Therapeutic community

PSYCHIATRIC NURSING, Classroom teaching

1. MILIEU THERAPY PRESENTED BY, Subarna Neogi M.Sc Nursing 1 st year C.O.N.,JIPMER

2. CONCEPT: Developed by MAXWELL in 1953 1 st published in ENGLAND book name is “SOCIAL PSYCHIATRY” Later on it was published in United States & name changes to “THERAPEUTIC COMMUNITY”

3. BACKGROUND: Two persons, namely T. Main in Bermingham and Maxwell Jones of UK during 2nd world war worked simultaneously on this concept without the knowledge of each other.

4. WHAT IS MILIEU THERAPY: A small cohesive communities where patients have a significant involvement in decision making & the practicalities of the running unit. the emphasis is on manipulation of the environment to bring about changes in the patients behavior.

5. DEFINITION: According to Kraft, “the therapeutic community is a very special type of milieu therapy in which the total structure of the treatment unit is involved as a part of the helping process.” Stuart and Sundeen defined milieu therapy as, “A therapy in which patient's social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care and the daily problems of his community."

6. OBJECTIVES: • To use patient's social environment to provide a therapeutic experience for him. • To enable the patient to be an active participant in his own care and become involved in daily activities of his community. • To help patients to solve problems, plan activities and to develop the necessary rules and regulations for the community. • To increase their independence and gain control over many of their own personal activities. • To enable the patients become aware of how their behaviour affects others.

7. TYPES: GENUINE THERAPEUTIC COMMUNITY OF DEMOCRATIC / ANALYTIC THERAPEUTIC MILIEU OF INSTITUTIONAL SOCIAL THERAPY OR CONCEPT BASED THERAPY

8. The therapeutic community attempts to: Respect the individual client as a citizen having capacity for autonomous action Share decision making with residents about day to day life of the community Use the mechanism of meetings and groups to develop openness of the communication about problems, feelings and conflicts. Stress an ordinary domestic environment, in which, clients can enjoy in meaningful, purposeful activity.

9. BASIC ASSUMPTIONS: The Health in Each Individual Is to Be Realized and Encouraged to Grow Every Interaction Is an Opportunity for Therapeutic Intervention The Client Owns His or Her Own Environment Each Client Owns His or Her Behavior Restrictions and Punishment Are to Be Avoided Peer pressure Appropriate behavior

10. PRINCIPLES: 1. Responsibility for treatment belongs to the staff and client 2. Roles of staff and clients are equalized – may discuss either staff behavior or client’s behavior. 3. Democratic environment is fostered 4. Open communication is encouraged 5. Focus is on client assets 6. Peer pressure is utilized to reinforce rules and regulations 7. Interpersonal interactions are utilized to improve communication skills 8. Inappropriate behavior is dealt with as they occur

11. CONTINUE…. 9. Group discussion and temporary seclusion are favoured approaches for acting out behavior 10. Team approach is used 11. Clients are treated as part of team and share in the responsibility and process of making decisions. 12. Clients are involved in all phases of treatment 13. Community government is set up – use meetings to teach standards, values and behavior, explore behavior, make decision, use problem solving 14. Two main goals for clients – learn to set limits, learn psychosocial skills

12. LIMIT SETTING: Behaviours that requires setting limits: Destructive : suicide, homicide, harm to person or property Disorganisation : psychotic behaviour- hallucinations, delusions, disoriented, dissociative episodes of post-traumatic stress disorders Deviants : acting out, breaking rules, illegal activities Dysphoric : depressed, withdrawn, elated, phobic, obsessive-compulsive Dependent : avoids responsibility for thoughts and behaviours

13. CONTINUE… Psycho social skill development: Leadership : client government Self-assertion : expressing feelings and attitudes is encouraged, focus is on taking it out. Occupational activities : basic skills for managing life, activities of daily living, vocational counselling, training Recreational activities : leisure activities, co-operation with others, conversation within social context Independence : focus on decision making, problem solving, self-care

14. SPECIFIC ROLES OF INTERDISCIPLINARY TEAM IN MAINTENANCE OF THERAPEUTIC MILIEU Psychiatrist. Clinical psychologist. Psychiatric clinical nurse specialists. Mental health technician/psychiatric technician. Psychiatric social worker. Occupational therapist. Recreational therapist.

15. HANDOUTS ON MILEU THERAPY TEAM MEMBER:

16. CONDITIONS THAT PROMOTE A THERAPEUTIC COMMUNITY: Basic Physiological Needs Are Fulfilled The Physical Facilities Are Conducive to Achievement of the Goals of Therapy A Democratic Form of Self-Government Exists Responsibilities Are Assigned According to Client Capabilities Community and Family Are Included in the Program of Therapy in an Effort to Facilitate Discharge from Treatment. A structured program of social & work.

17. THERAPEUTIC COMMUNITY ELEMENTS Free communication Shared responsibilities Active participation Involvement in decision making Understanding of roles, responsibilities, limitations and authorities

18. Components of Therapeutic Community Daily Community Meetings Patient Government or Ward Council Staff Meetings or Review Living and Learning Opportunities

19. PATIENTS FOR WHOM THERAPEUTIC COMMUNITY IS USEFUL Schizophrenia Substance abuse disorder Antisocial disorder Children's care taking environment

20. PERSONAL ATTRIBUTES REQUIRED BY NURSES Sensitive observation of patients and social relationships in order to form care plan Individualized care planning, using imaginative ways of enhancing patient’s co-operation and implementation Articulate and clear report writing and structuring of case notes Clarity of oral reporting Listening and counselling Group techniques as leader, co-worker and participants Managerial, administrative, and educational skills appropriate to own position and role in the community

21. SALIENT FEATURES: Free communication both within and between staff and patient group Communications are directed towards the modification of patient’s attitude, behavior and role performance Atmosphere in the community will be democratic as opposed to hierarchical, rehabilitative rather than custodial, permissive instead of limited and controlled Nurses will be more communal with the patient instead of displaying all the time therapeutic role Environment will be essentially permissive and flexible

22. CONTINUE…. Patients activities are individualized and the role of patients are unspecified and their participation is completely voluntary Group responsibility is emphasized and opportunities for corrective learning experience are deliberatively provided A compulsory daily community meeting that all staff members have to attend and all patients are encouraged to attend The primary role of staff is to help the patients gain new insights and test new behavioural pattern Problems of the patients are discussed and the solutions are sought in the small group therapy sessions following each community meeting

23. CONTINUE…. Patient government or ward council is to deal with practical unit details such as privileges and housekeeping rosters. Staff member is available to the patient government, and all decisions are fed back to the community through the community meetings Staff meeting or review is essential to on the ward training. It gives opportunities for the staff members to examine their own responses, expectations and prejudices Living – learning opportunities are provided to the patient within the social milieu. Thus, the therapeutic community is like a school for living in which the patient learns to meet the demands of everyday life. Feedback is one of the fundamental concepts in therapeutic community practice.

24. ADVANTAGES OF TC Patient develops harmonious relationships with other members of the community. Gains self-confidence. Develops leadership skills. Learns to understand and solve problems of self and others. Become socio-centric. Learns to live and think collectively with the members of the community. provides opportunities to participate in the formulation of hospital rules and regulations DISADVANTAGES OF TC Role blurring between staff and patient. Group responsibility can easily become nobody's responsibility. Individual needs and concerns may not be met. Patient may find the transition to community difficult

25. QUESTIONS:

26. ASSIGNMENT: Write an assignment on different types of milieu therapy and nurse role.