Creating + Maintaining a Therapeutic + Safe Environment
Chapter 7 in textbook: Milieu Therapy – The Therapeutic Community
Chapter 5 in ATI book: Creating + Maintaining a Therapeutic + Safe Environment
Milieu: French for <middle,= English translation: <surroundings, or environment=
• In psychiatry, therapy involving the milieu may be called milieu therapy, therapeutic community, or the
therapeutic environment
• Goal: manipulate the environment so that all aspects of the pt’s hospital experience are considered therapeutic
o This setting allows for pt to learn adaptive coping, interaction, and relationship skills that can be
generalized to other aspects of life
o Management of the milieu refers to the management of the total environment of the unit in order to
provide the least amount of stress, while promoting the greatest benefit for all pts
o The nurse, as manager of care, is responsible for structuring and implementing aspects of the
therapeutic milieu
o Structures: team meetings, individual sessions/meetings, community meetings
A therapeutic community is based on 8 basic assumptions
1) The health in each individual is to be realized and encouraged to grow
2) Every interaction is an opportunity for therapeutic intervention
3) Each individual owns their own environment (pts should have opportunity to make decisions and solve problem
r/t the milieu – personal needs for autonomy and needs pertaining to the group as a whole are fulfilled)
4) Each individual takes responsibility for their own behavior
5) Peer pressure is a useful and powerful tool (to establish behavioral group norms)
6) Inappropriate behaviors are dealt with as they occur
7) Restrictions and punishment are to be avoided
5 elements of a community environment that ae necessary for therapeutic outcomes
1) Containment
2) Structure
3) Involvement
4) Support
5) Validation
Characteristics of the therapeutic milieu
• Physical setting
o Unit should be clean and orderly
o The setting should include comfortable furniture placed so that it promotes interaction, solitary spaces
for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping
o Color scheme and overall design should be appropriate for pt’s age
o Materials used for such features as floors should be attractive, easy to clean, and safe
o Traffic-flow considerations should be conducive to pt and staff movement
• Health care team member responsibilities
o Promote independence for self-care and individual growth
o Treat pts as individuals
o Allow choices for pts within the daily routine and within individual tx plans
o Apply rules of fair tx for all pts
o Model good social behavior for pts, such as respect for the rights of others
o Work cooperatively as a team to provide care
o Maintain boundaries with pts
o Maintain a professional appearance/demeanor
o Promote safe and satisfying peer interactions among pts
o Practice open communication techniques with health team members and pts
o Promote feelings of self-worth and hope for the future
• Emotional climate
o Pts should feel safe from harm (self-harm and harm from others)
o Pts should feel cared for and accepted by staff and others
, Physical safety
• The RN station and other areas should be placed to allow for easy observation of pts by staff and access to staf
by pts
• Special safety features (bathroom bars and wheelchair accessibility for pts who are disabled) should be
addressed
• Set up the following provisions to prevent pt self-harm or harm by others:
o No access to sharp/harmful objects
o Restriction of pt access to restricted/locked areas
o Monitoring of visitors
o Restriction of alcohol and illegal substance access/use
o Restriction of sexual activity among pts
o Deterrence of elopement from facility
o Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by
trained staff
• Seclusion rooms and restraints should be set up for safety and used only after all less-restrictive measures have
been exhausted; when used, facility policies and procedures must be followed
• Plan for safe access to recreational areas, occupational therapy, and meeting rooms
• Teach fire, evacuation, and other safety rules to all staff
o Provide clear plans for keeping pts and staff safe in emergencies
o Maintain staff skills (CPR)
• Considerations of room assignments on a 24-hour care unit should include:
o Personalities of each roommate
o The likelihood of nighttime disruptions for a roommate if one pt has difficulty sleeping
o Mental health and medical diagnoses, such as how 2 pts who have severe paranoia might interact with
each other
Activities within the therapeutic milieu (are always structured)
• Community meetings
o Enhance the emotional climate of the therapeutic milieu by promoting:
▪ Interaction and communication between staff and pts
▪ Decision making skills of pts
▪ A feeling of self-worth among pts
▪ Discussions of common unit objectives (encouraging pts to meet tx goals and plan for d/c)
▪ Discussion of issues of concern to all members of the unit, including common problems, future
activities, and the introduction of new pts to the unit
▪ Meetings can be structured so that they are pt-led with decisions made by the group as a whole
• Individual therapy
o Characterized by scheduled sessions with a mental health provider to address specific mental health
concerns (depression)
• Group therapy
o Characterized by scheduled sessions for a group of pts to address common mental health issues
(substance use d/o)
• Psychoeducational groups
o Based on pts level of functioning and personal needs (adverse effects of medication)
• Recreational activities
o Includes games and community outings
• Unstructured, flexible time
o Includes opportunities for the RN and other staff to observe pts as they interact spontaneously within
the milieu
Therapeutic nurse-client relationship
• Is foundational to mental health nursing care
