Exploration and support in psychotherapeutic environments for psychotic patients.

Clinical experience and previous investigations suggest that insight-oriented milieu therapy with psychotic patients presupposes a specific balance of explorative and supportive factors in the milieu. Explorative and supportive factors were translated here to two optimal ward atmosphere profiles using the subscales in the Community-oriented Programs Environment Scale (COPES) as profile variables. Three Swedish therapeutic communities for psychotic patients were then studied by means of COPES. The study showed distinct patterns in these units regarding deviations from the optimal profiles, differences in the balance between the explorative and supportive factors, divergences between explicit treatment philosophy and the perceived ward atmosphere, and differences between patient and staff perceptions of the ward atmosphere. These patterns followed a continuum from a self-governing, nonhierarchical and nonmedical organization to a hierarchical unit that is an integral part of the medical care organization. The conclusion was that a beneficial psychotherapeutic environment requires consistency in the applied treatment model, including an organization and setting that corresponds to the explicit treatment philosophy, well mirrored in the patients' perceptions.     

Relationship between involuntary admission and the therapeutic process in a closed ward functioning as a therapeutic community

In a therapeutic community for acute psychiatric patients, the relationship between involuntary admission (13.6% of the episodes) and some patient and program characteristics was analyzed, using a total of 1586 treatment episodes in 838 patients between 1978-1987. Based on a logistic regression model, an elevated relative risk of involuntary admission was seen in the diagnostic groups of schizophreniform psychosis, unspecific psychosis, paranoid psychosis, and borderline psychosis. Also, the association with involuntary admission increased in the first or second treatment episode, or for patients that had a controversial or negative immediate outcome, for young patients under 21 years, and for patients who were passive in individual therapy. Still, the difference in outcome was minimal, and there were no differences in group or milieu therapy activity. The results suggest that involuntary admission is not necessarily a traumatic, negative experience in subsequent treatment episodes or in the patient career. The modified therapeutic community model presented contains peer and family support and ample opportunity to discuss and negotiate, which may alleviate the possible narcissistic pain of involuntary admission.     

The Art and Challenges of Long-Term and Short-Term Democratic Therapeutic Communities

This paper, cowritten by Kingsley Norton, since 1989 Director of Henderson Hospital (a therapeutic community founded by Maxwell Jones in 1947 in the United Kingdom), and Sandra Bloom, Founder of the Sanctuary Model in the United States, compares and contrasts the practice of the democratic therapeutic community (TC) as applied to the notion of long-term care (up to twelve months), to that of the democratic therapeutic milieu (TM) as applied to short-term care (up to one month).     

An adolescent group within a milieu setting

A group in a milieu setting is most effective when it uses the shared reality of the milieu in the group. This makes the issues come alive in the group and allows for the learning in the therapy to become applied in the larger environment of the milieu. A clinical example is presented to illustrate the effectiveness of bringing the “world” of the milieu in the group.     

Brief family therapy with alcohol-dependent men in Trinidad and Tobago

This study—the first of its kind in the English-speaking Caribbean—investigated the efficacy of modified brief family therapy in the treatment of alcoholism. Thirty men were treated with family therapy and milieu therapy and compared with 30 sex- and age-matched patients treated with milieu therapy alone. Follow-up over a period of 1 year showed significant levels of improvement in those treated with family therapy. The treatment group did not revert to their original drinking pattern. This can be attributed to family therapy. Family therapy was brief and involved seeing all significant members for 3 sessions, each session lasting 90 min. The role of family therapy and importance of culture in management of these patients are discussed. Our study confirms that a time-limited problem-solving family therapy approach is of use in these ethnic groups.     

Matching therapists and milieus: effects on engagement and continuance in psychotherapy

Systematic analysis of interactions between 60 schizophrenic patients, their therapists, and different types of psychiatric milieu programs revealed that (1) therapists whose treatment orientation conflicted with that of the patients' milieu had significantly more trouble engaging and maintaining patients in therapy over the course of two years than therapists whose treatment orientation matched that of the milieu; (2) the harmful effects of such a mismatch on a patient could be largely eliminated if the therapist remained administratively uninvolved.     

Where can therapeutic community ideals be realized? An examination of three treatment environments

Staff views about the actual and ideal treatment environment of three therapeutic milieus with psychoanalytic, biological, and rehabilitative orientations were assessed using the Community-Oriented Programs Environment Scale (COPES), real and ideal forms. COPES scores indicated that the staff of the three units shared many beliefs about the ideal milieu but that only staff of the rehabilitation unit felt the milieu had realized its ideals. Disparities between real and ideal COPES scores on the other two units were believed to reflect staffs' inability to resolve the conflicting demands of milieu therapy and other treatment approaches. The authors identify specific sources of conflict on the psychoanalytic and biological milieus and reasons for the greater compatibility of ideology and practice in the rehabilitation milieu.     

