CHAPTER 23: INTRODUCTION TO MILIEU MANAGEMENT
• 1953 –wrote the book “THE
PURPOSES:
• To help patients recover from
psychiatric and mental health
problems
• To protect patient from destructive
influences
• To maximize opportunities for patients
to learn about themselves and their
problems in daily living
THERAPEUTIC ENVIRONMENT &
THERAPEUTIC MILIEU
• Used interchangeably to describe
atmosphere of psychiatric unit
THERAPEUTIC MILIEU
• Formalized treatment modality called
MILIEU THERAPY
• Term Milieu Therapy has faded as era
of psychobiology has come to
dominate psych treatment
philosophies and inpatient treatment
have become centers of intervention
THERAPEUTIC ENVIRONMENT
• Term preferred now because it
acknowledges that site of treatment is
supposed to be therapeutic regardless
of specific treatment modality
• Avoids conveying idea that milieu
therapy is still practiced as intended
• All treatment environment affect
patient care so environment can be
therapeutic or non-therapeutic
HISTORICAL BACKGROUND
CUSTODIAL CARE
• Norm in inpatient settings
• Referred to mind-set in which patient
care focused exclusively on patient’s
activities of daily living (hygiene,
nutrition, elimination, safety needs)
• A paternalistic system in which staff
knew best what patient needed
AFTER WORLD WAR II
• Professionals began to be concerned
that an opportunity to enhance
treatment was being missed by not
taking advantage of potentially
therapeutic time
MAXWELL JONES
THERAPEUTIC COMMUNITY”, described
benefits of an
environment that was therapeutic in
and of itself
• He proposed patient involvement in
decision making thru daily group
meetings, termed THERAPEUTIC
COMMUNITY MEETINGS
THERAPEUTIC COMMUNITY MEETINGS
• Patients participated in planning ward
activities; they were expected to take
active role in treatment
• Replaced paternalistic system of
treatment team knows best
NOTE: Even if treatment program is not
using milieu therapy, a treatment
environment is still supposed to be
therapeutic
JOINT COMMISSION ON THE
ACCREDITATION OF HEALTHCARE
ORGANIZATIONS (JCAHO):
ENVIRONMENT OF CARE ISSUES
GOAL OF MANAGEMENT OF ENVIRONMENT:
• To provide safe, functional, supportive
and effective environment for
patients, staff members, and other
individuals in hospital
JCAHO ENVIRONMENT OF CARE STANDARDS
(BOX 23-1)
ENVIRONMENTAL SAFETY IS ATTAINED THRU:
• Ongoing assessment and maintenance
of equipment
• Hazard surveillance
• Reporting investigation of safety
issues
• Monitoring of safety management
techniques and procedures
• Orientation programs that address
safety issues
A HEALTHCARE FACILITY ENSURES THE
SECURITY OF ALL PEOPLE THRU:
• Mechanisms for addressing security CURRENT RESEARCH: WHAT’S THERAPEUTIC
issues ABOUT THERAPEUTIC MILIEU?
• Provision of appropriate identification
for all staff PURPOSE:
• Security orientation programs • To provide a refuge from self-
• Mechanisms for handling emergencies destructiveness
• Mechanisms for interacting with the
media
3 INTERRELATED THEMES IN REFUGE FROM
SELF-DESTRUCTIVENESS:
THE SOCIAL ENVIRONMENT MUST PROVIDE:
1) LIKE ME/NOT LIKE ME
• Space for storage of grooming and
hygiene articles • Identity was affirmed amid
kindred souls
• Closet and drawer space for personal
property • There was bonding that most
did not experience in outside
• Clothing that is suitable for clinical
world –that is, when not in the
conditions
hospital

