http://www.oliverhiggins.com

This essay examines the role that milieu therapy plays with the acute inpatient environment. It’s purpose is to further examine my own practice and the frameworks in which milieu is used. Milieu therapy was chosen as practicing clinicians were observed to understand very little of what it is, myself included. The primary literature used is based on the work by Jones, Gunderson and Peplau. Current literature still relays very heavily on these works. This draws profoundly on the concept of the therapeutic community. The essay explores my own personal experiences in relation to the milieu and how I may use it to create a therapeutic environment. It then examines and discusses the history, theories, frameworks and interventions of milieu therapy. The milieu is all encompassing and a very powerful tool in acute inpatient settings. It is a framework from which other therapies can work within. The milieu is very broad and powerful yet poorly understood in the current social climate. The basic principles provided by the milieu are essential in the acute inpatient environment but poorly practiced. Further research need to be undertaken to understand the frameworks set out by Jones and Gunderson to align them with current social trends.

Webster (2004) defines milieu therapy as “therapeutic milieu is an environment designed to promote health.” Whilst this is informative, it is very bland. The aim of this essay is to construct a short interpretation into what milieu therapy is in relation to acute inpatient mental health nursing. This essay will examine the history of milieu therapy including prominent researcher and the era in which they practised. It discusses the Theoretical frameworks of Jones, Gunderson and Peplau. It then moves on to examine the application of therapy in creating an environment and major interventions that are common in the therapy. It will detail and explore Gunderson’s five components of the therapeutic milieu. Before finally exploring my own practice and where milieu therapy fits within my own framework.

Milieu therapy has been in practice in various forms since the 1800’s. However significant research into understanding the milieu as a therapeutic approach began the 1950’s. Many individuals have contributed the research surrounding milieu therapy. These include Peplau (1952), Jones (1953), Herz (1969) and Gunderosn (1978). Since the 1950’s this work has continued to expand and extensively researched. The initial language used to refer to this style of therapy changed from therapeutic community to the French term of therapeutic milieu, which interprets to setting or environment (Webster, 2004).

To understand and be come effective in milieu therapy, the nurse must comprehend the underlying prerequisites in order to promote its principles. These underlying principles are that the client is an active, not passive, participant in their own life. This implies and allows the client to own their behaviour, environment and as a result need to be involved in the management of both. The milieu sees the individual as independent and it is the individual must deal with conflict, distortions and inappropriate behaviour in the here and now, whilst taking into consideration the impact on any other individual’s milieu. It is essential that peers be involved for the learning that comes from interaction as well as the therapeutic healing effect of peer pressure.

Jones (1953) developed a concept of the therapeutic community. He aimed to design a culture that would promotive positive healthy personalities. Jones wished to have his clients improve their behaviour. He is also one of the first to acknowledge that the acute inpatient or hospital environment affects behaviours, progress and symptoms of clients.

Key principles of Jones’ milieu therapy include the promotion of fundamental respect for individuals. The promotion of socialisation which provides opportunities for clients to be involved in the management and daily running of the unit. Encouragement of clients to act in a way that is at a level equal to their own ability and subsequently enhance their self esteem. Encourage staff and client communication for maximum therapeutic benefit (Jones, 1953).

Gunderson (1978) introduces five key therapeutic processes, containment, structure, validation, involvement and support. These will be discussed further in depth later in this essay.

Peplau’s work through the late 1950’s and 1960’s relied on the research set out by Jones (1953). With that particular book being essential reading in her summer classes (Sills, 1994; p100). Throughout her work, Peplau highlights the importance of the milieu in any patient focused environments (Winship, Bray, Repper & Hinshelwood, 2006). Peplau maintained that milieu enquiry was an opportunity for development (Peplau, 1989).