Day treatment of young psychotic children and their parents: Interdisciplinary issues and problems

The use of a developmental framework enabled milieu staff and psychotherapists to view the child from a multiaxial developmental framework and so gear each aspect of the therapeutic work in the milieu, individual therapy, and work with parents to each child and family's unique needs. A high level of parent participation in the milieu led to earlier identification of parental resistances and parent-staff conflicts. Such rapid problem indentification and confrontation leads to earlier effective parent-staff collaboration and a more rapid involvement of parents in the treatment process. Milieu day treatment can provide high quality intensive treatment of psychotic children and their families at much less cost than residential or inpatient treatment.     

Effects of a Modified Milieu Therapy Intervention on the Social Communicative Behaviors of Young Children with Autism Spectrum Disorders

The purpose of the current study was to evaluate the effectiveness of combining milieu therapy and functional communication training (FCT)] to replace aberrant behavior with functional communicative skills in 3 male preschool or elementary aged children with Autism Spectrum Disorders (ASD). Study activities were conducted in the natural environments of the participants and parents acted as change agents. A concurrent multiple baseline design across participants was used to evaluate the effectiveness of the modified milieu therapy intervention. Results indicate that aberrant behavior decreased concurrent with an increase in total percentage of communication responses (PCR). The children maintained communication and low rates of aberrant behavior, and generalized their communication from the home to the classroom. A discussion of limitations and future research directions is included.     

Relations between patients in psychiatric and psychotherapeutic inpatient care: A literature review and conclusions for clinical practice and research

Objective. In psychiatric inpatient units patients live closely together, which facilitates mutual interactions. Patient relations are part of the therapeutic milieu, which is an important factor in helping patients to recover. Types of patient relations are nonbinding superficial encounters, working alliances, personal relations like close partner relationships, or sexual contacts. Intimate relations between patients are scientifically and in clinical practice, a rather, neglected topic. Methods. A data search was conducted using the PubMed/MEDLINE databases with the key terms “patient relations” or “intimate relations between patients”. Results. Depending on the type of relation and inpatient unit, prevalence rates of 1.5–30% for intimate relations between patients in psychiatric hospitals are reported. Such relations can have beneficial effects, like the feelings of bonding or being liked, but also negative consequences, like burdening, worsening of the illness, treatment complications, or direct harm to the patient. Conclusion. Only a few units have development guidelines. It is the responsibility of the therapeutic staff and the hospital management to support a helpful therapeutic milieu, including positive patient interactions, and to protect as far as it is possible patients from negative encounters.     

A reevaluation of milieu therapy for nonchronic schizophrenic patients

Until recently almost all the controlled research on milieu therapy for schizophrenic patients involved nonintensive milieus and chronic patients. Under these circumstances the effectiveness of milieus was not evident. Recent studies have suggested that intensive milieus significantly benefit nonchronic patients. These studies have indicated the importance of defining what ingredients can make a milieu therapeutic. The existing research evidence is surveyed, and the nature of what some of these ingredients might be described.     

Adapting milieu approaches to acute inpatient care for schizophrenic patients

Classic therapeutic community or milieu therapy techniques are not applicable in many contemporary acute-treatment settings, which emphasize crisis intervention, short stays, psychotropic medication, and cost containment. However, milieu techniques can be integrated with an understanding of biological and psychosocial factors to provide a framework for the acute, short-term treatment of schizophrenic patients. After reviewing recent biological and psychosocial research, the authors outline three principles for incorporating such research with milieu techniques: creating a holding environment, developing a graduated therapeutic program, and focusing on common patient needs. Application of these principles in a short-stay setting will provide an intensely supportive treatment environment that allows the use of many different therapies and modulates stresses on staff.     

The psychiatric hospitalization of children: An overview

This paper reviews significant outcome studies regarding the hospitalization of latency-age children and examines pertinent admission criteria. Essential diagnostic and therapeutic components, including milieu therapy, individual therapy, family work, pharmacotherapy and school are discussed. The future role of psychiatric hospitalization of children is examined.     

What is a day center?

