Therapeutic milieu is “the controlled environment of treatment facilities that shelters patients from what they perceive to be painful and frightening stressors, thus providing them with a stable and coherent social environment that facilitates the development and implementation of treatment.” (Stuart, 2009)
The chief purpose of selecting this topic is that it is an exclusive way of dealing with patients problems, it offers chance to acquire adaptive coping skills and lets the patient to try these new coping skills in a protected, comfortable environment as well as it provides recreational, occupational, social, psychiatric, medical and nursing therapies. Secondly in Karwan-e-Hayat during my clinical I witnessed that a woman of middle age had an interfering attitude and used to force others for the activities that were held there. She used to get aggressive on every small thing and now and then becomes difficult to control. She was incapable of differentiating between acceptable and unacceptable behaviors in the hospital setting.
In Stuart 2009 it is cited that the idea of therapeutic milieu was coined by Abroms, 1969, which served the two main purposes. The first objective is setting limits on disturbed and maladaptive behavior. The intervention that could be helpful for patients for keeping maladaptive behavior under control and allowing treatment to progress includes the goal to control or setting limit on the maladaptive response but supporting the feeling that underlines the behavior, examining the behavior with the patient and identifying the consequences and convenient substitute approach, establishing a therapeutic association and working with patient to draw on any remaining parts of independence and strengths. Secondly it aims to teach patient the psychosocial skills. It comprises of orientation i.e. the patient has the knowledge and has understanding of the time, place, person and the purpose. For instance, introducing oneself, one’s role, and the rationale for an interaction helps in disoriented patients to have the mindfulness about their surroundings, Assertion i.e. supporting patients in expressing themselves effectively and in a socially acknowledged way over a specific topic or an issue. Some interventions includes assertiveness training groups, focus groups for lower functioning patients and interactive patients groups, Occupation i.e. the patient can feel confidence and success through the productive activity. Some interventions include individual or group hands-on-activities, jigsaw puzzles, physical skill development etc., Recreation i.e. providing patients a diversity of recreational opportunities and assisting patients to apply their learnt skills, comprising orientation, assertion, social interaction and physical dexterity. Some examples include informal games, brief outdoor walks etc. Thibeault CA in his article Understanding the milieu experiences of patients on an acute inpatient psychiatric units states that the inpatient milieu remains an important but often neglected component of psychiatric treatment as patients with acute and severe mental illness are admitted for short periods of intense treatment and are discharged quickly to community based care.
The milestone contribution in the concept of therapeutic milieu is associated with Henderson (1978) that was cited in Stuart 2009; he described the framework that have the five specific components of a therapeutic milieu that includes containment, support, structure, involvement and validation. Containment offers for the physical wellbeing of patients, it includes making the food, shelter, medical attention accessible and taking the necessary steps for averting the patient harming self or others. Therapeutic practice of containment communicates to patient that for keeping them and the environment safe the nurse will impose external controls, support includes the staff’s conscious efforts to help patients in feeling better and enhancing their self-esteem. It can be communicated through empathy, being available, offering encouragement and reassurance, giving helpful directions and engaging patients in doings that they are reluctant to do, promoting reality testing, and modeling healthy relationships. Milieu that offers support also provides nurturance and encourages patients in engaging in other therapeutic efforts. Structure denotes to all the aspects of milieu that is a predictable organization of time, place, and person. It helps patients to feel safe. Some features of structures includes having a predictable timetable of meetings, groups sessions, setting limits and use of contracts, token economies, and expectation of attendance of meetings and groups. The further these uses are planned with the patient according to the shared ideas of what is adaptive and maladaptive, the more the structure grows into therapeutic itself. Involvement refers to the course that helps the patient to enthusiastically attend to their social environment and interact with it. The chief purpose is to strengthen a patient’s ego and modify the maladaptive interpersonal patterns. Nursing interventions includes practice of open door and open rounds, facilitating patient-led-groups, activities and self-assertive experiences. Through this patients learn appropriate interaction patterns and experience the consequences of unacceptable behavior. It strengthens the patient’s sense of self, behavioral control, and social interactive skills. Validation means that the individuality and value of each patient are recognized. It helps patients to develop greater capacity for closeness and a more consolidated identity. Nursing examples includes individualized treatment planning, showing respect for a patient’s rights, and providing opportunities for the patient to fail as well as succeed.
One of the ancient advocates of the importance of the environment for nursing care was Florence Nightangle. Since that time the inpatient environment and milieu management have continued to be important aspects of the role of all nurses. It is essential that psychiatric nurses working in structured setting realizes the potential impact that the environment can have on the patient. Milieu management has been described as environmental manipulation that minimizes stress and results in optimal benefit to the majority of patients (Benson and Briscoe, 2003). The nurse can engage aspects of the therapeutic milieu to meet the patient’s needs by providing physical safety and wellbeing (containment), education about the patient’s illness and treatment plan (support), therapeutic and predictable activity schedules (structure), opportunities for social interaction (involvement), and acknowledge the patient’s feelings (validation). According to (Delaney and Johnson, 2007)” nurses face the challenge of better articulating the nursing component of the inpatient treatment program and what specifically they contribute to improving patient outcomes.”
Safety, Structure, Support, and Symptom management are clinical functions that help to organize nursing practice from individual and environment perspectives (Delaney et al, 2000).
In hospital based psychiatric nursing it is anticipated that nurses must have clinical knowledge and skills are capable to apply them for the wellbeing of patients and families. The milieu created by the psychiatric nurse’s struggles to provide patients with activities and interactions prudently planned to encounter their needs. This includes both direct and indirect psychiatric nursing care functions as well as dependent, independent, and interdependent features of psychiatric nursing practice. The ultimate goal of the milieu setting is to provide patients with a stable and coherent social environment that creates a safe and therapeutic space by which healing, recovery and growth can occur.