Medication-free mental health treatment: a focus group study of milieu therapeutic settings.

BACKGROUND: Medication-free treatment within mental health care aims to offer therapeutic support as an alternative to psychotropic medication. Introducing milieu therapy for severely mentally ill persons in a medication-free unit requires significant changes to the traditional medication-based psychiatric setting. The present study examines how milieu therapists experience working with medication-free treatment for people with severe mental health challenges. The research question was "What may be required to succeed with medication-free treatment in milieu therapeutic settings?" METHODS: A qualitative study with four focus groups were conducted with 23 milieu therapists from three inpatient units in two mental health institutions. Thematic analysis was performed. RESULTS: One main theme was identified: medication-free treatment involves therapists and patients working together on holistic and personal health promotion. This common thread links the four themes: helping patients to make changes in their life; having time to focus on the individual patient; being a professional companion; and working together as a team with the patient. CONCLUSIONS: A holistic approach is necessary for medication-free treatment to succeed. This requires working together in multidisciplinary teams with a focus on the individual patient. Milieu therapists must engage and take more responsibility in the patient's process of health promotion. A change from a medical to a humanistic paradigm within mental health care is needed.

Psychiatric rehabilitation and cognitive deficit for treatment-resistant depression.

Patients with TRD often experience persistent impairment of affective, psychosocial, and cognitive function, which impedes their recovery. The continuation of pharmacotherapy for patients with TRD remains the cornerstone of functional recovery. Cognitive dysfunction is prevalent in patients with MDD and may make patients' depressive symptoms and psychosocial functioning worse, even in the remitted stage of illness. Deficits can manifest not only in specific cognitive domains but also in global cognitive function, which may reflect underlying persistent pathophysiological changes. Compared with nontreatment-resistant patients with MDD, patients with TRD exhibit greater subjective and objective cognitive impairment, which possibly contributes to a greater adverse impact on daily functioning. Cognitive and psychosocial remission should be a goal in treating MDD. How to appropriately and individualized perform pharmacological intervention, psychotherapy, neuromodulation, cognitive remediation or other rehabilitation treatment programs is a critical step to achieve our goal. Integrating multiple interventions that engage multiple physiological systems with a multidisciplinary team warrants increased attention, and personalized therapeutic programs may facilitate the complete restoration of patients' everyday functioning.

Impact of Environment and Milieu Therapy in Palliative Care.

The collaborative approach offered by palliative care benefits both patients and their caregivers. They provide a system of support that enables patients to lead as active a life as possible. This integrative review aimed to find out whether milieu and environment therapy has a significant impact on palliative care patients. Analyses and summaries of seventeen (17) papers were completed. There were three themes identified: environmental factors for quality of life, milieu therapy in forms of arts and music, and milieu therapy is safe, structured, and psychotherapeutic. This review demonstrates that milieu and environment therapy may also help to reduce physical symptoms, such as pain, and enhance quality of life. The study suggests that even if there are many interventions for palliative patients, more research is needed to generate a more thorough evaluation of the efficacy of various environmental control components and milieu therapies for palliative care patients.

O ambiente terapêutico segundo a milieu therapy: uma intervenção especializada / The therapeutic environment according to milieu therapy: a specialized intervention

Este documento descreve o percurso formativo para o desenvolvimento de competências de enfermeiro especialista e de mestre no âmbito do curso de Mestrado em Enfermagem, área de especialização em Enfermagem de Saúde Mental e Psiquiátrica. Tem como objetivos apresentar o percurso e atividades desenvolvidas nos contextos de estágio, refletir sobre aprendizagens e competências desenvolvidas, e identificar intervenções do enfermeiro especialista promotoras do ambiente terapêutico, segundo o modelo Milieu Therapy. Esta área temática constituiu o foco deste trabalho e pretendeu-se dar resposta à questão: "Quais as intervenções do enfermeiro especialista de enfermagem de saúde mental e psiquiátrica na promoção do ambiente terapêutico, segundo o modelo Milieu Therapy?". De acordo com este modelo, o ambiente terapêutico caracteriza-se por ser estruturado, dinâmico e flexível, cuja finalidade se centra em promover o desenvolvimento do potencial do cliente, assegurando a satisfação das necessidades de segurança, estrutura, suporte e autogestão do mesmo. Recorreu-se à metodologia de projeto através de pesquisa bibliográfica, elaboração de uma revisão integrativa da literatura, construção de um documento de apoio à prática e realização de dois estágios (Hospital de Dia ­ Unidade de Adolescentes e Serviço de Internamento de Psiquiatria de Doentes em Fase Aguda) tendo por base uma prática reflexiva. O referencial teórico de Enfermagem mobilizado foi o de Hildegard Peplau. A intervenção do enfermeiro especialista no ambiente terapêutico deve ter em consideração a estruturação nas vertentes do ambiente físico, relacional e de trabalho em equipa; o autoconhecimento; e a supervisão clínica. O ambiente terapêutico influencia positivamente a relação terapêutica e fomenta o potencial de desenvolvimento do cliente, tendo em conta as necessidades individuais e as de grupo.

