decisions in the ward management and cares for other
patients. In other words, he becomes less dependent and passive.

The patient learns to adopt a behaviour which is acceptable in the therapeutic environment like learns
to control hostility.

The patient learns to make decisions which improves his self confidence.

Milieu includes safe physical surroundings, al the treatment team members, and other clients, which is
supported by clear and consistently maintained limits and behavioural expectations.

A therapeutic milieu is a safe space, a non punitive atmosphere, which minimize the environmental
stress and provides a chance for rest and nurturance of self, a time to focus on the developments of
strengths, and an opportunity to learn to identify alternatives or solutions to problems and to learn
about the psychodynamics of those problems.

Patient develops harmonious relationships with other members of the community.

Develops leadership skills.

Becomes socio centric.

Learns to live and think collectively with the members of the community.

DISADVANTAGES

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.

Milieu therapy is limited to only hospitalized patients.

Conflict resolution is needed as part of the staff’s skills.

Low client- to- staff ratio.

Requires continuous open communication among all staff and clients.

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