• First milieu is French for ‘middle place’ so you might think of it as a nice safe ‘middle ground.’ Milieu refers to the people & all other social; physical factors in the environment with which the patient interacts. This may be 24 hours a day or partial (less than 24 hours, usually 4-6).
• This environment is designed to provide a secure retreat for person’s whose capacities for coping with reality have deteriorated (people who just can’t cope anymore).
• It offer opportunities to acquire adaptive coping skills (teaches you more effective or new ways to deal with problems) & lets the patient test them these new coping skills in a secure, comfortable physical facility.
• Provides recreational, occupational, social, psychiatric, medical & nursing therapies.
• Milieu protects & shelters the patient from:
• Perceived pain, terrifying stressors, can protect a person from their own or others maladaptive behavior (i.e. attempt at suicide or abuse by spouse). This therapy supports the patient physiologically, provides pleasant attractive sensory stimulation, teach patients & family adaptive coping strategies.
• All personnel in the environment must work together to provide a caring, healing environment.

• A group therapy approach to living experience with the following objectives:
• Correct or redefine perception of stressors
• Correct maladaptive behavior
• Develop adaptive coping
• Acquire interpersonal & stress-management skills
• Apply all of this in a social content

It is also very important that the milieu match the patient’s cultural background because it’s absence to match can causes greater cognitive or inner conflict.

To maintain & create a therapeutic milieu by - providing individualized treatment plans, promoting self-governance, progressive levels of responsibility, variety of activities, links with family & community & effective interaction among health team who are humanistic.

Further explanation of the above terms:

• Individualized treatment plans – are tailored as much as possible to the needs & right of the person. Definite structure, schedule, overall guidelines & social controls are set forth.
• Self-governance – refers to the development of self-responsibility & appropriate interdependence with peers. Patient’s participate in decision making regarding milieu issues (i.e. structured committee meetings, client-team committee meeting).
• Progressive Levels of Responsibility – refers to the fact that patients are expected to assume a role in maintaining the environment à assignments should be according to capabilities. This works to promote feelings of self-responsibility. MH team members assign levels and peer comments about readiness for level changes are considered.
• One approach is a ‘level system’ stating what the patient must do to earn a specific privilege, this is a type of behavior modification.
• Behavior modification is most appropriate with adolescents & much less so with adults. (p.223)
• A variety of meaningful activities – encourages proactive social behavior & adaptive coping skills (patients interact in activities & have a chance to ‘test’ the new communication/coping skills they have learned). Activities include exercise class, jogging, weight lifting, interpersonal skills training (such as assertiveness training, listening & communicating skills) & leisure skills classes.
• Links with family & Significant others – family education programs may be used to help members of the family understand the patient’s problems & learn how they can help with recovery. The family may be involved in selected milieu activities (i.e. interpersonal skill's classes, MH classes, family group therapy & medication classes). In partial settings the family may learn how to care for the patient at home (i.e. s/s related to the particular problem, medication side effects & guidelines to select a psychiatric home care service.
• Links in the community – include support groups such as AA. Support groups can also help the patient develop social skills & confidence.
• Effective interaction between MH team members – the mental health staff must have effective interaction à we are all human so from time to time there will be conflict à in this environment it is vital that conflict are resolved effectively & promptly or the entire milieu therapy/environment may decline.
• Humanistic mental health team members – members of this teams must posses certain attributes, they must be: optimistic, inspire hopefulness, be creative, lack fear or prejudice when confronted with bizarre unconventional behavior, provide daily contact, set limits, share control & provide effective education.

• Classification levels include:
• Severely limited self-care capacity.
• Level I – ex: not dangerous, oriented x3, good hygiene, attends one therapy daily.
• Level II – ex: states names of several staff members, goes to many therapies
• Level III – meets requirements for all other levels plus takes active role with other patients, assumes leadership role & initiates discussion with MH team about discharge. (for more detailed example see chart – p.223)

• To manage & coordinate from a holistic view rather than a fragmented perspective of other MH team members à this allows nursing to ensure continuity of care. Nurse’s also assess physiological & psychological status continually, influence of the milieu therapy, provide physical & safety care, medication administration & education, psychosocial care, mental health & health education.

Further explanation of the above terms:

• Physical & safety care – assess the patient’s ability to perform ADLs, signs of physical illness or adverse reactions to psychotropic drugs or reactions to withdrawal/detoxification when indicated. Assess self-destructive or other-destructive behaviors. Perform periodic safety checks (be sure to do it in a way as to not violate patient rights).
• Frequently patients with destructive tendencies are treated in Partial Programs, here safety contracts are used (a type of behavior approach). Contracts can be formed between patients and peers as well.
• Adequate staffing is very important, usually there is one RN per five patients, at least one activity therapist available 12hrs/day & two other paraprofessionals or MH workers.
• In Partial Programs a ratio of one RN to ten patients is considered safe, with again one activity therapist & two other professionals.
• Medication administration & education – in milieu therapy the nurse may be expected to gain informed consent before giving psychotropic drugs, this includes explaining desired & undesired effects. Encourage the patient to ask questions & respect that they had the right to decline the drug à this shows respect for the patient, begins education & this active involvement encourages compliance.
• The patient is expected to approach the nurse for medications at the specific times & places.
• A responsible patient may be given a 24-hour supply of their medication to take independently à this demonstrates readiness to assume self-care.
• The goal is to assist the patient to assume responsibility for taking their medication to avert recurrence of psychiatric symptoms & rehospitalization.
• Psychosocial care - consumes the greatest portion of the nurses time & effort and include the following:
• Reducing stressors such as loud voices, violent TV programs or video games, unsightly visual stimuli, unpleasant odors & crowded places.
• Encouraging the patient to identify problems & conflicts, and to attempt to understand them & use new problem solving methods.
• The nurse performs, when needed, brief on-the-spot reality therapy & limit setting to help the patient deal with destructive behaviors.
• Therapy by the nurse aims to increase self-awareness by helping the patient clarify & correct perceptions of current stressors, identify their thoughts & feelings toward the stressors and how they effect their behavior, evaluate which coping methods are effective and test the methods in the therapeutic milieu.
• Mental Health education – is provided by the nurse who teaches the patient & family all aspects of psychotropic medications or coping strategies for psychiatric illness (this improves compliance).
• Teaching related to family as mentioned earlier under Links with Family & Significant others is also provided.
• Stress management techniques taught to aid in coping include exercise, relaxation therapy & pursuit of leisure activities (fosters a sense of well being, self-confidence, self-control & increased self-esteem).
• Relaxation therapy includes progressive muscle relaxation, visual imagery, soothing auditory experiences & massage.
• Health education – the nurse provides education on physical health as well, some patients may be at risk related the self-neglect associated with many psychiatric disorders.

• Cultivate your self-awareness by evaluating yourself & evaluation by supervisors & peers.
• Be objective when interacting with clients, teams members & the milieu’s social atmosphere without becoming overly involved & don not take sides!
• Be sensitive to all but recognize personal limits as well.
• Communicate clearly (say what you mean) & do not hesitate to seek clarification of what someone else is saying.
• Always expect the unexpected not matter how well it was planned!
• Be clear at all times in what your values, principals & beliefs are regarding what is and what is not clinically appropriate for adequate patient care.

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