This paper describes the training process for competency development of students in a master's degree in nursing program with a specialisation in mental health and psychiatric nursing. The objectives are to present the experiences and activities completed in the internship, reflect on the learning and skills developed, and identify the interventions of the nurse specialist that promote the therapeutic environment, according to the milieu therapy model. These areas were the focus of this study and were intended to answer the following question: "What are the interventions of the mental health and psychiatric nurse specialist in promoting the therapeutic environment, according to the Milieu Therapy model?". According to this model, the therapeutic environment is characterised as structured, dynamic and flexible, and has the purpose to encourage the development of the patient's potential and ensure their safety, structure, support, and self-management needs. The project methodology included a bibliographic search, development of an integrative literature review, construction of a document to support the practice and implementation of two internships (Day Hospital - Adolescent Unit and Inpatient Psychiatric Service for Acute Patients) based on a reflective practice. Hildegard Peplau's theoretical framework of nursing was used. The intervention of the specialist nurse in the therapeutic environment should include the structure of the physical, relational, and teamwork environment; selfknowledge; and clinical supervision. The therapeutic environment positively influences the therapeutic relationship and fosters the patient's development potential, considering the individual and group needs.

Use of Therapeutic Milieu Interventions in a Psychiatric Setting: A Systematic Review.

BACKGROUND: The therapeutic environment is commonly acknowledged as a significant influence on mental inpatient treatment experiences and outcomes. Therapeutic milieu interventions provide a distinct, secure hospital ward/unit atmosphere where patients with mental illness receive therapeutic interactions and collaborative attentiveness. The review aimed to explore the studies related to the role of a nurse using therapeutic milieu/milieu therapy in a psychiatric setting. MATERIALS AND METHODS: A systematic literature search was conducted between 1976 and 2021 using PsycINFO, Medline, Embase, and Scopus. A total of 13 papers were identified for a full review. RESULTS: A total of 70 studies were found, out of which 13 of them were analyzed. These studies looked at several therapeutic milieu concepts, such as therapeutic communication, patient satisfaction, nurse involvement, ward design and structure, and a mixture of therapeutic milieu concepts. Most of the studies explored the concepts of milieu therapy in community settings. CONCLUSION: In the mental health nursing literature, the milieu, as well as milieu therapy, is a well-debated subject. Though the importance of therapeutic milieu in psychiatric settings is recognized, empirical studies on milieu implementation are scarce. Therefore, research is needed to explore the effectiveness of milieu therapy in inpatient psychiatric care, which facilitates patient recovery, safety, and good interpersonal relationships.

Nighttime Walking with Music: Does Music Mediate the Influence of Personal Distress on Perceived Safety?

There is growing interest in identifying the environmental factors that contribute to individuals' perceptions of safety and sense of well-being in public spaces. As such, this study examined how music listening during nighttime walking influenced female university students' psychological state and perceptions of their campus. A total of 178 female university students with a mean age of 23.0 years participated in this study. One group of 78 students listened to prerecorded music while walking across their campus at night, while the other 100 students did not listen to music during nighttime walking. Immediately following their nighttime walking, participants were asked to rate their psychological state, perceptions on the safety of their campus, and the music (only for the music-listening group). For the non-music-listening group, significant correlations were found between the perceived safety of the campus and psychological states (both anxiety and psychological distress); the correlations were not significant in the music-listening group. The results indicate that music can mediate psychological states, supporting the proactive use of music as a psychological resource for coping with their perceptions of adverse environments. Given the limitations of this preliminary study, further studies with controlled music listening conditions, type of music, and environmental issues are suggested.

