Download Therapeutic Milieu

Chapter 12The Therapeutic
Milieu
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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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
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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
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Behavior Therapy
• Behavior modification
• Aversion therapy
• Cognitive–behavior therapy
• Assertiveness training
• Implosive therapy
• Limit-setting
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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, daytreatment centers, and community-based mental health
programs.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Terms
• Activities of daily living
• Flooding
• Assertiveness training
• Implosive therapy
• Aversion therapy
• Limit-setting
• Behavior therapy
• Milieu therapy
• Cognitive–behavior
therapy
• Nurse-led psychotherapy
interventions
• Pavlov’s Theory of
Conditioning
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Terms (cont.)
• Protective nursing care
• Spirituality
• Religion
• Systematic
desensitization
• Skinner’s Theory of
Operant Conditioning
• Sleep pattern disturbance
• Spiritual distress
• Therapeutic lifestyle
change (TLC) counseling
• Therapeutic milieu
• Ward Atmosphere Scale
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
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?
?
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins