Creating a
Therapeutic Milieu
in an Acute Psychiatric Setting
Presented by:
Dr Laura Dannahy
“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)
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
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)
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
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
Referral Pathway
Assessment
Practice, Clinical Discussion Meeting,
Weekly Consult Meeting, Reflective
Training & Education Across MDT
Ad-hoc supervision & support
Individual Work
-Formulation
-Engagement
ECS Group -Motivation to change 1:1Skills Training
-1:1 Therapy (CBT/ DBT /
ACT)
Skills generalisation / coaching
on ward
Links with Discharge Audit & Evaluation
Community
Teams
Working with Service Users:
The 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
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)
Preliminary Data
Diagnostic Groups Gender
BPD 0 Male 2
Depression 4
Female 7
Schizophrenia 3
Schizoaffectiv 1
e Disorder
Anorexia 1
Nervosa
Total 9
Mean Scores Pre & Post Group:
CORE Scores
2.5
2
1.5
Pre
1 Post
0.5
p< .05
0
CORE
Mean Scores Pre & Post Group:
MHCS & LWE Scales
60
50
40
Pre
30
Post
20
10 p< .01
0
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
Training topics – 8 sessions
Service users involved
1. Understanding BPD 5. Behavioural theory
2. Formulation – 6. Chain analysis
biosocial model 7. Emotional coping
3. Devising a care plan skills – Mindfulness
– target hierarchy 8. Distress Tolerance
4. Validation
Evaluation of Training
Programme
Self-report measures being used to
evaluate the effectiveness of training
with the following aims: -
1. Explore the relationship between staff
attitudes towards BPD and stress & burnout
2. Examine whether the training programme
has an impact upon attitudes towards BPD,
development skills and staff stress levels
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
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
Results
Preliminary results available in November
2007
Working with Staff:
Reflective 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
Topics For Reflection
One hour weekly sessions for all staff
Direct Clinical Practice: working with
Clients
Functional Aspects of work
Self-Reflection
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
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.
Contact details and references
Dr Laura Dannahy
Laura.dannahy@hantspt-sw.nhs.uk
Dr Vivia Cowdrill
viv.cowdrill@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
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