Bridge over Troubled Water: Patients' Opportunities for Collective Participation in Substance Use Institutions through Research Circles.

This study explores patients' opportunities for collective participation in an institution for people with substance use disorder. Patients and staff from the treatment institution cooperated with researchers to make changes in the treatment practice, using a research circle as a model for the project. In the article, we discuss the following research questions: How and in what areas did patients have the opportunity to participate collectively in the treatment institution? How did the patients experience participation in the research circle? Data consist of minutes from meetings, seminars, and focus-group interviews. The participants analysed the material together, and the authors carried out a thematic analysis after the project. The participants chose to explore how milieu therapy could build a bridge from treatment in the institution to life after treatment, a "Bridge over troubled waters", to quote Simon and Garfunkel. Findings show that activities in the research circle led to changes at the institution, e.g., regular Sunday afternoon meetings, a weekly quiz, and less controlling procedures of substance use, and that the institutional culture in general became based more on participation and equality. Patients, staff, and researchers participated in a partnership; mutual recognition promoted cooperation and fellowship in the research circle. We conclude that the project provided the participants with opportunities for collective participation in the institution. In addition, the patients experienced partnership and empowerment in the research circle. Our attempts to change institutional practices yielded some improvements but also met with structural and cultural barriers. Thus, the project experienced challenges and obstacles mostly related to limitations in the institutional system and culture.

Effectiveness of therapeutic milieu intervention on inpatients with depressive disorder: A feasibility study from North India.

PURPOSE: This study examined therapeutic milieu interventions on self-esteem, socio-occupational functioning, and depressive symptoms among inpatients with depressive disorders. METHODS: A pretest-posttest nonequivalent control group quasi-experimental design was adopted. Sixty participants with depression who got admitted to the general hospital psychiatric ward were assigned to a control (Treatment as Usual) group and an experimental (therapeutic milieu intervention) group nonrandomly using a convenience sampling technique. We evaluated the following outcome measures: self-esteem, socio-occupational functioning, and depressive symptoms for both groups at baseline, 4th, 8th, and 12th weeks. RESULTS: Therapeutic milieu interventions improved self-esteem, socio-occupational functioning, and reduced depressive symptoms. The findings provided initial evidence for practice. IMPLICATIONS: Psychiatric nurses can implement simple, milieu therapy interventions in any setting, which will enhance the clinical outcomes and socio-occupational functioning of depressive patients.

Milieu therapy for hospitalized patients with late-life anxiety and depression: a qualitative study.

Background: Milieu therapy (MT) is an important interprofessional part of therapy for persons with late-life anxiety and depression in psychogeriatric inpatient units. Research on how this is conducted is scarce.Aim: To explore nurses' and nurse assistants' experience regarding MT interventions for persons with late-life anxiety and depression and how this is applied and conducted in the everyday life in a psychogeriatric inpatient unit.Method: Four focus group interviews with nurses and nurse assistants were conducted. Systematic text condensation was used for analyzing and interpreting the data.Results: MT was described as a dynamic and active process. Conscious individualized cooperation and communication day and night emerged as overarching theme, with following categories: 1. Collecting clues about the patient's history, challenges and coping strategies. 2. Active use of these clues. 3. Active use of the ward setting as arena for staff to learn from each other, for patients to learn from other patients and as frame for MT in general. Strategies from both psychiatric and dementia care were used in MT interventions.Conclusion: Results from this study describe content and complexity of MT strategies that can be supportive in everyday practice in psychogeriatric inpatient units and nursing homes, and have the potential to facilitate teaching, supervision and counseling of health professionals, caregivers and patients.

Effectiveness of Milieu Therapy in reducing conflicts and containment rates among schizophrenia patients.