• Differs from social and intimate relationships
Chapter 7 in textbook: Milieu Therapy – The Therapeutic Community
Chapter 5 in ATI book: Creating + Maintaining a Therapeutic + Safe Environment
Milieu: French for <middle,= English translation: <surroundings, or environment=
• In psychiatry, therapy involving the milieu may be called milieu therapy, therapeutic community, or the
therapeutic environment
• Goal: manipulate the environment so that all aspects of the pt’s hospital experience are considered therapeutic
o This setting allows for pt to learn adaptive coping, interaction, and relationship skills that can be
generalized to other aspects of life
o Management of the milieu refers to the management of the total environment of the unit in order to
provide the least amount of stress, while promoting the greatest benefit for all pts
o The nurse, as manager of care, is responsible for structuring and implementing aspects of the
therapeutic milieu
o Structures: team meetings, individual sessions/meetings, community meetings
A therapeutic community is based on 8 basic assumptions
1) The health in each individual is to be realized and encouraged to grow
2) Every interaction is an opportunity for therapeutic intervention
3) Each individual owns their own environment (pts should have opportunity to make decisions and solve problem
r/t the milieu – personal needs for autonomy and needs pertaining to the group as a whole are fulfilled)
4) Each individual takes responsibility for their own behavior
5) Peer pressure is a useful and powerful tool (to establish behavioral group norms)
6) Inappropriate behaviors are dealt with as they occur
7) Restrictions and punishment are to be avoided
5 elements of a community environment that ae necessary for therapeutic outcomes
1) Containment
2) Structure
3) Involvement
4) Support
5) Validation
Characteristics of the therapeutic milieu
• Physical setting
o Unit should be clean and orderly
o The setting should include comfortable furniture placed so that it promotes interaction, solitary spaces
for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping
o Color scheme and overall design should be appropriate for pt’s age
o Materials used for such features as floors should be attractive, easy to clean, and safe
o Traffic-flow considerations should be conducive to pt and staff movement
• Health care team member responsibilities
o Promote independence for self-care and individual growth
o Treat pts as individuals
o Allow choices for pts within the daily routine and within individual tx plans
o Apply rules of fair tx for all pts
o Model good social behavior for pts, such as respect for the rights of others
o Work cooperatively as a team to provide care
o Maintain boundaries with pts
o Maintain a professional appearance/demeanor
o Promote safe and satisfying peer interactions among pts
o Practice open communication techniques with health team members and pts
o Promote feelings of self-worth and hope for the future
• Emotional climate
o Pts should feel safe from harm (self-harm and harm from others)
o Pts should feel cared for and accepted by staff and others
, Physical safety
• The RN station and other areas should be placed to allow for easy observation of pts by staff and access to staf
by pts
• Special safety features (bathroom bars and wheelchair accessibility for pts who are disabled) should be
addressed
• Set up the following provisions to prevent pt self-harm or harm by others:
o No access to sharp/harmful objects
o Restriction of pt access to restricted/locked areas
o Monitoring of visitors
o Restriction of alcohol and illegal substance access/use
o Restriction of sexual activity among pts
o Deterrence of elopement from facility
o Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by
trained staff
• Seclusion rooms and restraints should be set up for safety and used only after all less-restrictive measures have
been exhausted; when used, facility policies and procedures must be followed
• Plan for safe access to recreational areas, occupational therapy, and meeting rooms
• Teach fire, evacuation, and other safety rules to all staff
o Provide clear plans for keeping pts and staff safe in emergencies
o Maintain staff skills (CPR)
• Considerations of room assignments on a 24-hour care unit should include:
o Personalities of each roommate
o The likelihood of nighttime disruptions for a roommate if one pt has difficulty sleeping
o Mental health and medical diagnoses, such as how 2 pts who have severe paranoia might interact with
each other
Activities within the therapeutic milieu (are always structured)
• Community meetings
o Enhance the emotional climate of the therapeutic milieu by promoting:
▪ Interaction and communication between staff and pts
▪ Decision making skills of pts
▪ A feeling of self-worth among pts
▪ Discussions of common unit objectives (encouraging pts to meet tx goals and plan for d/c)
▪ Discussion of issues of concern to all members of the unit, including common problems, future
activities, and the introduction of new pts to the unit
▪ Meetings can be structured so that they are pt-led with decisions made by the group as a whole
• Individual therapy
o Characterized by scheduled sessions with a mental health provider to address specific mental health
concerns (depression)
• Group therapy
o Characterized by scheduled sessions for a group of pts to address common mental health issues
(substance use d/o)
• Psychoeducational groups
o Based on pts level of functioning and personal needs (adverse effects of medication)
• Recreational activities
o Includes games and community outings
• Unstructured, flexible time
o Includes opportunities for the RN and other staff to observe pts as they interact spontaneously within
the milieu
Therapeutic nurse-client relationship
• Is foundational to mental health nursing care
• Differs from social and intimate relationships