“The idea of milieu as therapeutic environment, as it became popular during the 1950s and 1960s, gave recognition to the idea that the nurse-patient interactions within the milieu could be beneficial to patients. However, since at that time the clinical nurse specialist movement and graduate preparation of psychiatric nurses as psychotherapists were still in the early stages of development, consideration of the impingement of hospital systems and ward environments on patients, and the nature of interaction phenomena within the milieu, had to wait. Nurses first had to gain sophistication in theory and theory application before thinking about complex milieu phenomena. It would seem that there are many theoretically orientated nurses who, with knowledge, skill and a computer, could now address this complex task, providing insight and direction.” (Peplau, 1989, p.78).

What I believe that Peplau is trying to tell us is that the milieu is important, it always has been but it is poorly understood. Nursing has come forward in a professional context with the tools to allow us to better analyse, understand and implement practice that will achieve the therapeutic milieu as she envisioned it.

For the purpose of this essay the focus will be on creating and establishing a therapeutic milieu in a sub/acute inpatient unit. This is important as the setting incorporates the social and physical setting that care or rehabilitation must take place (Pryor, 2000). The nature of such environments in which the clients finds themselves should aim to be health promoting and facilitative of the whole person 24 hours a day 7 days a week. It is also important for the clinician to be mindful that what maybe be therapeutic to a client can be detrimental to others in the milieu. Gunderson (1978) suggests that the physical, social, cultural and temporal features of the setting can be constructed to support the client. Core to this is the belief that the client needs to hold their individuality as they undergo this journey. It is the role of the clinicians to facilitate this. It is essential to preserve the “wholeness” of the person, not concentrate on the diagnosis of the patient. The multidisciplinary team, the nurses in particular, can create a milieu that enhances and maintains the diversity of the individuals existing abilities and roles but allows health education, the prevention of relapses and the restoration of function and roles. The 24 hour nature of the therapeutic milieu is key to its success and essential in the engagement of clients (Pryor, 2000)..

Nursing is responsible for the environment and atmosphere of the ward. There must be adequate physical space available for socialisation and group activities. The physical and social atmosphere should be such that it is inviting for people to attend activities with companions of their choosing. If people are to return to a positive level of functioning they must be immersed in as much lifestyle as practicably possibly, given their condition. These interactions between the nurse and the client needs to be based on where the client is in their mental state, emotional state and physically. The nurse needs to identify these factors plus engage the client to find out their likes, dislikes and various interest to aid in finding activities suited to the client (Pryor, 2000).

This gives the nurses a significant and almost limitless range of interventions. Delany (2006) categorises interactions for milieu therapy into three strategies according to mechanisms. They include behavioural, with the goal to change behaviour through altering reinforcement pattens. Affective, with the goal to achieve change by regulating feelings and responses. Finally cognitive, to facilitate changes in thinking and responding.

Within these domains it is suggested that interventions should include the promotion of self-efficacy experiences, teach reinforcement techniques, interrupt patterned behaviours, teach problem solving skills, linking of mood-thought-behaviour, decreasing stimuli, relate using empathy, teach about affects and the self management of them (Delany, 2006).

Gunderson (1978) states that the therapeutic milieu consists of five components: containment, structure, support, involvement and validation. The clinician needs to comprehend these components to be able to but them into practice and establish a therapeutic milieu.

Containment is a maintenance function. It promotes physical well being whilst the individual is allowed to regain and maintain self control. This in turn presents a safe environment for the client. It is expected that the successful implementation of containment will lead and foster feelings of internal security (Lawson, 1998).

Structure is the process of organising time and activity. Clients need to be provided with the extra security offered by structure. It is not uncommon for clients to suffer from sleep related disturbances such as sleep/rest cycles becoming irregular. When these types of needs are meet the clinician can focus on interventions for dealing with problems such as maladaptive behaviours. Clinicians need to be aware of the necessity of both quiet and busy times. Structure needs to be created through activities, groups and socialisation. Successful implementation of structure allows the individual to learn and maintain self control. The client will therefore engage in daily activities such as active participation in ward activities (Lawson, 1998).