Observation of the behavior of clients results in a classification of modes of relating to an outpatient milieu therapy organization. Considered as clients' definitions of the situation, they are: the waiting room, the alumni club, the hospital, the social club, and the day center. A distinction is made between these patterns of behavior and verbalized metaphors. The former are attributed to assumptions that vary among individuals and are relatively resistant to change. The latter refer to the social organization of the milieu and occurred in a sequence expressive of increasing autonomous activity on the part of the clients.     

Severe obsessive compulsive disorder in adolescence: a report of eight cases

The treatment and clinical features of eight adolescents with obsessive compulsive disorder severe enough to warrant hospitalization are described. Attempts to use behaviour therapy failed, due to lack of co-operation from the patients. Nevertheless, response to non-specific psychotherapy and milieu therapy was surprisingly good. These observations are somewhat different from those reported in previous literature. The reasons for this difference are discussed.     

Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint

We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees’ perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.     

A developmental approach to diagnosis and treatment in a transitional living program

We hope that the reader has been able to vicariously share with us in the excitement of work in a transitional living program. The young people with whom we share this environment stand on the threshold of adult life. They have suffered medical, psychological, environmental, and social insults. Psychosocial developmental assessment helps us define the details of threats to the foundations of adult personality functioning. These young men and women are woefully unprepared for self-care, social interaction, occupational choice, and adult personal relationships.The premise of transitional living is that relationship-based milieu therapy,guided by psychoanalytic develop mental principles, provides an opportunity to heal these conflicted and immature young people to a degree that can tip the scale of their future lives toward productivity, self-esteem, and commitment. Like residential therapy, transitional living provides milieu therapy, corrective education, and psychotherapy. Unlike residential therapy, transitional living is also embedded in the urban community. It facilitates the transition from dependent childhood to independent living by intensive work with the psychological conflicts and physical and social barriers to success in making this important step.     

Research on the psychosocial treatment of schizophrenia: a summary report.

The authors present an overview of research on psychosocial treatments for schizophrenia. Findings from studies of five therapeutic approaches--individual psychotherapy, group psychotherapy, family therapy, milieu therapy, and community support systems--are discussed in detail. The usefulness of each type of therapy is critically assessed on the basis of available data from controlled outcome studies. The authors make recommendations regarding high-priority areas to be addressed in future studies of psychosocial treatment.     

Inpatient treatment of severe disruptive behaviour disorders with risperidone and milieu therapy.

OBJECTIVES: To evaluate the therapeutic impact of adding risperidone to milieu therapy of latency-aged inpatients with severe disruptive disorders. METHODS: The charts of 90 latency-aged patients consecutively admitted to a psychiatry ward were reviewed retrospectively. Fifteen of these patients received risperidone treatment, were nonpsychotic, and did not suffer from pervasive developmental disorder (12 male, 3 female; mean age 9.99 years, SD 1.76). Their scores on the Children's Global Assessment Scale (CGAS) were compared at admission, before risperidone treatment, and at discharge. RESULTS: All subjects were diagnosed with a disruptive behavioural disorder. Ten (66.67%) had additional learning difficulties, and 13 (86.7%) had pathological personality traits. The characteristics of the sample suggested borderline pathology or multiple complex developmental disorder. Following a mean of 38 days after admission (SD 22.3), the patients received risperidone for a mean of 46 days (SD 28.2) before being discharged. The mean maintenance dose of risperidone was 1.27 mg daily (SD 0.36). Mean CGAS scores increased from admission (21.9, SD 7.0) to before risperidone treatment (26.8, SD 7.6, P < 0.0001) and to discharge (50.3, SD 5.3, P < 0.0001). Only 2 patients had documented side effects. CONCLUSIONS: Low-dose risperidone used adjunctively to milieu therapy led to statistically and clinically significant additional improvement in the functioning of hospitalized latency-aged children with severe behavioural disorders. Low-dose risperidone is a safe and effective adjunct to milieu therapy for treating this population in inpatient settings. Prospective randomized controlled trials are needed to confirm these findings.     

Movement therapy with psychotic adolescents

Non-verbal behaviour has long been a focus of attention in the psychiatric literature. Furthermore, most psychiatric hospitals make use of non-verbal therapies in their milieu programmes. These include art, music and dance therapy, and related to the latter, movement therapy. This paper represents the beginning of an attempt to assess more scientifically the effectiveness of movement therapy. It describes the movement therapy programme on our adolescent unit, the evolution of a measuring scale and compares three groups of patients: (A) a group which had received individual therapy; (B) A group which had received group therapy; and (C) a control group. The results tend to confirm the effectiveness of movement therapy for psychotic adolescents.