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.

The violence prevention climate of mental health wards: a cross-sectional study of staff and patient views.

PURPOSE: Ward climate can shape the behaviour of both staff and patients. A subset of the ward climate is the violence prevention climate, the unique characteristics that are perceived by the people within the environment as contributing towards the prevention of violence. The aim of this study was to explore differences between and within staff and patient groups in terms of their perceptions of the violence prevention climate. METHODS: A cross-sectional survey was conducted with staff (n = 326) and patients (n = 95) in mental health care pathways within one charitable trust. All participants completed the VPC-14 to measure perceptions of the violence prevention climate, a validated 14-item two-factor scale (staff actions and patient actions). Staff demographic information was collected on the VPC-14 front sheet; patient demographic, clinical and violence data were collected from electronic case records. Bivariate analyses were conducted to compare within- and between-group variables. Significant staff and patient variables were entered into multiple hierarchical regression analyses to assess their relationship with VPC-14 factors. RESULTS: Staff had a more positive view than patients of staff actions and patients had a more positive view of patient actions than did staff; staff- or patient-group membership was the best predictor of staff action scores. Individual staff characteristics accounted for a small amount of the variance in staff and patient action scores; individual patient characteristics explained more variance, but this was still below 20%. CONCLUSIONS: Staff perceive their violence prevention-related contributions more positively than patients and vice versa. This has implications for staff; they may need to better articulate their role in violence prevention to patients, as well as recognise the role that patients play. However, within staff and patient groups, individual variables only make up a small amount of variance of perceptions of the violence prevention climate. This suggests that the violence prevention climate is a valid construct, i.e. that despite differences in individual variables, individuals within the patient group have similar perceptions of the VPC, as do those within the staff group.

Scales for assessing the therapeutic milieu in psychiatric inpatient settings: A systematic review.

OBJECTIVE: The therapeutic milieu is widely regarded as an important factor influencing experiences and outcomes of psychiatric inpatient treatment. Appropriate scales are needed to assess the milieu. The aim of this review is to identify and describe scales established for that purpose. METHOD: A systematic search of electronic databases was carried out. Scales used in two or more studies were identified, and data was extracted on key characteristics. RESULTS: Scales for assessing the therapeutic milieu were used in 78 studies. Five scales were identified that were used more than once. Four scales originate from 1964 to 1986, one was originally published in 2008. The Ward Atmosphere Scale (WAS) is the most frequently used scale and its psychometric properties have been reported as good. When tested alongside each other, the scales are weakly to moderately correlated. CONCLUSIONS: Few scales have been established to assess the therapeutic milieu. All scales capture aspects of relationships on the wards. The most commonly used scale (WAS) has 100 items and was developed more than 50 years ago. Given the changes in the practice of inpatient care over the last 50 years, new, briefer and psychometrically robust scales should be developed.

Acute psychiatric care for pediatric patients.

Higher level or acute psychiatric care for youth is intended to be active but short-term treatment focussing on crisis stabilisation, assessment, safety monitoring, and longer-term treatment planning. The focus of this article is on describing common challenges and the effort to address these challenges through new approaches to acute psychiatric care for children and adolescents. The review finds that (1) inpatient paediatric psychiatry beds are in high demand and often difficult to access, (2) there are a number of common challenges these units face including managing length of stays, readmissions, and adverse events, and (3) there are encouraging therapeutic approaches adapted for this setting. There is still much work to be done to advance the evidence-base for acute psychiatric care for youth particularly in defining and assessing an effective admission. Paediatric psychiatry patients are a vulnerable population and call for our best tools to be put to use to improve the quality and safety of care.

What Makes Soteria Work? On the Effect of a Therapeutic Milieu on Self-Disturbances in the Schizophrenia Syndrome.