Support is the enhancement of the individuals self esteem. It is characterised by the validation of ones ability to accomplish tasks associated with academic and athletic ability, social acceptance and physical appearance. With improved self esteem the client can move beyond simple survival toward a richer fulfilling life. Channels of support include psycho educational and group therapy opportunities. For example the ward program may offer activities such as problem solving and story telling with relaxation training. A successful outcome should include and be demonstrated by increased willingness to face unfamiliar tasks, decreased anxiety surrounding body image perceptions and personal appearance in addition to the ability to focus on accomplishing tasks (Lawson, 1998).

Involvement is the process in which a client attends actively to their social environment and interacts with it. Clinicians need to emphasise social involvement and assist in decision making processes if required. Interventions may include leadership programs, communication, assertiveness and personal communication skills. Whilst integration is difficult to evaluate within the short time frame of the acute setting a sign that integration is successful would include active participation with out prompting to attend groups and activities (Lawson, 1998).

Validation supports the differentiation of self, which can be defined as the ability to distinguish between thoughts and feelings within an emotional relationship system. It is a way of understanding thoughts and emotions and how to connect them with self enhancing rather then self destructive behaviours. Staff should focus on what has happened to the client rather than what may be wrong with them. Give the individual the opportunity to tell and explore their story. Story telling is a positive therapeutic tool in these situations. Positive outcomes for the client include an understanding of the emotive self and coping systems to help them neutralise any emotions assist them to work through the situation (Lawson, 1998).

In my practice I undertake client interaction within a large sub acute ward. The milieu of the environment is exceptionally dynamic. Having a large number of beds generally equates to having a large turnover of clients. This means that the acuity of the milieu changes on a daily basis due to new admissions and differing levels of current mental states. The milieu can also change quickly, especially when the nursing staff and skill mix change shift. With my own practice I find this to be particularly frustrating that the milieu can be turned on its head when particular members of staff are on duty. It is through this understanding of what milieu therapy is I aim to be aware of these changes promptly and seek interventions that will aid in creating a more therapeutic milieu.

For the purpose of this essay I chose to examine our daily morning meeting and its effectiveness in the creation of the milieu. The morning meeting is intended to give clients information in regards to whom the nursing and allied health staff are, what the activities planned for the day will be and what is expected of them throughout the day in regards to the locking of bedrooms and ward routine. Whilst this may sound simple enough many staff, myself included, have reduced what should be a simple forum or group to a very impersonal and even parental process at times.

To give an example a morning meeting will generally start with the nurses stating their name and then requesting that the current clients do likewise. From this they move on to the activities of the day followed by which member of staff will be conducting the group. The clients are then asked who wishes to see a doctor or allied staff member and if anybody requires information about the medication they are on. Staff then gives the clients an opportunity to raise any concerns before proceeding to inform them that their rooms will be shut from 1000 to 1330 so they must get them selves and their room in order before then. Meeting closed. Whilst the crucial aspects of care may have been addressed, the nurse leading the meeting has missed many opportunities understand and nurture the milieu (Webster, 2004).

The nurse is presented with an opportunity to enhance the current therapeutic milieu. Simple things that could be put into practice using the above scenario include changing the introduction from a simple “state your name” to a more inviting to conversation “Would you please introduce yourself and tell us all something about yourself”. This provides structure as well as offering a way to construct a therapeutic relationship with the clients. The leader is able to define purpose in not only the meeting but in the scope for the day’s activities, even if they are not involved. The leader needs to keep the focus for the group to promote goal accomplishment without letting it diminish into a gripe session. This will move the group away from a superficial feeling to a constructive facilitated movement with simple goals relating to organisation, orientation and introductions.

Little information exists on tracking the effectiveness of the milieu (Berkshire & McMahon, 1994). However tools do exist to measure the outcomes after the fact. The relationship of the client and milieu differs in every case.

In summary Milieu therapy has been in practice in various forms since the 1800’s with significant research into milieu as a therapeutic approach began the the 1950’s. Jones (1953) developed a concept of the therapeutic community. He aimed to design a culture that would promotive positive healthy personalities. Gunderson (1978) introduces five key therapeutic processes, containment, structure, validation, involvement and support. Throughout her work Peplau highlights the importance of the milieu in any patient focused environments.

