Use of Therapeutic Milieu Interventions in a Psychiatric Setting: A Systematic Review.

BACKGROUND: The therapeutic environment is commonly acknowledged as a significant influence on mental inpatient treatment experiences and outcomes. Therapeutic milieu interventions provide a distinct, secure hospital ward/unit atmosphere where patients with mental illness receive therapeutic interactions and collaborative attentiveness. The review aimed to explore the studies related to the role of a nurse using therapeutic milieu/milieu therapy in a psychiatric setting.
MATERIALS AND METHODS: A systematic literature search was conducted between 1976 and 2021 using PsycINFO, Medline, Embase, and Scopus. A total of 13 papers were identified for a full review.
RESULTS: A total of 70 studies were found, out of which 13 of them were analyzed. These studies looked at several therapeutic milieu concepts, such as therapeutic communication, patient satisfaction, nurse involvement, ward design and structure, and a mixture of therapeutic milieu concepts. Most of the studies explored the concepts of milieu therapy in community settings.
CONCLUSION: In the mental health nursing literature, the milieu, as well as milieu therapy, is a well-debated subject. Though the importance of therapeutic milieu in psychiatric settings is recognized, empirical studies on milieu implementation are scarce. Therefore, research is needed to explore the effectiveness of milieu therapy in inpatient psychiatric care, which facilitates patient recovery, safety, and good interpersonal relationships. Copyright:

Introduction

In the past, mental illness was shrouded in mystery and apprehension. Today, however, the mental health sector has made tremendous progress in understanding and, especially, the ability to offer effective treatments. Moreover, these improvements and advancements helped in erasing the stigma tied to mental illnesses. The psychiatric mental health nurse provides, structures, and manages a therapeutic atmosphere in partnership with the client and other health team members, according to the American Nurses Association's 2000 scope and criteria of psychiatric mental health nursing practice.[1]

The therapeutic milieu is an inpatient unit, nursing units, or other nursing practice setting's distinct nurse-created, nurse-led healing culture and atmosphere. The treatment environment is often discussed in nursing. The therapeutic milieu, on the other hand, is more than just the setting. It is a healing culture rich in therapeutic interpersonal relationships and cooperative attentiveness to patients. In addition, its physical features are soothing and provide for optimum safety and comfort.[2]

The word milieu comes from the French term milieu, which means “middle.”. The word's English meaning is surroundings or environment. In a therapeutic context, it refers to the overall environment and interactions of the environment. A therapeutic milieu is defined as a scientific structuring of the environment to affect behavioral changes and improve the individual's psychological health and functioning.[3]

The history of Milieu therapy dates back to the 1700s; Dr Philippe Pinel found that Paris asylum inmates were less violent when they were free to move around.[4] The medical model and early Freudian methods gained popularity in the 19th and early 20th centuries, and hospitals became places where patients prepared for treatment, emphasizing intrapsychic elements. As a result of this trend, many hospitals have become more regressive and controlling. Sullivan and Menninger reported that patients did not behave psychotically when certain people dealt with them. In 1953, probably the best-known early milieu approach was the therapeutic community, developed by Maxwell Jones, who insisted upon fostering a social-democratic culture. During late 1970, Gunderson (1978) identified five processes needed for a milieu to be therapeutic: containment, support, structure, involvement, and validation.[5]

Furthermore, the discovery of various new classes of psychotropics resulted in a change in psychiatric treatment toward symptom management.[6] At present, milieu for psychiatric care is identified under the standard implementation practice for any psychiatric setting. The milieu of a psychiatric hospital plays a fundamental role in a patient's treatment, yet it is one of the most neglected health-care aspects. Poor milieu management in psychiatric hospitals affects the patient's social environment and, ultimately, mental health. Lack of conducive milieu in psychiatric settings can leave a detrimental effect, such as feelings of self-harm and violence.

