How to Manage the Village

Transcription

1 How to Manage the Village Behavioral Health Therapeutic Milieu Management March 2015

2 What is a Therapeutic Milieu? A Therapeutic Milieu is a structured group setting in which the existence of the group is a key force in the outcome of treatment. Using the combined elements of positive peer pressure, trust, safety and repetition, the therapeutic milieu provides an idealized setting for group members to work through their psychological issues The keys to a successful Therapeutic Milieu are support, structure, repetition and consistent expectations. Therefore, the therapist s role in developing a therapeutic milieu is both complicated and highly important. He / She must serve as role model, practicing the behaviors that are expected of the group. They must facilitate the group in developing a list of rules and expectations and dealing with infractions without coming across as an authority figure. The therapist should guide the group towards self-management without allowing natural leaders to overshadow the participation of natural followers. By Lisa Fritscher Phobias Expert Updated November 25, 2014.

3 What is a Therapeutic Milieu? A Therapeutic Milieu is one that supports an individual s needs and the development of those skills necessary for individuals to get their needs met (coping skills). Since all individuals needs are different, a Therapeutic milieu is one that supports different individual s needs simultaneously. Teach people to be successful in meeting their needs. A Non-Therapeutic Milieu is one that fails to meet individual needs. A Toxic Milieu is one that supports a negative identity and/or ineffective or destructive behaviors.

4 Patient Needs Needs are the conditions necessary for a person to be physically, socially, and emotionally healthy. Abraham Maslow s Hierarchy of Needs is the best known listing of basic and advanced human needs. Individuals needs progress from the lowest level to the highest possible. If the lower level needs are met, Self-Actualization provides personal satisfaction. If the four lower levels of needs are not met the individual Feels Anxious and Tense.

5 How Does a Milieu Meet Needs? The Milieu of a Behavioral Health Unit Consists of the Physical and Social Environment. To be Therapeutic the milieu must: Provide for air, food, water, restrooms and shelter from the weather. Provide a sense of security of body, employment, morality, family, health and property. Recognize the need for friend & family relationships. Meet each patient s need for self-esteem, confidence, achievement and respect for and by others. Once basic needs are met we need to provide a SAFE ENVIRONMENT to learn and practice new skills.

6 What Does a Therapeutic Milieu Look Like? There is minimal expression of the power differential between staff and patients. Patients are involved in milieu decision-making. Patients are active participants in their treatment decisions and in goal-setting. The patient is considered the expert in his/her problems. Staff and patients mingle and interact fluidly and with respectful empathy. Boundaries are maintained but not emphasized.

7 What Does a Therapeutic Milieu Look Like? Patients assume an active role in discussion of community problems. (This may not always be possible with some Geriatric Milieus) Patients are encouraged to give and receive feedback, and to take an active part in therapeutic activities. A sense of responsibility for others and increased selfesteem are promoted with fostering of group identification and cohesiveness. ALL interactions are considered potentially therapeutic and a possible learning experience.

8 Goals for a Therapeutic Milieu The Goals of a Psychiatric Inpatient Therapeutic Unit are to: Provide a safe environment : where patients can develop a pattern of healthy interaction with their world. Individualize goals : depending on the patient and focus areas where they are not experiencing success. Alleviation of the patient s symptoms and return of patient to pre-morbid level of functioning, or stabilization of symptoms and slow progression of the illness. Provide opportunities :to improve interpersonal skills. Provide opportunities: to increase problem-solving ability. Provide opportunity for patient to develop a positive and realistic self-concept and increase self-esteem.

9 Goals for a Therapeutic Milieu The Goals of a Psychiatric Inpatient Therapeutic unit are to: Encourage patients to seek alternative solutions and behaviors in handling their problems. Encourage patients to verbalize feelings and explore meanings of behaviors and feelings Encourage expression of feelings in a safe and constructive manner. Provide safety: Structure and consistency are maintained, reducing uncertainty. Staff manage and set limits on dangerous or violent expressions of feelings (suicidal or homicidal acts, for example). Provide accepting atmosphere with emphasis on positive reinforcement for appropriate behaviors.

