INTRODUCTION:

 Milieu is a French word derived from Mi means ‘middle’, lieu means ‘place’. So Milieu means environment or
setting. In psychiatric therapy involving the milieu or environment may be called milieu therapy, therapeutic
community, or the therapeutic environment.
 Most of the psychiatric illnesses occur because of an unhealthy environment. So a therapeutic environment
helps the patient to become socially productive individual.

DEFINITION:
 Milieu therapy: A scientific structuring of the environment in order to effect behavioral changes and to improve
the psychological health and functioning of individual (Skinner, 1979).
 Milieu therapy or therapeutic community approach attempts to make the maximum use of –
i. The social system and its constituents (i.e. the patient, his relatives ,neighbors
ii. Personnel and the hospital community (i.e. psychiatric, nurse, psychologist, social worker, other
patients) to modify the patient’s behavior so that he may manage his life and his personal relationship in
a more constructive manner.

HISTORICAL OVERVIEW:
 Milieu therapy came into its own during the 1960s through early 1980s.
 The term “milieu therapy” was coined in Germany in the early 1900s to describe a new hospital treatment for
psychiatric patients.
 It was first called activere behandlugen-more active therapy-and later, milieu therapie.
 Its main element was the active role taken by the nursing staff in working with patients. A forerunner of this
type of treatment was “moral treatment” , developed at the end of the eighteenth century. This marked the
beginning of kindly and humane treatment for psychiatric patients.
 Its founder, P. Pinel, created a revolution in his time by urging that the mentally ill be treated compassionately
and with understanding.
 During this period, psychiatric in patient provided sufficient time to implement programs of therapy that were
aimed at social rehabilitation.
 Nursing focus of establishing interpersonal relationships with clients fit well within the concept of therapy.
 Patients were encouraged to be active participants in their therapy, and individual autonomy was emphasized.
 During world war II to rehabilitate neurotic patient it was discovered that
o The program of treatment was more effective when careful attention was paid to the Milieu in which the
casualty was kept
o The social system I.e. the IPR of an attendant provided emotional support during stress
o Immediate treatment, if provided where close friends were also available, improved the daily activity of
the patient and reduce the length of disability
o An opportunity to ventilate or talk about frightening or anxiety provoking experience before or during
sickness was helpful to the patients.
 This basic approach was used in a psychiatric setting by bringing more interaction between the staff and patient
and was called THERAPUTIC COMMUNITY by Maxwell Jones(1953).
 Dr Jones wrote a book on social psychiatric which was published with a changed title ,
The Therapeutic Community (to start with it was a report of the Belmot hospital in England to rehabilitate
neurotic patient through the use of a group method during and after world war II)
GOAL OR PURPOSES:

 To minimize the anti therapeutic environment for the patient in the ward. For example , telling other nurses
that he is always sad let him stay in the bed only(example of therapeutic environment).
 To minimize prolongation of hospitalization by helping in early recovery.
 To minimize maladaptive behaviour. Creating an environment where maladaptive behaviour is discouraged.
 To provide a free and favourable climate in which the patient can talk and gain awareness of his own feelings,
impulses and behaviour
 To help the patent to improve his self esteem by helping him understand that he can also make decisions, can
take responsibilities and his activities are appreciated if he performs them well.

PRINCIPLES :

 The patient is involved in his own therapy.

 Decision making ability improves the self confidence of the patient.
 It provides an environment of free communication. Hospital authoritativeness is reduced.
 The patient is also directed to focus his attention not only on his own needs but also on the needs of other
patents.
 In a mental hospital or psychiatric ward, patients are away from society. So they feel isolated. Milieu therapy
reduces social isolation and dehumanization of a large hospital. In large hospitals it is difficult to maintain one-
to-one contact. Patients are considered as Bed No. Suffering from types of schizophrenia and not by name.
 It attempts to reduce the feeling in the patient about the supreme power of the doctor. The patient feels that
he can approach the doctor.
 Through the nurse sets limits and has various roles to play, still the patient considers her part of milieu in which
he is living. The nurse needs to be consistent in setting limits.
 Continuous assessment should be made to evaluate the progress of a patient. Modification should be made in
nursing interventions.

COMPONENTS OF MILIEU THERAPY:

1) MAINTAINING SAFE ENVIRONMENT: 

 Dispose of all needles safely and out of reach of client. 

 Do not allow smoking. 
 Restrict or monitor the use of matches and lighters. 
 Keep away sharp instrument from patient. 
 Identify potential weapons e.g. mop handles, hammers. 
 Do not leave medicines unattended or unlocked. 
 Be aware of items that are harmful if ingested, e.g. mercury in monometer.

2) THE TRUST RELATIONSHIP :

 One of the key to therapeutic environment is the establishment of trust. 

 Trust is the foundation of therapeutic relationship, and limit settings and consistency are its building blocks.

3) BUILDING SELF-ESTEEM :

 Set and maintain limits. 

 Accept the clients as a person. 
 Be non-judgmental at all times. 
 Structures the clients time and activities. 
 Initially provide the client with task, responsibility and activities. 
 Allow the client to make his own decisions whenever possible.