Soteria represents an alternative approach to the treatment of acute psychosis providing a community-based social milieu, personal relationships ("being-with"), and meaningful shared activities ("doing-with") along with minimal neuroleptic medication. In this review article, we analyze Soteria's potential to adapt to and restore self-disturbances, a central element of phenomenological conceptions of the schizophrenia syndrome. Based on typical difficulties of psychotic patients in responding adequately to situational demands, in relating to others, and in utilizing skills, we analyze how the architectural and social context, being-with, and doing-with take account of self-disturbances. The central elements of the Soteria approach all appear to carry the potential to adjust to self-disturbances and even offer opportunities for their relief. We suggest that it is precisely this property of the Soteria paradigm that induces sustained relaxation in patients, allowing for symptom relief, thereby specifying a central claim of "affect-logic" to explain the antipsychotic effect of Soteria.

[Open-door psychiatry and community mental health work]. / Offene Psychiatrie und gemeindepsychiatrische Arbeit.

In connection with the UN Convention on the Rights of Persons with Disabilities, mental healthcare concepts increasingly focus on the prevention of violence and coercion. Hospital care with an open-door policy is linked with a reduction in violence and coercive measures. The authors describe a specific therapeutic milieu aiming to promote social resources and to reduce institutional exclusion. Open-door policies can be extended to and tied in with outreach community mental health work. Model projects according to § 64b of the German Social Code (SGB V) on interdisciplinary care enable flexible needs-based care including home treatment for severe mental illness.

Shared Decision-Making-Balancing Between Power and Responsibility as Mental Health-Care Professionals in a Therapeutic Milieu.

BACKGROUND: Shared decision-making (SDM) is supposed to position patient and expert knowledge more equal, in which will have an impact on how mental health-care professionals relate to their patients. As SDM has not yet been widely adopted in therapeutic milieus, a deeper understanding of its use and more knowledge of interventions to foster its implementation in clinical practice are required. AIM: To explore how mental health-care professionals describe SDM in a therapeutic milieu as expressed through clinical supervision. The research question was "What are prerequisites for mental health-care professionals to practice SDM in a therapeutic milieu?" METHODS: A qualitative content analysis of data from focus groups dialogues in 10 clinical supervision sessions where eight mental health-care professionals participated was performed. FINDINGS: The theme, practicing SDM when balancing between power and responsibility to form safe care, was based on three categories: internalizing the mental health-care professionals' attributes, facilitating patient participation, and creating a culture of trust. CONCLUSION: SDM is a complex and arduous process requiring appropriate interventions. Clinical supervision is necessary for reflection on SDM and for improving practice in a therapeutic milieu.

Roles of Psychiatry Nurses Within a Therapeutic Environment of Psychiatry Clinics in Turkey.

OBJECT: The object of this study is to determine the roles of psychiatry nurses within the therapeutic environment of psychiatry clinics in Turkey. METHODS: This study was performed in a cross-sectional and descriptive design in 195 institutes comprising psychiatry clinics in Turkey. RESULTS: When the responsibilities of nurses for clinical activities were asked, the following answers were obtained: playing with patients or painting at a rate of 54,4%. It was determined that in the majority of psychiatry clinics, there were educational activities which were conducted by nurses. CONCLUSION: The researchers propose that the increase in the roles and responsibilities of nurses in such activities be supported.

Intervening at the Setting Level to Prevent Behavioral Incidents in Residential Child Care: Efficacy of the CARE Program Model.

The current study examined the impact of a setting-level intervention on the prevention of aggressive or dangerous behavioral incidents involving youth living in group care environments. Eleven group care agencies implemented Children and Residential Experiences (CARE), a principle-based program that helps agencies use a set of evidence-informed principles to guide programming and enrich the relational dynamics throughout the agency. All agencies served mostly youth referred from child welfare. The 3-year implementation of CARE involved intensive agency-wide training and on-site consultation to agency leaders and managers around supporting and facilitating day-to-day application of the principles in both childcare and staff management arenas. Agencies provided data over 48 months on the monthly frequency of behavioral incidents most related to program objectives. Using multiple baseline interrupted time series analysis to assess program effects, we tested whether trends during the program implementation period declined significantly compared to the 12 months before implementation. Results showed significant program effects on incidents involving youth aggression toward adult staff, property destruction, and running away. Effects on aggression toward peers and self-harm were also found but were less consistent. Staff ratings of positive organizational social context (OSC) predicted fewer incidents, but there was no clear relationship between OSC and observed program effects. Findings support the potential efficacy of the CARE model and illustrate that intervening "upstream" at the setting level may help to prevent coercive caregiving patterns and increase opportunities for healthy social interactions.