10 Expectations of Staff The Key to Creating a Therapeutic Milieu: Staff Responsibilities Establish rapport with patients and encourage them to express their feelings, ability to socialize, ability to problem-solve, and in setting realistic goals for themselves. Maintain a non-judgmental attitude. Reinforce the concept that behavior may be unacceptable, but the patient and his/her feelings are still accepted. Encourage reality-testing, socialization, etc. as established in the patients care plans Emphasis is on positive reinforcement for appropriate behavior. Know what motivates your patients so that reinforcement is effective. Observe, report and record patients behaviors and responses.

11 Expectations of Staff The Key to Creating a Therapeutic Milieu: Staff Responsibilities Know ALL the patients well enough to understand their perceptions and feelings. Be able to say why a patient behaved the way he/she did. Do not use words to describe a patient s behavior that could be perceived as biased or misleading Validate your impressions with the patient so that you know you understand the patient correctly and the patient knows you care enough to understand his/her perspective.

12 Interdisciplinary Team Members People in the milieu include: Psychiatrists & other physicians Nurses Psychiatric Social Workers Occupational Therapists Activity/Recreational Therapists Mental Health Technicians Nursing assistants Support Personnel Patients Family * Guardian * Significant Others * Other Support Systems* (as indicated) *A person does not need to be physically present to be a part of the milieu.

13 Roles of the Interdisciplinary Team MAINTAIN THE MILIEU All staff are responsible for functioning as : Role Models Demonstrate professional, adult, appropriate behaviors at all times, e.g. in dress and personal appearance, interpersonal manner and interactions, problem-solving, sharing, work habits, conflict resolution. Counselor/ Coach All staff need to use psychotherapeutic techniques such as active listening, reflecting, redirecting and limit-setting when needed. Focus on the here and now. Follow the treatment plan. Formal psychotherapy is only provided by those licensed to do so. Teacher Educate patients and others about illness, treatment & symptom management. Socializing Agent Assist patients in appropriate interpersonal skills, including grooming hygiene and other self-care. Advocate ASSURE SAFETY, fulfill basic needs, & emphasize dignity. Enforcer If the milieu becomes toxic, assume control. Deal with toxic factors.

14 All Staff Members Must Be aware of everyone, what they re doing, how they re feeling, & what is in your environment. KNOW YOUR ENVIRONMENT Make sure all team members know necessary information about each patient. OBSERVE THE MILIEU from the inside as a participant, not as an outsider. IF YOU ARE SITTING IN THE NURSES STATION YOU ARE IN DANGER OF MISSING SIGNS OF IMPENDING PROBLEMS OR PATIENT BEHAVIORS. Sit in the dayroom will help you to know your patients. Attend to escalating situations. Notice who is becoming more irritable and agitated, or perhaps more withdrawn and secretive. Only through continuous observation & awareness can you intervene before there is a crisis. Ensure that effective communication occurs between disciplines, within disciplines and between shifts.

15 Keep everyone safe EMPHASIZE DIGNITY AT ALL TIMES Ethnic, cultural, spiritual, and other differences (including differences of opinion) are respected - in patients, staff, family, and visitors. Even when you feel it is not deserved! When the atmosphere is anxious, remember you are the professional & the role model. You keep the milieu therapeutic. Positively reinforce positive behaviors. Be alert for any crisis. Remember Use physical and social environmental tools to calm a restless environment and put out the fire before it is out of control.

