Chapter 22 Settings for mental healthcare
Learning outcomes
Historical overview
Ideas about what is considered a suitable environment for the care of the mentally ill have varied little over time or across cultures. On the whole, the mentally ill have been considered a domestic responsibility (Porter 2002), irrespective of beliefs about the nature of mental disorder. However, these beliefs have at times been highly influential, even if the conclusions drawn from them have been contradictory. For example, throughout most of history it has been believed that the mentally ill were possessed by supernatural forces. This belief usually led to their being feared and avoided. However, one exception to this rule is the Belgian colony of Gheel (sometimes spelt Geel), whose role as a haven for the mentally ill was founded on familial/community support and has existed since the thirteenth century. At Gheel is the church of St Dymphna, the patron saint of the mentally ill, to which the mentally ill seeking to exorcise their affliction have made pilgrimages (Sedgwick 1982). Many of them settled there. The inhabitants of this farming town made their homes available for shelter and care, and their fields for work, to severely disturbed, mentally ill patients. This township thus became one of the precursors of the idea of a community-based, therapeutic environment. Seven hundred years later, Gheel continues to serve as an example for the successful integration of modern treatments (Goldstein & Godemont 2007).
The eighteenth-century Enlightenment brought a general reforming zeal as well as new ideas about madness as a mental condition which could be best treated by mental means. Furthermore, greater experience in managing the mentally ill gave rise to the idea that the asylum could be used as a therapeutic tool, as opposed to being solely a means of confinement. One of the foremost advocates of this progressive thinking was Philippe Pinel (1745–1826). Pinel, who is considered the founder of modern psychiatry, freed the inmates of the Bicêtre and Salpêtrière asylums in Paris from their chains (Shorter 1997). He also provided them with nourishing food, warm baths and useful activity, abolished whips and other instruments of torture, and treated them with kindness. An important outcome of these acts was that many inmates improved dramatically, and others were less violent when allowed to move around. Pinel coined the term ‘le traitement moral’ which translated as ‘moral treatment’, a phrase later popularised by the Englishman and Quaker tea merchant, William Tuke (1732–1822) (Shorter 1997). Tuke’s humanitarian philosophy, which was in stark contrast to the bleedings, purges, chains and denial of basic necessities of life that had marked other treatment approaches, was that mental illness was best treated by beautiful scenery, pleasant distractions and physical comfort. He put his policies of care and kindness into practice at the York Retreat, which he established for the care of members of the local Quaker community suffering from mental illnesses.
An important assumption on which moral treatment rested was that a closed environment was most conducive to the reanimation of reason by psychiatry (Porter 2002). Consequently, purpose-built and designed institutions for confining the mentally ill were constructed during the nineteenth century (Porter 2002). Unfortunately, the humanitarian aspirations of the eighteenth century eventually collapsed under the weight of the huge numbers of mentally ill increasingly housed within them. These large, public institutions were rarely intended to be therapeutic, but were custodial. The mentally ill were housed and fed, but little occurred in the way of treatment. By the time of the First World War, they were little more than vast warehouses (Shorter 1997).
The next section considers the therapeutic community in hospital settings.
Therapeutic community
The therapeutic community has been described as ‘one of the most significant innovations in the history of psychiatry’ (Mills & Harrison 2007). Overturning earlier ideas about the nature of social control, its essence was the flattening of professional hierarchies and the institution of democratic as opposed to authoritarian processes.
Two of the most important early contributors to the development of therapeutic community during the twentieth century were Thomas Main (1946) in the United Kingdom and Maxwell Jones (1953) in the United States (Tuck & Keels 1992). They were among the first modern psychiatrists to recognise the role of the social environment in effecting change in both staff and patients. The foundation for Main’s therapeutic aims were laid at Northfield Military Hospital in the United Kingdom, where two psychiatrists, John Rickman and Wilfred Bion, had experimented with group treatments (Mills & Harrison 2007). Jones built his ideas on the observations made by him and other psychiatrists during the Second World War, that some army units created pathology among soldiers. Jones, however, pioneered the idea that ‘a hospital might become therapeutic as a social organisation’ (Main 1980, p 53). Jones believed that all human social organisation comprised a setting for social and interpersonal relations that could either enhance or limit human potential for health and wellbeing.