[Inpatient psychotherapy]. / Stationäre Psychotherapie.

In German-speaking countries inpatient psychotherapy plays a major role in the mental healthcare system. Due to its characteristic features, i. e. multiprofessionalism, multimodality and method integration, the inpatient approach represents a unique and independent type of psychotherapy. In order to be helpful, the manifold verbal and non-verbal methods need to be embedded into an overall treatment plan. Additionally, the therapeutic milieu of the hospital represents an important effective factor and its organization requires a more active construction. The indications for inpatient psychotherapy are not only based on the mental disorder but also on illness, setting and healthcare system-related criteria. In integrative concepts, the multiprofessional team is a key component with many functions. The effectiveness of psychotherapeutic hospital treatment has been proven by meta-analysis studies; however, 20-30% of patients do not benefit from inpatient psychotherapy and almost 13% drop-out prematurely.

Social climate of acute old age psychiatry inpatient units: staff perceptions within the context of patient aggression.

Patient aggression occurs in old age psychiatry and is contrary to their recovery and to the well-being of staff. A favourable social climate can contribute to a reduction in aggression. The aim of this study was to examine the perceptions of clinical staff about the social climate of acute old age psychiatry inpatient units. Eighty-five clinicians were recruited from these facilities. They completed a survey questionnaire about the social climate or ward atmosphere of inpatient units. The findings showed that, to some extent, respondents' perceived patient cohesion and mutual support were evident, units were perceived somewhat positively as safe environments for patients and staff, and the ward climate helped meet patients' therapeutic needs. Overall, clinicians were somewhat positive about the social climate of the units, and this has implications for the perception of aggression in old age psychiatry inpatient settings. As there is a direct relationship between social climate and aggression, clinicians should consider adopting a broad-based, person-centred approach to the promotion of a favourable social climate in old age psychiatry inpatient settings.

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.

Clinical psychologists' experiences of reflective staff groups in inpatient psychiatric settings: a mixed methods study.

UNLABELLED: Background Reflective practice groups have been recommended for improving staff wellbeing and team functioning in inpatient psychiatric services, and clinical psychologists have been identified as potential leaders in this type of work. Research is limited with little information about reflective practice group guidelines, prevalence and effectiveness. Aims The aims of this study were to describe clinical psychologists' practice in reflective groups for staff in inpatient psychiatric services and to explore how such groups are conceptualized and implemented. Methods Online questionnaires and follow-up interviews were used to gain broad descriptions of practice and in-depth information about participants' experiences. The sample consisted of 73 clinical psychologists working in the UK, six of whom were interviewed. Data were analysed using descriptive statistics, content analysis and thematic analysis. Results Clinical psychologists regularly facilitate reflective staff groups in inpatient psychiatric settings in the UK. Common outcomes related to staff wellbeing, service culture and teamwork. Engagement, group dynamics and lack of management support were common challenges. Group experiences were influenced by the organizational context. Conclusions Clinical psychologists' practices regarding reflective staff groups were in line with recent professional developments. Several difficulties were described, which may be indicative of both a difficulty inherent to the task and a training gap in reflective staff group process. The study had methodological limitations but offers a useful contribution to the literature, and enables practice and training implications to be drawn. The need for further research exploring facilitator characteristics, views of group participants and the impact of reflective staff groups on patients is indicated. KEY PRACTITIONER MESSAGE: The term 'reflective practice group' encompasses a range of practices, but a typical group structure was found with common aims, outcomes and challenges. Reflective staff groups are regularly facilitated by clinical psychologists in inpatient psychiatric settings in the UK and are influenced by practitioner experience as well as psychodynamic, systemic and group process theories. The safety required for reflective groups to function is influenced by the organizational context, and groups can contribute to shifts in culture toward including psychosocial perspectives. Reflective staff groups represent one type of contribution to an inpatient psychiatric service and team relationships; other processes to encourage alternative professional perspectives and values might also support change. More research is recommended to explore facilitator characteristics, the views of staff teams on reflective staff groups and the impact of these groups on patients.