Nurses working in a psychiatric ward have a significant responsibility to establish a therapeutic environment by identifying the risks of harming oneself and others, allowing the patients to express their feelings, and providing a safe and comfortable milieu.[7] According to the American Nurses Association, it is the mental health nurse's responsibility to provide, organize, and maintain a therapeutic milieu with the patient and health-care team members.[89]

The therapeutic milieu is better explained as creating a structured environment designed for teaching psychosocial skills and limiting disruptive and maladaptive behavior of patients.[10] A significant challenge for inpatient psychiatric care is maintaining a therapeutic milieu that facilitates patient recovery, safety, and good interpersonal relationship.[11] Pieces of evidence from the West depict that milieu therapy interventions were beneficial for depressive patients who positively impacted clinical outcomes.[1213]

The basic concepts adopted in the therapeutic milieu interventions are based on Gunderson's therapeutic milieu concept that uses containment strategies, structure, support, and involvement.[314] Therapeutic milieu interventions are simple strategies to do in day-to-day mental health nursing practice, and it is quite easy for nurses to practice.[7] These interventions are applied primarily on a long-term care facility for psychosis-related illnesses.[15]

There are qualitative studies, opinions, and narrative reviews documented about milieu therapy in psychiatric settings. Nevertheless, there is a considerable literature gap in empirical studies that tested therapeutic milieu interventions' effectiveness in psychiatric settings. Therefore, this review aimed to examine studies that used therapeutic milieu interventions applicable to psychiatric patients and settings.

Materials and Methods

Study design

This involved a systematic review design.

Search process and study identification

This review was conducted based on Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines using the following keywords “milieu,” “therapeutic milieu,” “milieu counselling,” “therapeutic culture,” and “milieu therapy” AND “psychiatric patients” AND “persons with mental illness” AND “psychiatric setting” AND “mental hospital” AND “serious mental illness.” The following repositories were searched: Science Direct, Web of Science, Medline, PubMed, Scopus and Embase, and Google Scholar. All matching results in the English language between (add month) 1976 and (January) 2021 were screened. After initial screening by the first author, 13 records were shortlisted, and two separate authors then cross-checked the relevance of selected records and jointly concluded. The studies were examined in detail by all the authors, and the studies that used milieu treatment concepts were appraised. [Table 1]

Table 1

Selection Criteria

Inclusion Criteria	Exclusion Criteria
Studies that used the concept of therapeutic milieu therapy, a therapeutic community in a psychiatric setting	Studies that have only abstract
Qualitative studies, Cross-sectional Surveys and experimental studies	Review articles, Scientific proceedings, Literature review
National and International Journals	Other than the English language
Studies undertaken by nurses in psychiatric settings using therapeutic milieu concept and therapeutic milieu interventions done among persons with mental illness.

Data analysis

Studies that match the inclusion criteria were grouped according to two main areas identified as qualitative studies that explored therapeutic milieu concepts (8 studies), and quantitative approaches used different therapeutic milieu models or interventions (5 studies).

Results

The findings of the studies were analyzed based on the study methodologies used and the conclusions presented by the various studies that were used [Figure 1]. The general properties of the studies are shown in Supplementary Table 1.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram, 2015

Supplementary Table 1

Summary of Articles explored the Use Of Therapeutic Milieu Interventions/Milieu therapy

