I.

Milieu Management
II. Group Therapy

Introduction
Healthcare professionals not only
share their personal lives with
groups of people, but also encounter
multiple group situations in their
professional operations
Clients learn from each other in a
group setting

Milieu Therapy
Clients as responsible people
Clients rights to choose and
participate in a variety of
treatments
Group and social interaction

Safety & Therapeutic Milieu

What characteristics of the nurse are
necessary to provide a safe &
therapeutic milieu?
What are the characteristics of a
therapeutic milieu?

Milieu Management Therapeutic

Modalities
A therapeutic milieu is where the client
feels respected, safe, and empowered
Confidentiality & privacy of information
Competent assessment & re-assessment
through therapeutic communication &
collaboration with other disciplines
Limits & boundaries are clear & consistent

Therapeutic Milieu, cont.

Physical environment is safe, lowstimulus
Adequate staff for census
Provides for clients physical needs:
sleep, hygiene, nutrition, ADLs,
exercise, spiritual needs, meds (nurse
checks for cheeking & hoarding)
Nurse must have knowledge of
medications, including side-effects
Client/Family Ed

Role of Nurse in Group

Intervention
Nurses who work in psychiatry may
lead various types of therapeutic
groups, such as client education
groups, assertiveness training, support
groups for clients with similar
problems, parent groups, transition to
discharge groups, and others.

Therapeutic groups vs. group

therapy

Group therapy has a sound theoretical base, and

leaders generally have advanced degrees in
psychology, social work, nursing, or medicine.
Therapeutic groups are focused on group relations,
interactions among group members, and the
consideration of a selected issue.
Leaders of both types of groups must be
knowledgeable about group process (the way in
which group members interact with each other)
and group content (the topic or issue being
discussed in the group).

Role of Nurse in Group Intervention

(cont.)
Guidelines set forth by the
American Nurses Association
specify that nurses who serve as
group psychotherapists should
have a minimum of a masters
degree in psychiatric nursing

Interventions in Groups
Definition of a group:
A collection of individuals whose
association is founded on shared
common interests, values, norms, or
purpose

Functions of a Group
Socialization -The teaching of social

norms occurs through group interaction

Support - Fellow group members are
available in time of need
Task completion - Groups can assist in
endeavors that are beyond the capacity of
one individual alone
Camaraderie - Individuals receive joy
and pleasure from interactions with
significant others

Functions of a Group
(cont.)
Normative - Different groups enforce

established norms in various ways

Informational - Learning takes place
when group members share their
knowledge with the others in the group
Empowerment - Change can be made by
groups at times when individuals alone
are ineffective
Governance - Large organizations often
have leadership that is provided by
groups rather than by a single individual

Types of Groups
Task groups - This is a group formed to
accomplish a specific outcome or task
Teaching groups - The focus is to convey
knowledge and information to a number
of individuals
Supportive/therapeutic groups - The
primary concern is to prevent possible
future upsets by teaching the
participants effective ways of dealing
with emotional stress arising from
situational or developmental crises

Types of Groups (cont.)

Self-help groups
Composed of individuals with a similar
problem
Serve to reduce the possibilities of further
emotional distress leading to pathology and
necessary treatment
May or may not have a professional leader;
run by members; leadership often rotates
from member to member

Dialectical Behavioral
Therapy
Originally developed
for treatment of
(DBT)

individuals with borderline personality

disorders, but currently has wider
applications
Group participants learn alternative coping
strategies to improve interpersonal,
behavioral, cognitive, and emotional skills
and reduce self-destructive behaviors
See text for other types of groups and
strategies for working w/ difficult clients

Physical Conditions that Influence

Group Dynamics
Membership - Two types of groups
exist:
Open-ended groups members
leave and others join at any time
during the existence of the group
Closed-ended groups all members
join at the time the group is organized
and terminate membership at the end
of a designated period

Physical Conditions that Influence

Group Dynamics (cont.)
Seating - Best = no barrier between
the members; for example, a circle of
chairs is better than chairs around a
table
Size - Size matters; seven or eight
members provide for optimal group
interaction and relationship
development

Yaloms Curative Factors of

Groups

Instillation of hope - By observing the

progress of others in the group with similar
problems, a group member gains hope that
his or her problems can also be resolved.
Universality - Individuals come to realize
that they are not alone in the problems,
thoughts, and feelings they are
experiencing.
Imparting of information - Group
members share their knowledge with each
other. Leaders of teaching groups also
provide information to group members.

Curative Factors of Groups,

cont.
Altruism - Individuals provide assistance and

support to each other, thereby helping to create

a positive self-image and promote self-growth
Corrective recapitulation of the primary
family group - Group members are able to reexperience early family conflicts that remain
unresolved
Development of socializing techniques Through interaction with and feedback from
other members of the group, individuals are
able to correct maladaptive social behaviors
and to learn and develop new social skills

Curative Factors of Groups

(cont.)
Imitative behavior - Group members who

have mastered a particular psychosocial skill or

developmental task serve as valuable role
models for others
Interpersonal learning - Group offers varied
opportunities for interacting with other people
and learning about self through interaction
Group cohesiveness - Members develop a
sense of belonging rather than separating
individual (I am) from group (we are)

Curative Factors of Groups

(cont.)
Catharsis - opportunity for expression of

strong affect
Existential resolution - recognition of the
basic features of existence through sharing
with others (e.g. ultimate aloneness,
ultimate death, ultimate responsibility for
our own actions)
Box 34-2

Phases of Group
Development

Phase I. Initial or orientation phase

1. Leader and members work together to
establish rules and goals for the group.
2. Leader promotes trust and ensures that
rules do not interfere with fulfillment of the
goals.
3. Members are superficial and overly polite.
Trust has not yet been established.

Phases of Group Development

Phase II. Middle or working
phase
1. Productive work toward completion of
the task is undertaken.
2. Leader role diminishes and becomes
more that of facilitator.
3. Trust has been established among the
members, and cohesiveness exists.
4. Conflict is managed by the group
members themselves.

Phases of Group Development

Phase III. Final or termination phase
1. A sense of loss, precipitating the grief
process, may be experienced by group
members
2. The leader encourages the group members
to discuss these feelings of loss and to
reminisce about the accomplishments of the
group
3. Feelings of abandonment may be
experienced by some members. Grief for
previous losses may be triggered

Leadership Styles
Autocratic. Focus is on the leader, on
whom the members are dependent for
problem-solving,
decision-making, and permission to
perform.
Production is high, but morale is low

Leadership Styles (cont.)

Democratic - Focus is on members, who
are encouraged to participate fully in
problem-solving of group issues, including
taking action to effect change. Production
is somewhat lower than with autocratic
leadership, but morale is much higher

Leadership Styles (cont.)

Laissez-faire
There is no focus in this type of
leadership. Goals are undefined, and
members do as they please.
Productivity and morale are low.

Member Roles
Members play one of three types of roles
within a group:
Task roles - serving to complete the
task of the group
Maintenance roles - maintaining or
enhancing group processes
Individual (personal) roles - fulfilling
personal or individual needs