Jones used the concept of therapeutic community to describe his innovations in the wards of large asylums during the 1940s and 1950s, although the term therapeutic community can be traced to an earlier lecture given by the American psychiatrist Harry Stack Sullivan in 1939 (Mills & Harrison 2007). For Jones, the essence of the concept of therapeutic community was a change to the organisational ethos of large mental institutions. He started this change in 1940 when he altered the structure of a psychiatric unit at the Maudsley Hospital in London from a punitive, authoritarian one to one where the patients, 100 soldiers with ‘effort syndrome’, a psychosomatic disorder marked by fatigue, were encouraged to become actively involved in their treatment, were educated about their symptoms and given a work program (Watson 1992). The outcomes of these changes were staff who behaved less like custodians and more like facilitators, and a more democratic ward culture. Following the war, Jones tested his theories about therapeutic communities on a group of men with severe antisocial personality disorders. His aim was to reduce acting-out behaviours and to focus on developing social skills. Prior to his experiment the men had failed to respond to any of the currently available therapies; in the therapeutic community, nearly half of them improved.
One of the most important tenets to be derived from Jones’s work is that, in order to be therapeutic, a setting has to be engineered that way. In the hospital setting, a therapeutic milieu is a consciously organised environment demanding deliberate decision-making (Tuck & Keels 1992) and experienced staff who understand inpatient psychiatry (Delaney 1992). The concept of milieu means more than just the physical environment. It includes the social, emotional, interpersonal, professional and managerial elements that comprise a particular setting. In a therapeutic milieu these elements are not considered simply part of the usual background to treatment but critical influences on therapy. The principal components of the therapeutic milieu are outlined in Box 22.1.
In its original conception, the milieu was intended not only to meet a client’s need for psychiatric, medical and nursing care, but also their need for recreation, occupation and social interaction. These needs were to be met through open communication, democratisation, reality confrontation, permissiveness, group cohesion and the multidisciplinary team (see Box 22.2). Democratisation, reality confrontation, permissiveness and communalism were identified by Rapoport (1960, cited in Watson 1992) as the four fundamental themes characterising the therapeutic community. Each of these components is considered in the next section.
Principles governing the inpatient therapeutic milieu
Open communication
Open communication helps build morale and is considered to have a therapeutic effect on staff as well as clients. Staff need to be clear about what behaviour is expected and acceptable, and staff and clients are expected to be candid about their feelings, perceptions and needs. Open communication can be facilitated through warmth and the formation of trusting, one-to-one relationships. Thomas et al (2002) found that one of the most valued aspects of hospitalisation for clients was socialisation with staff and other clients (Thomas et al 2002). An important assumption underlying the therapeutic milieu is that normal functioning results from the social interaction and peer pressure attending activities designed to facilitate open communication. Interaction with others promotes a capacity for selfacceptance and self-realisation, and can be facilitated by regular group and community meetings.
In the contemporary short-stay environment, the community meeting might be held at best once a week, but is more often an ad-hoc affair used to address unit crises (Munich 2000). Kahn (1994, p 23) argues that the contemporary emphasis on short inpatient stays has led to psychiatric units ‘characterized by disorganization, dysphoria and fear’. He suggests that the client–staff community meeting is one of the major means of restoring the therapeutic potential of inpatient units. The typical community meeting is held in a large room where all the staff and patients can be seated comfortably in a circle. Kahn (1994) has outlined six techniques, based on Yalom’s (1983) standard principles of group therapy, for ensuring the effectiveness of community meetings in short-stay inpatient units (see Box 22.3).
Box 22.3 The six principles of effective community meetings
Source: Kahn 1994.
Democratisation
Democratisation is a core element, especially in an institutional context. The aim is to create an environment in which staff and clients feel free to express themselves without fear of rejection and to participate in decision-making to the extent of their abilities. Although clients’ participation will always be qualified and at the discretion of staff, clients can be provided with opportunities to take an active part in ward affairs. They can participate in setting some rules and can be encouraged to solve problems through enquiry and reason. For example, in their account of democracy at work in a rehabilitation unit, Benbow & Bowers (1998) report how clients set the guidelines about television watching and smoking times. Client participation in decision-making communicates an expectation of healthy behaviour. This practice is therapeutic insofar as it recognises the strengths of clients, and facilitates interaction and understanding. In order to achieve this aim, the traditional institutional hierarchies of authority are flattened. According to Watson (1992), democratisation is not to be confused with egalitarianism. In a bureaucratic organisation, it is not possible for everyone to have a say about everything and it is not always appropriate for clients to attend business meetings (Benbow & Bowers 1998). Furthermore, clients will vary in their ability to contribute to decisionmaking according to the severity of their symptoms. Staff and management need to take care that they do not delegate decisions they feel they cannot live with.
Reality confrontation
Staff and patients contribute to reality confrontation by reflecting individuals’ behaviour back to them. The confrontation spoken of here is not about creating conflict or being critical, although it may result from a conflict or crisis, but the giving of information and sharing of feelings in an acceptable way (Watson 1992). Confrontation makes possible the expression of feelings and thereby contributes to social interaction and social learning.
