1. Creating a Therapeutic Milieu in an Acute Psychiatric Setting
Presented by:
Dr Laura Dannahy

2. “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)

3. 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

4. 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)

5. 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

6. 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

7. Referral Pathway
Training & Education Across MDT
Weekly Consult Meeting, Reflective Practice, Clinical Discussion Meeting, Ad-hoc supervision & support
Assessment
Individual Work
-Formulation
Engagement
Motivation to change
1:1 Therapy (CBT/ DBT / ACT)
Skills generalisation / coaching
on ward
ECS Group
1:1Skills Training
Audit & Evaluation
Discharge
Links with Community Teams

8. 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

9. 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)

10. Preliminary Data Diagnostic Groups Gender BPD Depression 4
Depression 4
Schizophrenia 3
Schizoaffective Disorder 1
Anorexia Nervosa
Total 9
Male 2
Female 7

11. Mean Scores Pre & Post Group: CORE Scores

12. Mean Scores Pre & Post Group: MHCS & LWE Scales

13. 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
From the ECS data we noticed that we needed more help with helping people with BPD to remain in the group. In line with the philosophy of therapeutic milieu we adopted a multidisciplinary approach to this and decided to recruit the nursing staff. But mental health workers hold notoriously negative attitudes towards people with BPD so to overcome these difficulties we devised a staff training programme based on DBT principles provided to small groups of staff – hourly session during cross over of staff. Recent research suggest that DBT can be adapted to inpatient settings Bohus et al 2004; Kroger et al 2006 ; Swenson et al 2001

14. Training topics – 8 sessions Service users involved
Understanding BPD
Formulation – biosocial model
Devising a care plan – target hierarchy
Validation
Behavioural theory
Chain analysis
Emotional coping skills – Mindfulness
Distress Tolerance

15. 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

16. 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

17. 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

18. Results
Preliminary results available in November 2007

19. 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
In addition to providing clinical interventions and training the opportunity to reflect on one’s practice is crucial to the development and maintenance of a therapeutic environment.

20. Topics For Reflection One hour weekly sessions for all staff
Direct Clinical Practice: working with Clients
Functional Aspects of work
Self-Reflection

21. 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

22. 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.
CBT needs to be willing and ready to involve service users…….

23. Contact details and references
Dr Laura Dannahy
Dr Vivia Cowdrill
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

24. 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,
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,