Chapter 12  The Therapeutic Milieu

1. Chapter 12The Therapeutic Milieu

2. 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. Schultz & Videbeck, 2009

3. Learning Objectives • After studying this chapter, you should be able to • Explain the concept of milieu therapy • Articulate the standards for a therapeutic milieu or environment as set forth by the JCAHO • Describe the components of the therapeutic milieu • Identify participants in the therapeutic milieu or environment • Discuss the role of the psychiatric–mental health nurse in the therapeutic milieu or environment

4. Learning Objectives (cont.) • Formulate a list of educational strategies to promote client education • Explain the importance of providing interventions to meet a client’s spiritual needs • Create a list of nursing interventions to promote an optimal balance of rest and activity

5. Learning Objectives (cont.) • Articulate the rationale for pain management in the therapeutic milieu or environment • Explain the rationale for the use of seclusion and restraints • Recognize examples of behavior therapy techniques • Distinguish clients who would benefit from participation in occupational, educational, art, music, or recreational therapy

6. Therapeutic Milieu • It is an environment structured to provide clients with the opportunity to practice interpersonal relationship skills, provide feedback to peers about behavior, and work together to develop problem-solving skills. • Hospital • Community • Home • Private practice of a counselor or therapist

7. JCAHO Criteria for Establishing a Therapeutic Milieu • Provide safety from physical danger and emotional trauma; provide for privacy and physical needs • Promote interaction and communication among clients and personnel • Provide a testing ground for new patterns of behavior • Provide for consistent limit-setting • Encourage participation in group activities and free-flowing socially acceptable communication • Provide for client respect and dignity, encouraging the use of personal resources to resolve problems or conflicts • Convey an attitude of overall acceptance and optimism • Allow for continual assessment and evaluation of clients’ progress, with modifications in treatment and nursing interventions as needed

8. Interventions Used in the Therapeutic Milieu • Client education • Spiritual interventions • Personal and sleep hygiene management • Pain management • Protective care • Behavior therapy • Adjunctive or management therapy • In shape

9. Educational Strategies • Prioritize the client’s needs, and focus on everyday issues. • Present specific information. • Use simple language, and avoid speaking in a monotone. • Utilize different educational approaches. • Involve family members and support persons. • Educate and reinforce information while providing care.

10. Protective Care (Use of Restraint or Seclusion) • Physician or other licensed independent practitioner (LIP) must perform a face-to-face assessment within the first hour after emergency application. An initial order is good for four hours. • After the first four-hour order expires, a qualified RN or other qualified staff member reevaluates the client’s need for continuation of restraint or seclusion. • If restraint or seclusion is still deemed clinically necessary, the LIP orders an additional four hours. • Following the eight-hour period of restraint or seclusion, the LIP conducts another in-person reevaluation. If necessary, another (3rd) four-hour order is written. • This cycle continues as long as the client requires restraint or seclusion. • If a client requires continuous uninterrupted monitoring to ensure safety, the in-person observer must have direct eye contact with the client. • If a client requires continuous uninterrupted monitoring to ensure safety, the in-person observation can progress to audio and visual monitoring after the first hour in seclusion.

11. Nursing Interventions in Protective Care • Assess and assist with signs of injury associated with the application of restraint and seclusion • Nutrition and hydration • Circulation and range of motion in extremities • Vital signs • Hygiene and elimination • Physical and psychological status and comfort • Readiness for discontinuation of restraint and seclusion • Visual checks

12. Behavior Therapy • Behavior modification • Aversion therapy • Cognitive–behavior therapy • Assertiveness training • Implosive therapy • Limit-setting

13. Principles of Behavior Therapy (Rowe, 1989) • Faulty learning can result in psychiatric disorders. • Behavior is modified through the application of principles of learning. • Maladaptive behavior is considered to be deficient or excessive; thus, behavior therapy seeks to promote appropriate behavior or decrease or eliminate the frequency, duration, or place of occurrence of inappropriate behavior. • One’s social environment is a source of stimuli that support symptoms; therefore, it also can support changes in behavior through appropriate treatment measures.

14. Evaluation of the Therapeutic Milieu • The Ward Atmosphere Scale (WAS), which consists of 10 subscales, can be used to evaluate the effectiveness of a therapeutic milieu. • The WAS is appropriate for evaluating therapeutic milieus in inpatient settings, partial hospitalization programs, day-treatment centers, and community-based mental health programs.

15. Key Terms • Flooding • Implosive therapy • Limit-setting • Milieu therapy • Nurse-led psychotherapy interventions • Pavlov’s Theory of Conditioning • Activities of daily living • Assertiveness training • Aversion therapy • Behavior therapy • Cognitive–behavior therapy

16. Key Terms (cont.) • Spirituality • Systematic desensitization • Therapeutic lifestyle change (TLC) counseling • Therapeutic milieu • Ward Atmosphere Scale • Protective nursing care • Religion • Skinner’s Theory of Operant Conditioning • Sleep pattern disturbance • Spiritual distress

17. ? Reflection Interview three members of the staff who work with clients in your current clinical area (the members may represent different disciplines such as nursing, social services, or occupational therapy). Ask each of them to describe his or her perceptions of a therapeutic milieu. • Do they have similar perceptions? If not, how do their perceptions differ?