Principles of a Therapeutic Milieu: An Overview

Mary Walker, MA, RN

The author provides a concise overview of how the

milieu functions of structure, involvement, contain-

ment, support, and validation can be used to create a

positive treatment environment. Examples of an

unhealthy milieu aye contrasted with these fherapeu-

tic principles.

H o w the milieu is managed profoundly affects the experience of individual clients. A case in point rn- volves Joe H., a newly admitted, depressed client wlio is being escorted to the acute psychiatric unit of a rnC3jor medical center. This is Joe's first hospitalization and naturally he is somewhat apprehensive about tre'it- ment. When Joe enters the unit, he notices a spacious room with comfortable furniture that can acconiniu- date group therapies or quiet conversations. Bulletin boards on the wall display current events and unit dc-

tivities. Other clients are referring to personal note- books that outline their individual schedules and thcr- apeutic assignments for the day.

Joe notices that staff members are engaged uith other clients. Indeed, staff members are actively, yuret- ly processing issues and behavior with clients, while the clients are interacting warmly with each other. After admitting him to the unit, the charge nurse introduc t>s Joe to a high functioning client who is close to tits- charge. This client serves as a resource and support to Joe and facilitates his continued orientation to the unit. Joe begins to feel more relaxed and integrated into the hospital environment.

Although a popular concept in the 1960s and early 1970s, therapeutic milieu has not been a focus of much clinical interest for several years. Trus lack of interest may be due to decreasing lengths of hospital stays, an increa5e in client acuity, and unclear role expectations of the nurse in the milieu (Lecuyer, 1992). However, managing the milieu has always been and will continue to be a power- ful intervention for nurses practicing in a psychiatric set- ting. The milieu manager role is also an expectation set forth by the American Nurses Association in its stan- dards of psychiatric and mental health nursing practice.

The Therapeutic Milieu

According to Gunderson (1983), the therapeutic mi- lieu provides five important functions: structure, in- volvement, containment, support, and validation.

Structure. The structure of a therapeutic milieu refers to the organization of time, space, and activity of

Perspectives in Psychiatric Care Vol. 30, No. 3, July-September 1994 5

Principles of a Therapeutic Milieu: An Overview

each client’s environment (Gunderson, 1983). Structure relates to aspects of the physical environment, such as color, lighting, furniture, spatial layout, and unit pro- grams and policies. Structure encompasses the expec- tations that clients participate in prescribed activities.

Ensuring that each client receives an individualized orientation is one aspect of structure. Some clients may need reorientation to the environment every time staff has contact with them. Healthier clients may assist a newcomer in learning the program, rules, and positive norms, the “unwritten” rules of the unit (Gunderson, 1983).

Use of a client privilege system is another element of structure. The client is made aware of what behavior is expected in order to advance to greater levels of re- sponsibility. Setting consequences for functional and dysfunctional behavior is a method to implement levels of responsibility. Consequences for behavior through responsibility levels are most powerful when consis- tently carried out by all members of the multidisci- plinary staff across treatment teams.

Structure can also be put into place by a consistent daily/weekly schedule. Providing organization for the day gives the client an opportunity to focus on internal reorganization, rather than constantly having to deci- pher shifting environmental expectations.

Characteristics of an unharnessed milieu may in- clude minimal activities for clients. Units operating on a medical model may convey the idea that clients’ main activity is to pass time until their medication takes effect or they meet with their psychiatrist. Inconsistent im- plementation of a schedule for clients undermines structure. Such inconsistencies may reflect a lack of staff commitment to clients, or a feeling among staff mem- bers that their interventions don’t really make a differ- ence in the client’s recovery. Inadequate numbers of staff or a lack of ancillary support also can impact on the consistency of structure.

Ineffective structure is also seen when clients receive only a brief orientation to the unit. In this case, ”orien- tation” consists of handing clients a set of ”ward rules” as they enter the hospital. The lack of consequences or

inconsistently applied consequences for positive and dysfunctional behavior also signify low structure on a unit.

Involvement. The second function of a therapeutic milieu is to provide that clients attend to and interact with a social environment conducive to client interac- tion (Gunderson, 1983). Involvement occurs as clients accept feedback from the staff and their peers regarding their behaviors, as they work within the group to mod- ify certain behaviors, and are willing to provide con- structive feedback to their peers.

A central assumption of involvement is that clients are active participants in the healing process rather than passive recipients of care. Decisions about treatment are made with client input, which does not mean that clients dictate treatment, but that client goals are given high priority. The nursing staff expects the client to at- tend mutually agreed upon activities. If the client does not attend, the staff discusses with the client how non- involvement influences recovery.

A primary nursing model, or case management care delivery system, is helpful in promoting involvement of clients. Nurses who develop an intense working rela- tionship with a client can better assess the client’s in- teractions with others, including transference issues be- tween client and nurse. These issues can be used to assess interpersonal patterns in the client’s relation- ships with significant others.

When few mechanisms are available in the milieu for clients to increase responsibilities, freedom, and control, client involvement will be undermined. When clients are left powerless, expectations for them may vary among staff members, or from shift to shift. Lack of expectations for them leaves the clients in a confus- ing, defenseless situation in which they do not know exactly which behaviors to change or how to effect change.

