1. Milieu Therapy— The Therapeutic Community
Chapter 12
Milieu Therapy—
The Therapeutic Community

2. Introduction
“The psychiatric-mental health nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health care clinicians.”
Standard 5c of the American Nurses Association Standards of Psychiatric–
Mental Health Nursing Practice (2007)

3. Milieu, Defined
Milieu therapy, or therapeutic community, is defined as
“a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual”
Within the 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.

4. Current Status of Milieu Therapy
Milieu therapy came into its own during the 1960s, 1970s, and early 1980s when psychiatric inpatient treatment provided sufficient time to implement programs of therapy aimed at social rehabilitation.

5. Current Status of Milieu Therapy (cont.)
Although strategies for milieu therapy are still used, they have been modified to conform to the current short-term approach to care and to outpatient treatment programs.

6. Basic Assumptions of Milieu Therapy
The health in each individual is to be realized and encouraged to grow.
Every interaction is an opportunity for therapeutic intervention.
The client owns his or her own environment.
Each client owns his or her own behavior.
Peer pressure is a useful and powerful tool.
Inappropriate behaviors are dealt with as they occur.
Restrictions and punishment are to be avoided.

7. Conditions That Promote a Therapeutic Community
Basic physiological needs are fulfilled.
The physical facilities are conducive to achievement of the goals of therapy.
A democratic form of self-government exists.
Responsibilities are assigned according to client capabilities.
A structured program of social and work-related activities is scheduled as part of the treatment program.
Community and family are included in the program of therapy in an effort to facilitate discharge from treatment.

8. The Program of Therapeutic Community
Care is directed by an interdisciplinary team.
A comprehensive treatment plan is formulated by the team.
Team members of all disciplines sign the plan and meet regularly to update the plan as needed.
Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy, recreational therapy, art therapy, music therapy, dietetics, and the chaplain’s service.

9. The Program of Therapeutic Community (cont.)
Which of the following best describes the role of the psychiatric social worker as a member of the interdisciplinary treatment team?
A. Provides ongoing assessment of client’s mental and physical condition
B. Functions under the supervision of the psychiatric nurse
C. Serves as the leader of the treatment team
D. Conducts individual, group, and family therapy

10. The Program of Therapeutic Community (cont.)
Correct answer: D
The psychiatric social worker is a member of the interdisciplinary treatment team and conducts individual, group, and family therapy.

11. Role of the Nurse
Through use of the nursing process, nurses manage the therapeutic environment on a 24-hour basis.
Nurses have the responsibility for ensuring that the client’s physiological and psychological needs are met.

12. Role of the Nurse (cont.)
Nurses are also responsible for:
Medication administration
Development of a one-to-one relationship
Setting limits on unacceptable behavior
Client education

13. Role of the Nurse (cont.)
A client, diagnosed with borderline personality disorder, approaches the nursing station often with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?
A. Providing reality orientation
B. Ensuring physical need fulfillment
C. Setting limits on behavior
D. Providing client education

14. Role of the Nurse (cont.)
Correct answer: C
In this situation the nurse is responsible for setting limits on unacceptable behavior in the therapeutic milieu. Consistency in carrying out the consequences of violation of the established limits is essential if learning is to be reinforced.