16 Safety First 1 Physical & Psychological Safety are the Highest Priority. Patients have a right to expect they will be kept safe and their welfare will be maintained. ALL staff must identify Potential and Actual hazards and eliminate or minimize them when you identify them. Survival requires air, water, food, clothing, shelter. Does the unit feel safe? Does the unit provide adequate warmth, food, water? Does the staff make the patients feel important, smart, attractive, in control, supported, respected, trusted, strong and healthy? There is just one room of the milieu it is the entire unit

17 Some Thoughts About the Milieu Light, sound, space, smell, furnishings, wall, floor and ceiling construction, cleanliness, new, old? Allows and supports privacy? Encourages togetherness or apartness? Inclusive or separates into distinct classes or cliques? Does the physical environment support the patients basic needs? How? In what ways does the physical environment of your unit not support physiological needs, safety, love and belonging and self-esteem? What is the furniture like? How many pieces of what type? Color? Condition? What other objects are in the room? Anything that could be potentially hazardous? What are the walls like? Color? Condition? Any windows? Window coverings? Color? Condition? What is outside? Any pictures or signs? What do the signs say? Calendar? Clock? Does the clock tick? What about the floor? Color? Condition? Shiny or dull? Anything on the floor? What is the room temperature like? Too hot or cold? Who controls it?

18 Some Thoughts About the Milieu What sounds are there? Loud or soft? Harsh or soothing? Outside sounds? Any TV or music? What is playing? What message is the show conveying? How will patients respond? Who is in the room? What are they wearing? How are they groomed? Anything else you can recall about the environment, the contents of the environment, the people, and what is happening? Who is there? Where are they? What do they look like? How are they dressed? How do they conduct themselves? What are their facial expressions? What are they doing? What are they saying? How are they saying it? How are they responding to others? How are others responding to them? What is happening to make the patient feel less than or equal to peers & staff in worth, respect, value? Do the social interactions and structures support patients basic needs? How? In what ways does the social environment of your unit not support physiological needs, safety, love and

19 Why Do We Do Community Meetings Provides direct communication between patients and staff. Orients patients to unit rules and behavioral expectations. Provides opportunity to deal with community problems. Provides opportunity for staff to offer guidance in problem-solving. Helps patients and staff gain insight into problem areas on the unit. Allows members of the community to give and receive feedback. Increases sense of responsibility and promotes self-esteem with involvement in the community. Serves as a forum for discussion of community problems, policies, etc.

20 Behavioral Expectations of Patients Personal Responsibility: Each of us is accountable and responsible to be honest and for our own behavior Appropriate Behavior To Include: No violent or aggressive behavior Appropriate dress Respect personal boundaries, no flirtatious or sexual behavior No use of alcohol or non-prescribed drugs No smoking except in designated areas (according to unit rules) Adherence to unit rules Participation in treatment activities (according to the treatment plan) Participate as a responsible member of the community Show respect, practice the Golden Rule and help each other

21 Safety Attachment Guidelines THIS INFORMATION IS MEANT TO BE A GUIDELINE AND REFERENCE FOR YOU GUIDELINES FOR PERFORMING OBSERVATIONS/PRECAUTIONS Staff who conduct special observations (1:1, 15-minute checks, etc.) play an important role in the care of the patient with special needs. What may often seem a mundane task can be one with significant impact on the patient from both a therapeutic and safety-related standpoint. Observations should entail more than just eye-balling the patient every minutes. Here are some pointers for making this task effective for the patient and the staff. When assigned to perform special observations, know the reason for the closer observation. Is it due to the patient s suicidality, aggression, sexual acting out, propensity for arson, propensity for elopement, fall precautions, disorientation or severity of psychosis or disorganized thinking? The more you know about why the patient needs closer observation, the more effective you can be in carrying out the observation task. Well-informed staff can assess and intervene with the patient to make an impact on the problems identified by the treatment team. Being aware of the need for monitoring will help you be more astute in your observations of the patient. If the patient is being monitored because of suicidal ideation, you would want to be particularly aware of any mood changes, suspicious behavior or potentially dangerous items that the patient might possess. For those patients on elopement precautions, you might watch for signs that the patient is planning to run, such as watching the doors closely, pacing in front of the doors, checking windows or exits and wearing layers of clothes or a jacket on a hot day. You might also be more observant of alternative exits, such as windows in patient rooms, checking to see that they are secure.