4) LIMIT SETTINGS :

 State the expectation or limits as clearly, directly and simply as possible.

 The consequence that will fallow the clients exceeding the limits also must be clearly stated at the outset. The
consequence should immediately follow the clients exceeding's the limits and must be the consistent, both over
time and among staff.

ADVANTAGES OF MILIEU THERAPY:

 Patient develops harmonious relationship with other members of the community.
 Gains self-confidence.
 Develop leadership skills.
 Learns to understand & solve problems of self & others.
DISADVANTAGES OF MILIEU THERAPY:

i. Role blurring between staff and patient.

ii. Milieu therapy is limited to only hospitalize patient.
iii. Role blurring between staff and patients 
iv. Individual needs and concerns may not be met. 
v. Patient may find the transition to community difficult.
vi. Low client-to-staff ratio.

ROLE OF NURSE IN MILIEU THERAPY:

1. Nurses are involved in all day-to-day activities that pertain to client care.
2. Suggestions and opinions of nursing staff are given serious consideration in the planning of care for individual
clients.
3. Nurses have input into therapy goals and participate in the regular updates and modification of treatment
plans.
4. Clients must be encouraged to perform as independently as possible in fulfilling activities of daily living.
5. ongoing assessments to provide assistance for those who require .
6. Assessing physical status is an important nursing responsibility that must not be overlooked in a psychiatric
setting that emphasizes holistic care.
7. Reality orientation for clients who have disorganized thinking or who are disoriented or confused is important
in the therapeutic milieu.
8. Clocks with large hands and numbers, calendars that give the day and date in large print, and orientation boards
that discuss daily activities and news happenings can help keep clients oriented to reality.
9. Nurses should ensure that clients have written schedules of activities to which they are assigned and that they
arrive at those activities on schedule.
10. Some clients may require an identification sign on their door to remind them which room is theirs.
11. On short-term units, nurses who are dealing with psychotic clients usually rely on a basic activity or topic that
helps keep people oriented.
12. A nurse participate in the design and or renovation of the settings can greatly affect the therapeutic physical
environment.
13. The nurse responsible for making the referrals, encouraging clients participation.
14. The coordinate all team member is involve in team.
15. The nurse may interpret the need of the client population for design expert with knowledge of colour.
16. The nurse control and set the limitations of the group.
17.  Thorough use of the nursing process, nursing manage the therapeutic environment on a 24- hours.
18. Nurses have the responsibility for ensuring that the clients psychological needs are met 
19. Nurses are also responsible for- 
a) Medication of administration 
b) development of a one-to-one relationship. 
 c) Setting limits on unacceptable behavior. 
d) Client education

PATIENT EDUCATION POINTS :

 Ways to improve self esteem

 Ways to manage anger appropriately
 Stress management
 Identify the increasing anxiety and reduce its progression.
 Normal stages of grieving and behaviors associated with grieving.
 Assertiveness techniques
 Relaxation techniques
 Medications
 Effects of substance on the body
 Problem solving skills
 Thought stopping and thought switching skills
 Good nutrition
 Parental guideline

SUMMARIZATION:
The word milieu is French for “middle.” The English translation of the word is “surroundings, or environment.” In
psychiatry, therapy involving the milieu, or environment, may be called milieu therapy, therapeutic community, or
the therapeutic environment.The goal of milieu therapy is to manipulate the environment so that all aspects of the
client’s hospital experience are considered therapeutic.  Milieu therapy came into its own during the 1960s through
the early 1980s. management of medication administration on inpatient psychiatric units. In some treatment
programs, clients are expected to accept the responsibility and request their medication at the appropriate time.
Encourage clients to be self-reliant. Nurses must work with the clients to determine methods that result in
achievement and provide positive feedback for successes.In patient education points-Ways to improve self esteem,
ways to manage anger appropriately, stress management, identify the increasing anxiety and reduce its progression.

CONCLUSION:
Milieu therapy is an approach in which there is maximum use of social system, hospital personnel and hospital
community to modify the patient’s behavior so that he may manage his life and his personal relationship in a more
constructive manner.

BIBLIOGRAPHY:
 Kapoor bimla, textbook of psychiatric nursing, kapoor publising house, 2nd edition,
page no 98-102.
 Ahuja nirja, a short textbook of psychiatric, jaypee publication, 17th edition, page no
396-398.
 https://www.google.com/search?q=milieu+therapy
 https://en.wikipedia.org/wiki/Milieu_therapy
 https://www.slideshare.net/kulthevikrant/milieu-therapy-111938631
 CONTENT:
 INTRODUCTION
 DEFINITION
 HISTORICAL OVERVIEW
 GOALS OR PURPOSES
 PRINCIPLES
 COMPONENTS OF MILIEU THERAPY
 ADVANTAGES OF MILIEU THERAPY
 DISADVANTAGES OF MILIEU THERAPY
 ROLE OF NURSES
 PATIENT EDUCATION POINTS
 SUMMARIZATION
 CONCLUSION
 BIBLIOGRAPHY