Creating a Therapeutic Milieu in an Acute Psychiatric Setting

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Creating a Therapeutic Milieu in an Acute
Psychiatric Setting

• Presented by
• Dr Laura Dannahy

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• The creation of the atmosphere of a therapeutic
  (milieu) is in itself, one of the most important
  types of treatment which the hospital can
  provide
• World Health Organisation (1953)

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Defining a Therapeutic Milieu

• Creation of a supportive and nurturing
  interpersonal environment for both service users
  and staff
• Multidisciplinary effort
• Teaches, models and reinforces constructive
  interaction
• Promotes strategies for symptom reduction,
  increasing adaptive behaviours and reducing
  subjective distress
• Encourages service user participation in
  decision-making and collective responsibility for
  ward events
• Creation of time space for staff to learn and
  reflect

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Our Service

• The Department of Psychiatry in Southampton is an
  Inpatient psychiatric unit serving an inner city
  area in Hampshire
• It has 3 wards
• 25-bed Male Acute Admission Ward
• 25-bed Female Acute Admission Ward
• 9-bed Psychiatric Intensive Care Unit (PICU)

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Ethos of Inpatient Psychology Service

• Establishing a culture of acceptance, validation
  optimism, based on DBT-informed principles
• Centred around the service user
• Focused on promoting effective coping strategies
• Recognition of the need to support the
  multidisciplinary team working in this area

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Working with Clients DBT in an Inpatient Setting

• Working with Service users
• Individual therapy (formulation / commitment work
  / therapy)
• Individual Skills Training
• Emotional Coping Skills Group
• Working with Staff
• Staff training support
• Input to care planning
• Clinical Discussion Meetings
• Reflective Practice

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Referral Pathway
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Working with Service UsersThe Emotional Coping
Skills Group

• 6-session rolling programme (bi-weekly)
• Aims enhance skills, improve motivation,
  encourage generalisation of skills
• Focus on crisis survival core skills
• Mindfulness
• Distress Tolerance
• Emotion Regulation

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Evaluation of the ECS Group

• Audited via pre post therapy questionnaires
• Clinical Outcomes in Routine Evaluation (CORE
  Barkam et al., 1998)
• Mental Health Confidence Scale (MHCS Carpinello,
  Knight, Markowitz Pease, 2000)
• Living with Emotions Scale (LWES)

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Preliminary Data

• Diagnostic Groups

• Gender

BPD 0
Depression 4
Schizophrenia 3
Schizoaffective Disorder 1
Anorexia Nervosa 1
Total 9
Male 2
Female 7
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Mean Scores Pre Post GroupCORE Scores
plt .05
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Mean Scores Pre Post GroupMHCS LWE Scales
plt .01
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Working with Staff Training Programme

• Aims
• Gain an understanding of borderline personality
  disorder
• Increase skills in assessing risk, presenting
  problems and providing treatment
• Increase staffs level of perceived competence
• Decrease level of fatigue

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Training topics 8 sessionsService users
involved

1. Understanding BPD
2. Formulation biosocial model
3. Devising a care plan target hierarchy
4. Validation

1. Behavioural theory
2. Chain analysis
3. Emotional coping skills Mindfulness
4. Distress Tolerance

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Evaluation of Training Programme

• Self-report measures being used to evaluate the
  effectiveness of training with the following
  aims -
• Explore the relationship between staff attitudes
  towards BPD and stress burnout
• Examine whether the training programme has an
  impact upon attitudes towards BPD, development
  skills and staff stress levels

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Self-report measures include -

• Attribution Questionnaire
• (Markham Trower, 2003)
• Examines participants attributions of the
  causes of behaviour, level of sympathy with the
  patient and optimism for change using six
  scenarios.
• Borderline Personality Disorder
• (Kennedy, unpublished)
• This is a 16-item questionnaire used to measure
  attitudes towards working with people with BPD.
  General Health Questionnaire
• (Goldberg Williams, 1988)
• Measures psychological distress

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Self-report measures cont.

• The Mental Health Professionals Stress Scale
  (Cushway, Tyler Nolan, 1996)
• This is a 42 item measure grouped into seven
  subscales of sources of stress at work
• workload
• client related difficulties
• organisational structure and processes
  relationships and conflicts with other
  professionals
• lack of resources
• professional self-doubt and home/work conflict

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Results

• Preliminary results available in November 2007

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Working with StaffReflective Practice

• Reflective Practice involves
• the critical analysis of everyday working
• practices to improve competence, promote
  professional development, develop
  practice-generated theory, and help professionals
  make sense of complex and ambiguous practice
  situations
• Cowdrill Dannahy, 2007

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Topics For Reflection

• One hour weekly sessions for all staff
• Direct Clinical Practice working with Clients
• Functional Aspects of work
• Self-Reflection

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Challenges Solutions

• Support from hospital management (e.g. Modern
  Matron)
• Support from ward managers to ensure involvement
  of staff members
• Terms of Reference, describing aims, requirements
  expectations.
• Promoted viewed as integral part of working
  life of the ward
• Timing of sessions negotiated handover periods

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Ongoing Challenge

• Cognitive Behaviour Therapy has a great deal to
  offer in-patient services
• It provides the theoretical background, pragmatic
  clinical tools and philosophy for developing
  therapeutic milieu
• Need to be creative and adaptive for the ever
  changing environment of the psychiatric hospital
• Involve service users in order to provide a high
  quality mental health service that meets
  individual needs.

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Contact details and references

• Dr Laura Dannahy
• Laura.dannahy_at_hantspt-sw.nhs.uk
• Dr Vivia Cowdrill
• viv.cowdrill_at_hantspt-sw.nhs.uk
• Forthcoming book chapter Reflective Practice,
• by Vivia Cowdrill Laura Dannahy in Cognitive
  Behaviour Therapy for Acute Inpatient Mental
  Health Units working with clients, staff and the
  milieu. Edited by Isabel Clarke Hannah Wilson.
  Routledge

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References cont.

• Bohus, M., Haff, B., Simms, T., Limberger,
  Schmakl, C., Unckel, C., et al (2004)
  Effectiveness of inpatient dialectical behavioral
  therapy for borderline personality disorder a
  controlled trial Behaviour Research and Therapy
  42, 467-499.
• Swenson, C.R., Sanderson, C., Dulit, R.A.,
  Linehan, M.M. (2001) The application of
  dialectical behavior therapy for patients with
  borderline personality disorder on inpatient
  units Psychiatric Quarterly, 72, 307-324