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Creating a Therapeutic Milieu: An Environment of Respect and Support
by Tom Medlar, MA, LMHC
September 2007

A skilled nursing facility can be an extremely challenging place to work, or to visit, or to live in. Few other jobs could be as difficult, or potentially satisfying, as being a nurse or nurse's aide in a skilled nursing facility. The atmosphere in a facility is filled with tensions that arise from caring for many ill residents, but also because each worker has life problems and stresses outside of work that can impact on the mood of a facility.

We can help improve the mood of a facility if we put aside our personal problems when we come to work and put aside the problems of the facility when we leave our work. But even still the emotional feeling of a facility will often be tense with conflict and frustration. This emotional tone, or atmosphere of a facility, can also be referred to as its milieu (pronounced: mill-you). The milieu can be positive and nurturing for all or it can sometimes be harsh and draining but the difference is created by you; by each person at work in the facility and by the ways you act and react to the challenges and opportunities before you.

A 'therapeutic milieu' refers to a supportive interpersonal environment that teaches, models, and reinforces helpful interactions between all persons. "Milieu" is a French word that means "environment" or "ecology". The term "therapeutic milieu" was first used in the early 20th century by August Aichom in his work with Austrian youth.

In a therapeutic milieu every interaction should help to create an enriched social environment of mutual trust, respect, and support. It is a noble ideal to work toward because of the tangible benefits for every person involved.

Many residents demonstrate medical and psychiatric conditions that are highly sensitive to interpersonal stress. Psychotic illnesses, anxiety disorders, personality disorders, and other conditions can be exquisitely sensitive to stresses in the environment, and in particular, to interpersonal frictions. Emotional tensions, arguments, criticisms, disapproval, and anger expressed between persons create stress. Most persons react with hurt, or resentment, or defensiveness to those sorts of tensions. Even healthy, mature adults may find it difficult to maintain composure and openness in the face of such social stress. Many times a staff person has remarked that dealing with social stresses among coworkers can be more difficult that dealing with behavior problems of residents.

But some residents, especially those residents with psychosis, with cognitive dysfunction, with anxiety or other affective disorders, or personality disorders may be easily overwhelmed by these types of social stresses, and their abilities to cope with stress are often quite limited. Interpersonal frictions can easily worsen an individual resident's symptoms, and can add to his or her emotional suffering, and add to their social dysfunction. Social stresses can worsen many of the problems that caregivers are trying to treat.

Many of these medical conditions are not optional, they are not something the resident can choose to experience or exhibit or not. These are biologically based medical and psychiatric disorders; they are not bad attitudes or simple inappropriate choices that the individual can snap out of.

On the other hand, a staff person may, for example, engage in gossip and critical remarks about another person. This staff person could choose to not speak in that way, and could replace a negative habit (gossiping) with a better habit (restraint). The obligation falls to staff persons to notice and to change the negative emotional aspects of the atmosphere; and make deliberate and disciplined choices of whether or not to contribute to a negative tone in the environment. Each individual staff person has at any moment the opportunity to put aside personal problems from outside of work and to contribute to a pleasant, positive emotional environment. How do we go about creating a therapeutic milieu, or an atmosphere of mutual trust, respect, and support? There are things we should stop doing or avoid doing, and things we should emphasize and practice doing. What are the things we should avoid doing?
  1. Negative comments about others should be stopped.
  2. Harsh judgment statements about others should be eliminated.
  3. Critical remarks and voicing disagreements in language that insults or puts down the other person. Two persons may simply have different viewpoints or a lack of complete information or different roles within an overall team process. In many instances the different perspectives between team members can be healthy differences, yet we can make them unhealthy if we talk about them in negative or harshly critical ways.
Sometimes, in the process of unloading stress or blowing off steam a staff person might speak in a harsh or negative way about a resident or a family member. The staff person does not, of course, mean this as an objective statement about how they really feel about the person, but the reaction may pretty much result in name-calling. We have to catch ourselves and each other, so we notice such actions and stop them.

So, again, eliminating negative, harsh, critical remarks about others is a very important step in creating a therapeutic milieu.