Article title	Authors	Time	Type of Study	Findings, Conclusions& Suggestions
What’s therapeutic about the therapeutic milieu?	Thomas SP, Shattell M, Martin T	2002	Qualitative Study, Existential phenomenology	The author explored what is therapeutic in the therapeutic milieu found that patients expressed the longing for a deeper connection with staff and more intensive insight-oriented therapies. Although their safety, structure, and medication needs were met, patients were not gaining a greater understanding of their dysfunctional patterns of behaviour. Therefore, renewed emphasis must be placed on the nurse-patient relationship and the therapeutic alliance.[16].
Characteristics of effective nursing interventions in the management of challenging behaviour	Lowe T	1992	Qualitative Semi-structured interviews and participant observation.	The study investigated the interventions of Providing Structure used by psychiatric nurses by semi-structured interviews and participant observation. Confirming messages, personal control, staff honesty, giving face-saving alternatives, setting limits, use of structure, facilitating expression, monitoring, timing and soothing, and non-verbal abilities were found to be ten categories of effective interventions. The effects of Providing Structure appeared to increase when patients report feeling safe and protected by an individual nurse and not forced to do what others want them to do[17].
Milieu Therapy How to implement it in Aceh mental hospital	Armiyadi M.	2012	Qualitative study. Multi-stage focus group interview with 22 nurses.	The result showed that there was a desire of respondents to provide better treatment and care for the patients. The study concluded that involving family members, patients, and all staff involved are necessary to succeed in the milieu therapy program[18].
The importance of a Psychiatric Milieu in Inpatient Settings	Caesar LG	2015	Qualitative study. Geriatric patients and Nurses working in psychiatric wards.	The study described implementing a structured milieu, which included one nurse-led group focused on activities of daily living, exercise groups, grief management, current events and reminiscence, discharge planning, problem-solving, spiritual health, and medication management. The results showed increased patient satisfaction, nurse job satisfaction, and improvement in patients’ clinical outcomes after the intervention among patients with geriatric depression[3].
Patients’ Experiences of Participating Actively in Shared Decision-Making in Mental Care	Beyene LS, Severinsson E, Hansen BS, Rørtveit K,2018	2018	A qualitative study, ten clinical sessions with eight mental health professionals.	The findings indicate that there are some conditions for using Shared Decision Making in a therapeutic setting. The findings were interpreted to reveal a single theme: using SDM when balancing power and responsibility to build safe care, which served as an internal link between the three categories, each of which had two subcategories. The first is centred on applying professional abilities and being attentive to the patient. The third category, creating a culture of trust, is based on applying guidelines in a person-centred way and standing together as a team. Clinical supervision is required for SDM reflection and practice improvement in a therapeutic environment.[19]
Understanding the milieu experiences of patients in an acute care psychiatric unit	Thibeault CA, Trudeau K, d’Entremont M, Brown T.	2010	Qualitative, Phenomenology	Patients’ experiences of recovery and wellness in a rule-bound, controlling, and occasionally repressive atmosphere was reported by the authors and patient experiences of recovery and well-being in the same context. The authors shared narrative accounts to generate a new understanding of patient experiences and suggested that the in-patient psychiatric milieu remains an essential but often neglected component of psychiatric treatment. (20)
Worker perspectives on contemporary milieu therapy: A cross-site ethnographic study.	Smith Y, Spitzmueller MC	2016	Qualitative Ethnography	Participants stated that (a) everything in the physical and social milieu has the potential to affect therapeutic change; (b) the milieu itself acts as a therapeutic agent; (c) the milieu provides a context for modelling and practising desired behaviours; and (d) MT is a principle-based ethos rather than a set of specific interventions. [21].
User participation when using milieu therapy in a psychiatric hospital in Norway: a mission impossible?	Oeye C, Bjelland AK, Skorpen A, Anderssen N,2009	2009	Qualitative Ethnographic study	Three significant tensions and challenges were identified on implementing user participation in milieu-therapeutic work. First, implementing individual-based user engagement while also considering collective house rules and norms of conduct is difficult. Second, user participation was problematic when patients’ perspectives clashed with professional judgments about correct conduct and goals that patients might pursue. Third, user participation becomes a challenge when establishing relationships based on equality when using milieu therapy in a biomedical hierarchical hospital structure[22].
Factors influencing the ward atmosphere	Friis S	1986	A cross-sectional, descriptive study.	The study evaluated 35 short term wards with a good milieu index among psychotic and non-psychotic patients who needed different types of atmosphere. It was found that psychotic patients benefited primarily from a milieu with a high level of support, practical orientation and order and organisation, and a low level of anger and aggression, while the non-psychotic patients mainly benefited from a milieu with a high level of staff control and the level of anger and aggression.[23].
Roles of Psychiatry Nurses Within a Therapeutic Environment of Psychiatry Clinics in Turkey	Ergun G, Isik I, Dikecc G	2017	Cross-sectional and descriptive design in 195 institutes comprising psychiatry clinics in Turkey, 1535 Nurses	The study revealed that Most of the Psychiatric clinics of Turkey had documents in which the clinic rules had been written, and that they were either hung on walls or doors and that these rules were explained to the patients and their families by the nurses in all the clinics. It was found that there were in-service training for psychiatric patients in more than half of the clinics. When the educational contents were reviewed, there were schizophrenia and psychosis, intervention in the crisis, depression, anger management, and neurotic disorders. The following responses were collected for nurses’ clinical responsibilities: 54,4 percent said they play with patients or paint. Nurses were found to be in charge of teaching activities in the majority of psychiatry clinics. The researchers advise that the expansion of nurses’ roles and responsibilities in such activities be encouraged.[11]
Level of Satisfaction of the Patients Regarding New Milieu Therapy Provided by the Health Team in a Selected Psychiatric Hospital.	Thomas S	2013	A one-group pre-test post-test design using an evaluative approach 45 patients	The study compared the patient’s level of satisfaction after introducing a structured new milieu therapy (Physical environment, ward programme and communication) with the existing milieu. It was found that after a month of stay in a hospital, the clients with mental illness were more satisfied with the new milieu than the existing milieu. The satisfaction scores related to ward programmes were higher in the new milieu therapy. Clients seem to be motivated and enthusiastic in participating in the sessions.[15]
Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients.	Bhat S, Rentala S, Raveesh BN, Chellappan XB	2020	Quasi-experimental non-equivalent control group pre-post design 100 patients	This study revealed that compared with the control group, the experimental group participants showed a decrease in aggressive behaviour, self-harm behaviours and general rule-breaking behaviour at baseline and follow up assessments (F=4.61, P<0.004, ηp2=0.04; F=11.92, P<0.001, ηp2=0.11; F=6.94, P<0.001, ηp2=0.06) over seven days interval[24]
Effectiveness of therapeutic milieu intervention on inpatients with depressive disorder: A feasibility study from North India.	Chellappan XB, Rentala S, Das A	2021	Pretest-posttest non-equivalent control group quasi-experimental design.	This study concluded that over 3 months’ follow-up, participants in the Therapeutic Milieu Intervention group reported significant improvement on depression (F (1,58) = 9.645, P=0.000, ηp2=0.573), social occupational functioning (F (1,58) = 114.765, P=0.000, ηp2=0.401) and self-esteem (F (1,58) = 23.11, P=0.000, ηp2=0.574), compared to control group.[25]