22 Safety Attachment Guidelines THIS INFORMATION IS MEANT TO BE A GUIDELINE AND REFERENCE FOR YOU When a patient is on close observation for fall prevention, your monitoring might include observation of the patient s gait or steadiness on his/her feet and his/her level of compliance with safety instructions from staff. (Did the patient ask for assistance before getting up? Is he/she using assistive devices such as a cane or walker as instructed?) For patients who may sexually act out, you may observe for preoccupation with sexual thoughts, seductive remarks or gestures, provocative dress, insufficient physical boundaries with others, attempts to touch others inappropriately, attempts to hide or seclude oneself with someone in a room, bathroom, or out-ofthe-way places. You might be more observant of this patient s location and with whom he/she is socializing. Is the patient loitering near certain rooms? Does he/she behave in a secretive manner with select peer(s)? When a patient has a propensity for arson, you might observe carefully for flammable items or for an exchange of flammable items (such as a lighter, matches or cigarettes) with visitors. Does this person try to isolate self away from observation? Does he/she appear to hide items in pockets or away from view? You may also be closely observing a patient for unpredictable behavior or inability to sustain simple ADL activity such as dressing or eating due to psychosis or dementia. In this case, you can assess the patient s reality orientation and unusual behaviors.

23 Safety Attachment Guidelines THIS INFORMATION IS MEANT TO BE A GUIDELINE AND REFERENCE FOR YOU Not only can the special observation tasks be used to assess the patient, but also to provide important interventions. Constant or frequent contact is an excellent opportunity to establish rapport with the patient. A patient who feels connected with you or other staff is more likely to be trusting and open with you. Making contact with the patient s family members when they are visiting and observing their interactions with the patient can also provide some valuable information for the treatment team. All of these can be accomplished through contact during 1:1 or 15-minute observations. Other interventions can be implemented during close observations if you know why the observations are ordered. For the suicidal patient, providing support and encouraging the patient to discuss clinical issues and feelings of suicide intent is an important part of decreasing the potential for suicide attempts. When close observation is indicated for fall prevention, frequent contact can be used to educate and/or remind the patient to rise slowly or ask for assistance when needed as well as ensuring that the patient s environment is free from obstacles. Disoriented or psychotic patients can be reoriented as necessary but sometimes get angry if they feel they are being chastised or corrected too much. If the patient is assessed to be increasingly agitated or confused during attempts to reorient, it is best to back off and not insist that their orientation be correct. In this case, focus more on feelings than facts.

24 Safety / Observation Tips Many patients in our facility require special observation at some point in their hospitalization, usually at the onset. If you truly understand the importance of this observation and utilize the time spent to assess and intervene with the patient, you can have significant impact on the patient s care and increase the possibility of the outcome. SAFETY / OBSERVATION TIPS When a patient is on 1:1 observation, that means just that, one-to-one. You should observe the patient at all times; don t trust the patient to run to the bathroom real quick. Patients who are intent on eloping or attempting suicide often deceive staff to gain an opportunity to act on their intent. If you are conducting unit rounds, these are done continuously while assigned to that time period for rounds. Although observations are documented every 15 minutes for those on 15-minute checks, observations are made at least every 15 minutes, with times staggered so the patient cannot predict exactly when you will make your next observation. When the patient is in bed, be sure that the form in the bed is actually the assigned patient and that he/she is in no distress. That may sound obvious, but when it s dark in the patient room and everyone seems to be asleep, it s often difficult to assess the situation without the potential for disturbing someone s sleep. A flashlight low to the ground can oftentimes provide enough light to be sure the patient is safe and sound. Observe the rise and fall of the patient s chest to confirm that he or she is breathing without difficulty. Explain to the patient, on admission, your facility s desire to provide a safe environment for patients, staff and visitors. Describe the processes for providing special monitoring. Educating patients about our systems will usually help alleviate the problem of a frightened patient awakened in the middle of the night by staff members conducting rounds or an angry patient who feels like staff are always barging in. We all respond better to situations when we know in advance what to expect.

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