To be effective in milieu therapy the nurse must comprehend the underlying prerequisites and promote its principles. These underlying principles ensure that the client is an active, not passive, participant in their own life. This allows the client to own their behaviour, environment and as a result need to be involved in the management of both. The milieu sees the individual as independent entity.

Gunderson (1978) suggests that the physical, social, cultural and temporal features of the setting can be constructed to support the client. Core to this is the belief that the client needs to hold their individuality as they undergo this journey. It is the role of the clinicians to facilitate this. The 24 hour nature of the therapeutic milieu is key to its success and essential in the engagement of clients with nursing, it is responsible for the environment, ambiance and atmosphere of the ward.

This gives the nurses a significant and almost limitless range of interventions. Delany (2006) categorises interactions for milieu therapy into three strategies according to mechanisms. They include behavioural, with the goal to change behaviour through altering reinforcement pattens. Affective, with the goal to achieve change by regulating feelings and responses. Finally cognitive, to facilitate changes in thinking and responding.

I also think that it is interesting to note that a significant proportion of this work was conducted in the 1950’s, with Gundersons framework in 1978. Peplau’s quote raises a important point in understand the milieu as everything in which we do. Society has changed since 1950. Can we understand entirely how the milieu affects clients today? No I think we need much more research, but this will continue to increase in demand as our society changes. This is a variable that must be encompassed and remain dynamic.

Personally in my own practice I will change the way in which I not only approach nursing but how I approach the client as a whole. The milieu is more then I ever imagined it to be and working within the medical model alone can not accommodate this.

This essay was aimed at being able to define and understand what the milieu is. My goal was to able to summarise what it was in a short sentence. This is impossible, the more research I do the more I see the milieu in everyday practice. It is my practice, my interactions, my clients, their life, their circumstance, our ward and our interactions. I will view my practice in a very different light.

To conclude, milieu therapy is a very powerful tool that can be built on a very flexible framework. This framework can encompass interventions from many different therapies and can prove to be very powerful. All nurses should understand what the milieu is, as they are all part of it.

References

Berkshire, D. B., & McMahon, B. (1994). Adolescent milieu rating scale: Tool for therapeutic management. Nursing Management, 25(10), 94.

Delany, K. (2006). Top 10 milieu interventions for inpatient Child/Adolescent

treatment. Journal of Child and Adolescent Psychiatric Nursing, 19(4), 203.

Gunderson, J. G. (1978). Defining the therapeutic process in psychiatric milieu.

Psychiatry, 41, 327-335.

Herz, M. I. (1969). The therapeutic milieu: A necessity. International Journal of

Psychiatry, 7, 209.

Jones, M. (1953). The therapeutic community. New York: Basic Books.

Lawson, L. (1998). Milieu management of traumatized youngsters. Journal of Child

and Adolescent Psychiatric Nursing, 11(3), 99.

Peplau, H. (1952). Interpersonal relations in nursing. New York: Putnam. .

Peplau, H E (1989) Selected Works. Interpersonal Theory in Nursing. London.

Macmillan.

Pryor, J. (2000). Creating a rehabilitative milieu. Rehabilitation Nursing, 25(4), 141.

Sills, G. (1994). Use of milieu therapy. In C. A. Anderson (Ed.), Psychiatric nursing

1974-1994: State of the art (pp. 99-111). St Louis: Mosby.

Webster, M. M. (2004). Therapeutic modalities: Interactive, activity and

electroconvulsive therapies. In K. M. Fortinash, & P. A. Holoday Worret (Eds.),

Psychiatric mental health nursing (pp. 427-454; 19). Philidelphia: Mosby.

Winship, G., Bray, J., Repper, J., & Hinshelwood, R. D. (2006). Collective biography

and the legacy of Hildegard Peplau, Annie Altschul & Eileen Skellern: The origins

of mental health nursing and its relevance to the current crisis in psychiatry.

Unpublished manuscript.

Share on Facebook