Years of studies

About two studies on therapeutic milieu were documented between 1986 and 2000. Three studies were conducted studies between 2001 and 2010. Most studies (8) related to the subject were published after 2011.

Types of participants

The sample group consisted of nurses, caregivers, and patients. Of the empirical studies, the sample size varied from 45 to 100.

Geographical regions

The studies were carried out in various parts of the world, with the majority of them coming from western countries.

Data collection methods used in the studies

Questionnaires developed by the researchers and standardized tools were used in five quantitative studies, while other qualitative studies used structured or semi-structured interview questionnaires created by the researchers is based on relevant literature review.

Discussion

This review observed that the number of studies on the therapeutic milieu/milieu therapy concept in mental health settings is increasing slowly in national and international forums. This progress is associated with the change of psychiatric nurses' role in the health-care system. This review revealed that the milestone contribution in the concept of therapeutic milieu is associated with Gunderson, 1976, who described the framework that has the five specific concepts of a therapeutic milieu. Figure 2 describes the common assumption by which milieu therapy is managed. The ultimate purpose of the milieu setting is to give patients a stable and cohesive social context in which they can heal, recover, and grow in a safe and therapeutic atmosphere.[11]

Figure 2

Basic assumptions of establishing a therapeutic milieu

Need for establishing therapeutic milieu

To increase the overall patient satisfaction by creating a structured therapeutic program that involves nurses in groups creates an environment in which nurses feel more engaged with the patients and have more autonomy in their practice.[13]

To explore patients' experiences of constant observation to determine whether they derive any therapeutic benefits beyond the intended protective benefit from suicidal intent or behavior.[25]

To understand and evaluate the need for a good ward atmosphere for psychotic and nonpsychotic illness.[23]

To assist nurses, control the environment's tone, pace, and activity level in the inpatient psychiatric setting.[26]

To reduce aggression, self-harm, and other risky behaviors of a selected group of patients with mental illness using safe ward interventions.[27]

To evaluate “Providing Structure” as a psychiatric nursing intervention: Strategy of therapeutic milieu.[28]

To identify the adverse events associated with general hospital inpatient psychiatric care environments.[29]

The review sheds light on various the need for establishing the therapeutic milieu in a psychiatric setting. Safety and security are vital components in a ward atmosphere since no other treatment works if the safety is compromised. The milieu has both structured and unstructured components, including the diverse interactions between patients, staff, and visitors throughout the hospitalization.[16] A preponderance of the literature describes the structure of the milieu, such as the program schedule or an activity schedule, as contributing to the overall success in treating mental health patients in the inpatient setting; however, the literature lacks studies on the potential benefits of the unstructured milieu which includes interpersonal interactions with other patients and with staff.