OBJECTIVES: To evaluate effectiveness of Milieu Therapy in reduction of conflict and containment rates among schizophrenia patients. METHODS: This study utilized quasi experimental non-equivalent control group pre-post design. One hundred schizophrenia patients admitted in acute psychiatric wards were non-randomly assigned to either of the experimental (n=50) or control group (n=50). The experimental group received both milieu therapy and routine hospital treatment. The Milieu Therapy intervention Included environmental modification and structuring ward activities, establishing effective interaction with patient, and teaching caregivers on managing conflict behavior of patient. The control group received only routine treatment in the hospital. Outcome measures on conflict and containment rates were evaluated for both the groups at baseline and at 2nd, 3rd and 15th day. The Patient-Staff Conflict Checklist Shift Report (PCC-SR) was used to collect information about rates of conflict and containment. RESULTS: Compared with control group, the experimental group participants showed decrease in aggressive behavior, self-harm behavior and general rule breaking behavior at baseline and 2nd, 3rd and 15th day (F=4.61, p < 0.004, η2=0.04; F=11.92, p < 0.001, η2=0.11; F=6.94, p < 0.001, η2=0.06) over seven days interval. CONCLUSIONS: The present study findings provided evidence for the effectiveness of integrating Milieu Therapy in psychiatric acute wards in reducing conflict behaviors among schizophrenia patients. Milieu therapy should be considered as an integral part of psychiatric care settings in these patients.

The Impact of Milieu Nurse-Client Shift Assignments on Monthly Restraint Rates on an Inpatient Child/Adolescent Psychiatric Unit.

INTRODUCTION: Restraints in the inpatient child/adolescent psychiatric population pose a threat to client safety and quality of care. Nurses are key in reducing restraints through implementation of evidenced-based interventions to improve quality and safety. AIM: To identify the impact of milieu nurse-client shift assignments on monthly restraint rates when compared with individual nurse-client shift assignments on an inpatient child/adolescent psychiatric unit. METHODS: A quantitative, retrospective, comparative project design was used. The sample included all inpatient child/adolescent clients admitted to the child/adolescent psychiatric unit between the months of January-May 2016 and 2017 who were physically or mechanically restrained. Retrospective chart audits were conducted, and information transcribed onto an adapted chart audit tool by Edwards et al. (2006). Monthly restraint rates were compared using the Mann-Whitney U test. A p value of <.05 was used to determine statistical significance. RESULTS: The Mann-Whitney U test revealed statistical significance between the impact that the individual nurse-client shift assignments (Mdn = 61.2, n = 6) and the milieu nurse-client shift assignments (Mdn = 6.8, n = 6) had on monthly restraint rates, U = .000, z = -2.88, p = .004, r = .83. CONCLUSION: Use of milieu nurse-client shift assignments are associated with lower monthly restraint rates when compared to individual nurse-client shift assignments. Milieu nurses provide structure, safety, consistency, and security, leading to early intervention and de-escalation of clients who display aggressive behaviors. Nurse staffing structures also need to be optimized to meet the needs of this population.

The Importance of Nidotherapy and Environmental Change in the Management of People with Complex Mental Disorders.

Much has been done in the last 50 years to achieve a better understanding of the psychosocial causes and other factors influencing the manifestation of mental illness, but there has been a conspicuous omission. Although gross environmental deficiencies were exposed in old mental institutions, 70 years ago the more subtle maladaptive settings that reinforce chronicity in mental illness have often been forgotten. In this review, the potential of systematic environmental manipulation as a treatment (nidotherapy) and other similar forms of management, used many times in the past but now mainly in forensic settings, is examined. There is now accumulating evidence, reinforced by controlled trials, that planned environmental change, preferably carried out with the full cooperation of the patient, can be a major contributor to therapeutic benefit. It is also very cost-effective. All forms of the environment, physical, social and personal, can be addressed in making assessments, and once a planned way forward has been chosen, progress can be monitored by personnel with limited mental health experience. These interventions have applications in general mental health and occupational health services and deserve much wider use.

Worker Perspectives on Contemporary Milieu Therapy: A Cross-Site Ethnographic Study.

