TREATMENT MODES

Milieu Therapy

Milieu therapy consists of treatment by means of controlled modification of the client’s environment to promote positive living experiences.

1. Concepts and principles related to milieu therapy:
1. Everything that happens to clients from the time they are admitted to the hospital or treatment setting has a potential that is either therapeutic or antitherapeutic.
1. Not only the therapists but all who come in contact with the clients in the treatment setting are important to the clients’ recovery.
2. Emphasis is on the social, economic, and cultural dimension, the interpersonal climate, and the physical environment.
2. Clients have the right, privilege, and responsibility to make decisions about daily living activities in the treatment setting.


2. Characteristics of milieu therapy:
1. Friendly, warm, trusting, secure, supportive, comforting atmosphere throughout the unit.
2. An optimistic attitude about prognosis of illness.
3. Attention to comfort, food, and daily living needs; help with resolving difficulties related to tasks of daily living.
4. Opportunity for clients to take responsibility for themselves and for the welfare of the unit in gradual steps.
5. Client government.
6. Client-planned and client-directed social activities.
7. Maximum individualization in dealing with clients, especially regarding treatment and privileges in accordance with clients’ needs.
8. Opportunity to live through and test out situations in a realistic way by providing a setting that is a microcosm of the larger world outside.
9. Opportunity to discuss interpersonal relationships in the unit among clients and between clients and staff (decreased social distance between staff and clients).
10. Program of carefully selected resocialization activities to prevent regression.


3. Nursing care plan/implementation in milieu therapy:
1. New structured relationships - allow clients to develop new abilities and use past skills; support them through new experiences as needed; help build liaisons with others; set limits; help clients modify destructive behavior; encourage group solutions to daily living problems.
2. Managerial - inform clients about expectations; preserve orderliness of events.
3. Environmental manipulation - regulate the outside environment to alter daily surroundings.
1. Geographically move clients to units more conducive to their needs.
2. Work with families, clergy, employers, etc.
3. Control visitors for the benefit of the client.
4. Team approach uses the milieu to meet each client’s needs.


4. Evaluation/outcomes criteria:
1. Physical dimension: order, organization.
2. Social dimension: clarity of expectations, practical orientation.
3. Emotional dimension: involvement, support, responsibility, openness, valuing, accepting.

Behavior Modification

Behavior modification is a therapeutic approach involving the application of learning principles so as to change maladaptive behavior.

1. Definitions:
• conditioned avoidance (also aversion therapy) a technique whereby there is a purposeful and systematic production of strongly unpleasant responses in situations to which the client has been previously attracted but now wishes to avoid.
• desensitization frequent exposure in small but gradually increasing doses of anxiety-evoking stimuli until undesirable behavior disappears or is lessened (as in phobias).
• token economy desired behavior is reinforced by rewards, such as candy, money, and verbal approval, used as tokens.
• operant conditioning a method designed to elicit and reinforce desirable behavior (especially useful in mental retardation).
• positive reinforcement giving rewards to elicit or strengthen selected behavior or behaviors.
2. Objectives and process of treatment in behavior modification:
1. Emphasis is on changing unacceptable, overt, and observable behavior to that which is acceptable; emphasis is on changed way of acting first, not of thinking.
2. Mental health team determines behavior to change and treatment plan to use.
3. Therapy is based on the knowledge and application of learning principles, that is, stimulus-response; the unlearning, or extinction, of undesirable behavior; and the reinforcement of desirable behavior.
4. Therapist identifies what events are important in the life history of the client and arranges situations in which the client is therapeutically confronted with them.
5. Two primary aspects of behavior modification:
1. Eliminate unwanted behavior by negative reinforcement (removal of an aversive stimulus, which acts to reinforce the behavior) and ignoring (withholding positive reinforcement).
2. Create acceptable new responses to an environmental stimulus by positive reinforcement.
6. Useful with: disturbed children, rape victims, dependent and manipulative behaviors, eating disorders, obsessive-compulsive disorders, sexual dysfunction.
3. Assumptions of behavioral therapy:
1. Behavior is what an organism does.
2. Behavior can be observed, described, and recorded.
3. It is possible to predict the conditions under which the same behavior may recur.
4. Undesirable social behavior is not a symptom of mental illness but is behavior that can be modified.
5. Undesirable behaviors are learned disorders that relate to acute anxiety in a given situation.
6. E Maladaptive behavior is learned in the same way as adaptive behavior.
7. People tend to behave in ways that “pay off.”
8. Three ways in which behavior can be reinforced:
1. Positive reinforcer (adding something pleasurable).
2. Negative reinforcer (removing something unpleasant).
3. Adverse stimuli (punishing).
9. If an undesired behavior is ignored, it will be extinguished.
10. Learning process is the same for all; therefore, all conditions (except organic) are accepted for treatment.
4. Nursing care plan/implementation in behavior modification:
1. Find out what is a “reward” for the person.
2. Break the goal down into small, successive steps.
3. Maintain close and continual observation of the selected behavior or behaviors.
4. Be consistent with on-the-spot, immediate intervention and correction of undesirable behavior.
5. Record focused observations of behavior frequently.
6. E Participate in close teamwork with the entire staff.
7. Evaluate procedures and results continually.
8. Health teaching: teach preceding steps to colleagues and family.
5. Evaluation/outcome criteria: acceptable behavior is increased and maintained; undesirable behavior is decreased or eliminated.