Containment. The third function of a therapeutic milieu is containment: the use of locked areas, seclu- sion, restraint, and the grouping together of similar clients for the protection of self and others (Gunder- son, 1983). Containment functions assist clients to mod-

6 Perspectives in Psychiatric Care Vol. 30, No. 3, July-September 1994

ulate aggressive behaviors and bolster their internal controls. Containment also serves to decrease environ- mental stimuli so the client is not overwhelmed by pro- cessing information from the environment.

One major containment function of a therapeutic mi- lieu is safety. Nurses monitor clients continually when they are in seclusion and/or restraints. Frequent mon- itoring is a common method of providing safe contain- ment. Suicide or elopement precautions, equipment checks, and policies restricting client’s freedom are ex- amples of containment strategies. A particularly pow- erful approach occurs when clients themselves enforce containment through “peer pressure.” In some settings, clients assume responsibility as a group to increase or decrease another client’s privileges and responsibilities based on how well the client controls his or her behav- ior. This method of providing containment often proves more effective than staff sanctions if clients are well-in- tegrated into the group.

When nurses fail to provide appropriate contain- ment in the milieu, the clients suffer. For instance, if a particular client is having difficulty with personal boundaries, nondirective communication by the nurses may cause him or her to become more con- fused and disorganized. Psychotic clients benefit from external controls until they are able to provide this control for themselves. On the other hand, in some facilities the staff may provide too much con- tainment, using coercive techniques rather than act- ing therapeutically.

Support. A fourth function of a therapeutic milieu is support, which involves the active efforts of the staff to promote a sense of well-being and self-esteem in clients (Lecuyer, 1992). Not only the can staff perform this function, but other clients can encourage and reinforce healthy behaviors as well. A therapeutic milieu serves as a “safe place” where clients can be valued as persons despite problematic personal actions. Behaviorally, clients sense support through respectful, thoughtful in- terventions. Verbally, clients feel support through en- couragement and a communicated belief that hope ex- ists for them.

Elements of support that can be built into the milieu might include individualized client teaching programs and personalized postdischarge follow-up. Some pro- grams offer certificates after clients complete education modules or treatment itself. Ideally, nurses create op- portunities in which clients can interact with one an- other and build supportive relationships. Group recre- ational opportunities and community meetings are two other mechanisms to encourage clients to get to know one another and develop cohesion.

Only the most sterile environments would lack any support, but some psychiatric environments exist where support is minimal. A low-support environment is characterized by a focus on one or two primary rela- tionships, such as with the psychiatrist or therapist. When this situation occurs, the relationship is kept fair- ly exclusive. A healthier approach would encourage a network of relationships. Although a solid, trusting re- lationship with a therapist is crucial to clients, it could be restrictive if all other activities and relationships are seen as secondary. Such a ”norm” develops when the client is expected to relinquish other unit activities if a psychiatrist appears on the unit at an unscheduled time to meet with the client. If the client is taken out of other activities for the convenience of one staff member, i t sends a clear message that integrating into the unit so- cial network is of secondary importance.

Having minimal opportunities for clients to interact with each other is another sign of a low-support mi- lieu. When clients do not have structured opportunities to interact, they may isolate themselves out of fear, mis- understanding, or poor communication skills. Nursing staff can informally encourage supportive bonds by Ini- tiating interactions among clients, or by suggesting that clients collaborate in special activities. When a low level of support exists in the milieu, clients will not have a sense of connectedness with, or empathy for, other clients.

Validation. The fifth and final function of a thera- peutic milieu is that of validation, a process that af- firms a person’s individuality (Gunderson, 1983). Clients do not lose their personal uniqueness when

Perspectives in Psychiatric Care Vol. 30, No. 3, July-September 1994 7

Principles of a Therapeutic Milieu: An Overview

they develop a mental illness. Individualized care re- quires focusing on a person's unique personal at- tributes when planning treatment, and is a standard of practice (Lecuyer, 1992). In reality, major varia- tions in treatment are rarely seen except in the most unusual circumstances. Program design, staff values, and system barriers often preclude an individualized approach.

Optimal milieu characteristics for validation would include a respect for a person's right to be alone, to make mistakes, and even to regress. When a high de- gree of validation is present, clients feel affirmed and accepted even if their behavior is not. In such a posi- tive milieu, staff members constantly are viewing clients, not only as they are, but as the people they have the potential to be.

A milieu that lacks a strong sense of client validation often 1s characterized by overly structured programs, with which all clients are expected to comply. No at- tempts are made to modify existing structure in order to meet a particular client's needs. Certainly, common structure and consistency are important for clients to develop group cohesion; however, if rigid adherence to the structure is the overriding consideration, clients may feel devalued as persons.

Summary

The therapeutic milieu involves a challenging or- chestration of structure, involvement, containment, support, and validation. Nurses must attend not only to individual clients but also to the group and environ- ment a5 a whole. Creating a healing therapeutic milieu is a realizable goal for a nursing staff and a responsi- bility that is uniquely nursing's own.

References

Gundcrson, J. (1983). Princ ip les and prac t ices of milieu therapy. Hillsborough, NJ: Jason Aronson, Inc.

Lecuycr, 1;. (1992). Milieu therapy for short stay units: A transformed practice theory. Archives $Psychiatric Nursing, 6, 108-116.

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8 Perspectives in Psychiatric Care Vol. 30, No. 3, July-September 1994