2) POSSIBILITIES/NO POSSIBILITIES
THE PHYSICAL SETTING MUST PROVIDE:
• Hospitalization opened
• Adequate privacy to ensure respect
possibilities for future
for patients
• Participants described feeling
• Door locks consistent with program
more levelheaded, straightened
goals
out, and back in balance again
• Availability of telephones that allow for
• Patients feared of being
private conversations
released from safe hospital
• Sleeping rooms with doors for privacy
environment
unless clinically contraindicated
• Furnishings suitable to population 3) CONNECTION/DISCONNECTION
served
• Refers to patients’ experiences
• Access to outdoors unless within milieu of connecting or
contraindicated for therapeutic failing to connect with other
reasons people
• Socialization was valued by
patients
NURSING AND THE THERAPEUTIC
• Patients perceived PEER-
ENVIRONMENT
ADMINISTERED THERAPY as
most beneficial aspect of their
FLORENCE NIGHTINGALE
hospitalization
• Recognize the importance of
• They expressed longing for
environment on patient’s recovery
deeper connection with staff
WHY DOES PATIENT BENEFIT FROM • They did not gain greater
THERAPEUTIC ENVIRONMENT? understanding of their
dysfunctional patterns of
• Because it provide opportunities to try
behavior although their needs
out new behaviors and solve problems
for safety, structure and
in real situations with others
medications are met
WHY DOES NURSE BENEFIT FROM
MENTAL WORK
THERAPEUTIC ENVIRONMENT?
• Large part of work required of
• Because positive nurse-patient
psychiatric nurses and is very active,
relationship contribute to professional
carefully coordinated and thought-out
satisfaction and knowledge that she or
process
he has made a difference

HOW TO KEEP ENVIRONMENT THERAPEUTIC?
• By paying attention to one’s personal
values, reactions, and preconceptions
• Elements of treatment environment
o Safety
o Structure
o Norms
o Limit setting
o Balance
ROLE OF NURSES:
• Identify elements to begin
comprehend the types of
competencies required of psychiatric
nurse
SIGNALS THAT ENVIRONMENT IS NOT
THERAPEUTIC:
• Nurses rarely leave nursing station
(except in event of crisis or medically
prescribed treatment)
• Excessive television watching by
patients
ELEMENTS OF THE TREATMENT
ENVIRONMENT
1) SAFETY
• Primary to all other aspects of
environment
• Cannot be fully accomplished
unless nurse are regularly out
among patients in environment
• Nurses must be attentive to
complaints of abuse made by
patients
• Includes both physical and
psychological protection
PHYSICAL PROTECTION
• Safety from physical harm thru
management risks in
environment
PSYCHOLOGICAL PROTECTION
• Involves nurses’ active
intervention to prohibit verbal
abuse, ridicule, or harassment
of patients
2) STRUCTURE
• Refers to physical environment,
rules and daily schedules of
treatment activities
• Essential component of
psychiatric treatment because
w/o it there is no justification for
patient being in a treatment
environment
• Opportunities for recreation
help provide structure to
treatment environment
• Physical design is also an
aspect of structure
• Adequate space, areas of
socializing and receiving
visitors, telephones, and areas
of privacy are all required
elements
• Physical structure can constrain
or enhance nursing care of
patients
3) NORMS
• Specific expectations of
behavior that permeate
treatment environment
• Intended to promote safety and
trust thru sanctioning of socially
acceptable behaviors and
consistency about what to
expect
• Attempt to create environment
that is more predictable and
applicable to all who share
environment
4) LIMIT SETTING
• Important element of treatment
environment and is related to
norms
• Limits should be set on acting-
out behavior such as:
o self destructive acts
o physical aggressiveness
o sexual behavior
• It is necessary to set limits on
behaviors such as:
o excessive requests
o attempts to overly
personalize therapeutic
relationship
o refusal to participate in
treatment activities
• Rules are closely related to limit
setting
• It reinforces norm of making
rules and expectations clear
and also encourages milieu
 therapy concept of
“responsibility for self”
• Written copies of unit rules
should be provided to each
patient and should be posted on
unit or patient’s room
• PURPOSE: to assist patients with
behaviors that get in the way of
their recovery

5) BALANCE
• Represents value of developing
expertise in nursing
• Involves process of gradually
allowing independent behaviors
in dependent situation
• Nurse has to balance patient’s
personal rights with those of
other patients

NURSE AS MANAGER OF THE

TREATMENT ENVIRONMENT

ENVIRONMENTAL MODIFICATION
• Important intervention of psychiatric
nurse
• Entails using elements of safety,
structure, norms, limit setting, and
balance to facilitate meeting patients’
treatment goals
• Thru this nurse can develop
therapeutic environment for patient