The term "milieu therapy" (MT) is commonly used in mental health literatures. However, because MT has historically encompassed a wide range of practices, it has invited the criticism that it is simply an attractive theoretical packaging of the time clients spend between other specified interventions, such as individual and group therapies. Some have suggested that, because of its conceptual ambiguity, MT should be abandoned altogether. Despite these challenges, MT endures as a common approach to social work practice in a range of clinical settings. This article describes a study that used ethnography to investigate the perspectives of workers from two mental health organizations that claim to provide MT. By analyzing four themes common to both sites, this article brings exploratory empirical findings to bear on the question of what constitutes MT in contemporary mental health organizations. Participants reported that (a) everything in the physical and social milieu has the potential to affect therapeutic change; (b) the milieu itself functions as a therapeutic agent; (c) the milieu provides a context for modeling and practicing desired behaviors; and (d) MT is a principle-based ethos, rather than a set of specific interventions. Implications of these findings for social work research, practice, and funding are discussed.

The effect of training in mindfulness and affect consciousness on the therapeutic environment for patients with psychoses: an explorative intervention study.

RATIONALE: The ward atmosphere and the relationships between patients and staff contribute to the improvement in symptoms and psychiatric patient functioning and satisfaction. The quality of the therapeutic relationship is connected to the degree of self-reflection and self-awareness by the staff. OBJECTIVE: To examine the effect of two different training programmes for healthcare professionals on the ward atmosphere in wards for psychotic patients. DESIGN AND METHODS: Exploratory intervention study with two eight-week interventions of mindfulness training and affect-consciousness training. The outcome was measured on mindfulness and on relevant subscales of the Ward Atmosphere Scale. Data were collected by means of questionnaires and analysed using paired samples t-tests and repeated measures anova. RESULTS: Two groups professionals (n = 27 & n = 23) participated in the study. Improvements indicated that both interventions had a positive impact on the ward atmosphere. STUDY LIMITATIONS: The exploratory design and the small samples size make definitive conclusions difficult. Patient assessment on the ward atmosphere scale would have strengthened the validity of the results. CONCLUSION: The ward atmosphere in two different wards for psychotic patients improved after staff training in mindfulness or affect consciousness. There were differences in change profiles for the groups in accordance with the differences in the two interventions. PRACTICE IMPLICATIONS: We recommend awareness on the quality of the ward atmosphere in wards for psychotic patients. Both training in mindfulness and affect consciousness can support healthcare professionals in their awareness.

Therapeutic Use of Music and Television in Neurocritical Care: A Practice Survey.

INTRODUCTION: Although health care providers often play music via radio, or play television, to calm and soothe patients, limited research is available to guide practice. METHOD: This study used a 17-item practice survey that was distributed electronically to neurocritical care society members in July 2014. Responses were collated and analyzed using SAS (Version 9.3). RESULTS: There were 118 completed responses, including from 71 attending physicians, 9 resident or fellow physicians, 30 nurses, and 8 affiliate professional members. The majority of respondents sometimes or always play music (65%) and agree that music is therapeutic (70%). However, there was no clear practice pattern regarding when or why music or TV should be used as an intervention in the neurocritical care unit. CONCLUSION: The use of music and TV is a common intervention in the neurocritical care unit but lacks a strong scientific foundation and is associated with a high practice variance.

Effect of environmental enrichment on cognitive function and the expressions of hypoxia inducible factor 1α and vascular endothelial growth factor in rats with chronic cerebral hypoperfusion / 中华老年医学杂志

Objective To observe effect of environmental enrichment on the learning and memory ability and the expressions of hypoxia inducible factor 1α (HIF-1a) and vascular endothelial growth factor (VEGF) in rats with chronic cerebral hypoperfusion.Methods A total of 40 rats were randomly divided into 3 groups: bilateral vascular occlusion (2VO) of the common carotid arteries group (n=14, 2VO group), 2VO + enriched environment (EE) group (n=14, 2VO+EE group) and sham group (n=12, SHAM group).Morris water maze, novel object recognition test, real-time reverse transcription-polymerase chain reaction (real-time RT-PCR), immunohistochemistry methods and Western blotting were used to detect changes in learning and memory ability of rats and HIF-1α and VEGF expression levels in hippocampus.Results Morris water maze showed that the escape latency was longer in the 2VO group than in the SHAM group at 3, 4 and 5 day during the training (all P＜0.05), while the 2VO+EE group spent significantly less time in finding the platform as compared with the 2VO group at 4 and 5 day (both P＜0.05).The time for space exploration in target quadrant was less in 2VO group than in SHAM group (P＜0.05), while it was longer in 2VO +EE group than in 2VO group (P＜0.05).Novel object recognition test showed that the 2VO operation impaired the priority index (PI) of time spending at exploring the novel object (P＜0.05), and environmental enrichment could improve the PI in 2VO group (P＜0.05).The real-time RT-PCR and Western blotting showed that the HIF-1α mRNA expression was higher in 2VO group than in SHAM group (P＜0.05).The VEGF mRNA and protein expressions were higher in 2VO+EE group than in 2VO group (both P＜0.05).The expression of HIF-1α in hippocampal CA1 area was higher in 2VO group than in SHAM group (P＜0.05).Conclusions Environmental enrichment can alleviate the damages of spatial and non-spatial learning and memory ability which are caused by chronic cerebral hypoperfusion.And HIF-1α and its downstream gene VEGF may be involved in the restoration of cognitive function by enriched environment.