Changing the environment to affect a patient's behavior and improve his or her health is the definition and function of a milieu. The patient learns how to exist within and to interact in a better environment. This facilitates learning and helps develop the skills to make behavioral changes after his/her hospital experience by learning adaptive techniques. In milieu therapy, patients' lives are organized, and they learn practical and social ways of coping with their symptoms through group sessions and individual one-to-one discussions with their nurse or other health-care providers. Furthermore, the patients involved in milieu therapy actively participate in groups and activities to help provide some sense of normalcy.

The goals of milieu environments are to change the patients' environment to a therapeutic area of healing. In the environment, the patient and health-care provider must practice respect. Communication occurs between the patient and the health-care provider to enhance the patient's self-esteem and help create autonomy. In the milieu, patients are encouraged to participate in decision-making and are given responsibility for their activities.

According to studies, people who use mental health services often feel that being in the hospital is not helping them and that they are not treated with respect by staff and high bed occupancy rates combined with low staffing levels means that there is often little time for interaction between staff and service users.[13]

Standards and principles of practice governmental health nursing as a health-care profession and these principles must be evaluated and backed up by evidence. A strong nurse–patient relationship and an organized therapeutic milieu are essential features of high-quality mental health care in inpatient settings. Literature shows various psychosocial interventions used for patients with mental illness to establish the therapeutic milieu in a psychiatry setting.[3031]

Patients with mental illness have unique needs (physical and psychological) and require a safe ward environment to manage persons with mental illness. The milieu therapy intervention is very beneficial, such as environmental modification and structuring ward activities, establishing effective interaction with patients, and teaching caregivers' communication skills in a psychiatric setting in low or middle countries. The study results suggest that nurses can implement milieu therapy in an inpatient psychiatric setting.

The current study explored the usefulness of implementing therapeutic milieu interventions in psychiatric settings. This study will empower nurses to take the lead in implementing milieu therapy interventions for persons with mental illness. Nurses can play a crucial role in implementing a therapeutic milieu, hence helping the patients within the limits of their capability to become productive members of society. Establishing a quality nurse–patient relationship and a structured therapeutic milieu in a psychiatric setting is a fundamental element of mental health care. Conducting structured group activities with all levels of staff in a psychiatric ward will help to create a healing atmosphere in the psychiatric unit. Implementing an activity schedule as part of routine care can ensure the involvement of patients and caregivers in their treatment. Nurses can manage and prevent inpatient suicides and self-harm by conducting a suicide risk assessment and using a suicide observational checklist in everyday clinical practise.

Although the present review explored a much-needed topic of psychiatric settings and tried to cover pieces of literature worldwide, there are few limitations. Due to limited empirical studies, there were only a few interventional studies reviewed. The present study sheds light on other researchers to carry out an interventional study by testing therapeutic milieu interventions on various outcome variables. Studies on cost-benefit analysis, patient and provider satisfaction, and nurse-led therapeutic milieu interventions in psychiatric settings can be carried out. Community-based milieu therapy interventions can be planned to emphasize preventive health care, which provides cost-effective therapeutic benefits for patients with mental illness.

Conclusion

Milieu therapy interventions are simple, safe, cost-effective which can be used in any inpatient psychiatric setting. However, there are few experimental studies found on milieu therapy. Nurses play a crucial role in the management of the therapeutic milieu who carry the responsibility for ensuring that clients basic needs are fulfilled; assessing physical and psychosocial status, administering medications, ensuring safety, helping the client to develop trusting relationships, setting limiting on unacceptable behaviors, structuring ward activities for the clients, educating patients and caregivers, and ultimately, helping the patients within the limits of their capability, to become productive members of society.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.