Sometimes when people live or work in a chronically stressful environment - and the clinical environment in a skilled nursing facility is unquestionably chronically stressful- it stirs much tension and emotion and we tend to make the mistake of looking around in the immediate environment and blaming others and thinking that things are unorganized or unpleasant because So & So over there is such a _. It is important to notice and interrupt any such thoughts that others are acting out of bad faith or incompetence, and that they are the cause of the tensions in the environment. It is more helpful to remember that long term care of frail residents is an enormously complicated undertaking, one that is naturally fraught with discord and human emotions that can be unpleasant, and it is not somebody's fault, and we are all trying to make it productive.

Daily clinical activity is not difficult because So & So is being a jerk. It is difficult because it is really difficult. And, it is not only difficult for your team but for all teams in all such settings wherever you go.

Catch hold of the tendency to think or speak critically of others, or of thinking that if the others were smarter, more competent, and more well-intentioned that everything would be fine.

Gossip is a common human activity, and it is not one that produces healthy fruit. Gossip produces bitter fruit. The fact that gossip is widespread and commonplace does not make it acceptable. Gossip is one of those things we all know is wrong to do and we all more or less do it. But part of creating an atmosphere of mutual trust and respect and support requires noticing gossip, holding back from contributing to it, and perhaps speaking up to suggest it stop.

What are the things to actively do and practice to help create a therapeutic milieu?

The Golden Rule applies, of course: treat others as you want to be treated. Recognize and acknowledge others as hardworking and making a good effort and trying to learn and understand. More freely give words of approval, praise, of appreciation to others. Not compliments on personal appearance but compliments on helpful, thoughtful, kindly actions, for example: "I noticed that you responded very nicely to that person just now, that was good, I liked that."

Another step involves preparing oneself emotionally as you come in to work. Recognize that emotions will bounce around like a ball in a pinball machine, and that you don't want to simply be reactive; to light up like the pinball machine or go into a state of 'tilt'. It will never be the case that emotions will be consistently calm in an environment like a skilled nursing facility. It is necessary and inescapable that there will be widespread disarray in the environment.

This is not due to someone's fault but because of the close concentration of many individuals who each bring specific, concrete disorders of a physical, and mental, and emotional nature. Some individuals have multiple disorders and they are clustered with others with various disorders, and therefore the environment will unavoidably include turmoil. Our job is to manage but not to eliminate these conditions of disorder. We care for many medical conditions for which we have no cure. If you think it is your task to simplify or eliminate all the disorderliness it will generate a frantic feeling, and feelings of anger and exhaustion. This can lead to unintentionally adding to the negative qualities of the atmosphere.

The atmosphere in a skilled nursing facility will inevitably be tense, complex, highly emotional and exhausting. This is not because someone is at fault but because of the astonishing complexity of the human situation in a facility. Don't look for fault because in small daily ways (such as how we react to tensions) we are each at fault, and finding fault is like standing in quicksand; it leads in only one direction. Instead we want to look at the many available steps we can take to make this complex and challenging environment also one that is helpful and nurturing for every person involved.

It is possible that individuals can, and do, become stronger, wiser, and more compassionate and patient as a result of living, visiting, or working at a skilled nursing facility. We can every day, and at each moment, choose to act in ways that help make the environment more wholesome and beneficial for all.

A skilled nursing facility is a place of great goodness. It is filled with educated and dedicated and loving persons who feel called to help others who are frail and suffering. It is a business of health care that operates with enormous creativity under complex regulatory pressures and severe financial restraints. It is a home away from home for wise and wonderful seniors who have acquired medical conditions that create needs for care and supervision. It is a place that is highly praised by many families for the kind and thoughtful care given to their loved ones.

It is also, unavoidably to some extent, a place of significant human suffering. The caring persons who staff a facility are often vulnerable to risks of burnout as a result of caring or giving too much and not receiving enough of the personal satisfactions that can make one's caregiving work most rewarding.

The unavoidable tensions in such a clinical environment can bring out negative or positive responses from us all. We always have a choice to make positive contributions by acts of kindness and patience and skillfulness. We can each help to make the atmosphere, or milieu, one that is friendly, helpful, supportive, and therapeutic. In such a therapeutic milieu every interaction can add to creating the trust and respect and support that each person needs and wants.


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