Schizophrenia and Healing Environment

Treatment of schizophrenia is one of the most challenging areas in the field of psychiatry. There has been much improvement in psycho-pharmacotherapy, and at present, psycho-pharmacotherapy along with milieu therapy and social rehabilitation is the standard first-line treatment for schizophrenia. Healing environment, a concept which has arisen from the architectural field, has similarities in meaning to milieu therapy in psychiatry. In other words, healing environment may be an encountering point between psychiatry and architecture. In this encountering, each field can understand each other and expand its concept to aid the treatment of schizophrenia and to plan the build-up of the entire environment considering its social and psychological effects. In this paper, we aim to establish the basic concept of healing environment to alleviate the psychopathologies in schizophrenic patients. We worked under the premise that physical setting affects human behavior and mind, and that physical setting should play a role as a medium with therapeutic potential for patients with medical problems. The aims of this paper are as follows. First, theoretical discussion of the concept and the constructs of healing environment : second, understanding of the schizophrenic symptoms that may be affected by supporting environment : and third, discussion of supporting environment that may alleviate the symptoms of schizophrenia.

Mesenchymal stem cells in tissue repair.

The advent of mesenchymal stem cell (MSC)-based therapies for clinical therapeutics has been an exciting and new innovation for the treatment of a variety of diseases associated with inflammation, tissue damage, and subsequent regeneration and repair. Application-based ability to measure MSC potency and fate of the cells post-MSC therapy are the variables that confound the use of MSCs therapeutics in human diseases. An evaluation of MSC function and applications with attention to detail in the preparation as well as quality control and quality assurance are only as good as the assays that are developed. In vivo measures of efficacy and potency require an appreciation of the overall pathophysiology of the model and standardization of outcome measures. The new concepts of how MSC's participate in the tissue regeneration and wound repair process and further, how this is impacted by estimates of efficacy and potency are important new topics. In this regard, this chapter will review some of the in vitro and in vivo assays for MSC function and activity and their application to the clinical arena.

Cognitive milieu therapy and physical activity: experiences of mastery and learning among patients with dual diagnosis.

During the last decade, there has been a growing interest in implementing cognitive milieu therapy (CMT) in psychiatric institutions. However, there is a lack of systematic evaluations from patients' point of view. The aim of this study was to explore and describe patient perceptions of essential experiences of mastery, learning alternative ways of thinking, and acquiring new skills through CMT and physical activity in an inpatient setting. Qualitative interviews were carried out with 20 patients with dual diagnosis. A hermeneutic - phenomenological approach was used in the data collection and analysis. The results showed that the learning climate in the unit was important. This included a proactive attitude from the staff, focusing on cooperation on equal terms between patients and staff, and a professional methodological approach through CMT. The optimal balance between staff-induced activities and patient initiatives was not easy to obtain. Patients appreciated both the education provided by the staff and learning from other patients. The cognitive method was sometimes experienced as too theoretical and difficult to understand. Physical activity, however, was experienced as 'concrete' and providing practical knowledge. It motivated patients to establish new habits and provided opportunities for the development of mastery together with other patients.

Advance in Acupuncture Associated with Milieu Therapy for Neonatal Rats with Hypoxic-ischemic Brain Damage (review) / 中国康复理论与实践

@#This paper would review the experimental research over acupuncture associated with milieu therapy towards neonatal rats with hypoxic-ischemic brain damage during the past decade, while focus on exploring the therapeutical mechanism of acupuncture and rehabilitation for cerebral palsy.