Permissiveness
In a psychiatric ward, staff and patients need to learn to tolerate deviant behaviour. People with mental illness will often exhibit unconventional behaviour. It is important that staff withhold judgment and not exhibit fear or prejudice, although at times they will exert authority and control. Clients need to learn self-regulation and this lesson is best learned in contact with others, where peers and staff can influence and limit behaviour rather than through physical means such as locked doors and medications. Benbow & Bowers (1998) provide an example of how permissiveness can provoke change in client behaviour. Clients were provided with a range of activities that gave them a reason to get out of bed and get dressed in the morning, rather than being forced to get up by nursing staff.
Group cohesion
Group cohesion is important in order to create a climate of support and involvement. Sharing among staff and patients of daily duties and unit resources facilitates communalism. Developing group cohesiveness has become increasingly difficult since the advent of very short lengths of stay (Watson 1992). Short lengths of stay also mean clients rarely know about the progress of their peers and are therefore not in a position to provide feedback.
Multidisciplinary team
consists of individuals from multiple disciplines and acts as an embodiment of the neo-biopsychosocial model, with each team member providing not only a unique perspective on viewing the patient but also offering unique opportunities to aid in creating an environment that is conducive to change (Tobias & Haslam-Hopwood 2003).
The professionals who comprise the MDT usually include a psychiatrist, a psychologist, psychiatric or mental health nurses, social workers and occupational therapists. Depending on local, national and regional variations, other members might include medical officers, social work associates, enrolled nurses and activity therapists. While every discipline has a specific role to fill, in general their roles often overlap. This overlapping can be observed most clearly in the conduct of various therapies including individual, group and family therapies, where any member of the team may take the lead role. The discipline-specific roles are set out in Box 22.4.
Box 22.4 Members of the multidisciplinary team
Psychologist
The clinical psychologist is educated at least to Honours level and many will also have a Masters degree or PhD. There are a variety of particular skills that psychologists can bring to the care of the mentally ill. First among these is that of therapist. Many psychologists have undergone extensive training in specific therapies, especially cognitive-behavioural therapies. In rehabilitative settings clinical psychologists can teach and develop the life skills necessary to assist the mentally ill to function in the community. The clinical psychologist is also responsible for choosing and administering a variety of psychological tests, such as those designed to assess attributes like intelligence or mood states such as depression. These tests are useful in diagnosis. Clinical psychologists often have a strong background in research methods. These skills can be helpful in devising and evaluating programs for the mentally ill (Farhall 2001).
Mental health nurse
Nurses make up the largest group of workers in the mental health system. As noted in Ch 5, there is no universally accepted credential for mental health nurses. In order to practise, nurses must be registered or enrolled with the relevant licensing authority. Registration is possible after the completion of a three-year undergraduate degree in nursing. Many nurses in the mental health area undertake postgraduate studies in mental health nursing, which in some jurisdictions enables them to become endorsed mental health nurses. A credentialling process for mental health nurses has been developed by The Australian College of Mental Health Nurses (see Ch 5). This process identifies the credentialled mental health nurse as having attained a particular standard.
Mental health nurses are the only members of the inpatient team responsible for meeting the needs of clients 24 hours a day, 365 days a year. The nurse observes clients with respect to ‘daily psychopathology, sociability, social skill level and deviant and adaptive behaviours, and the positive and negative consequences of treatment interventions’ (Munich 2002, p 11, cited in Tobias & Haslam-Hopwood 2003). The role of the inpatient nurse is to manage the inpatient milieu, to observe inpatients for changes in symptoms and behaviour, to assess their risk for aggression and/or self-harm, and to de-escalate emotionally charged situations. The nurse, alongside the psychiatrist, takes some responsibility for monitoring the effects of biological treatments. It is also the nurse’s role to coordinate interdisciplinary and nursing care planning. A number of strategies are used in the inpatient milieu; they are designed to facilitate consistent, goal-directed care and include case conferences and nursing/multidisciplinary team handovers. At these occasions there is opportunity to discuss clients and build a level of consensus about treatment in order to ensure a consistent and integrated approach to clients. Mental health nurses in hospitals also sometimes work in a consultation/liaison role where they offer assessment services, advice and assistance to staff in general wards about the management of patients with mental health problems (Elsom 2001).
Social worker
Social workers undertake an undergraduate degree in social work. They work in both inpatient and community settings with individuals, families, groups and the community. The social worker is interested in how aspects of the social environment affect the experience of mental illness and the person’s recovery (Bland 2001). The relevant environmental aspects range from a person’s gender and culture to their individual strengths and family supports. The particular skills social workers bring include counselling, individual case work and group therapy. Social workers are often involved in ensuring that clients receive their just entitlements in state pensions and benefits. Social workers also assess the accommodation needs of clients, taking into consideration the client’s familial and social strengths and problems, and then help clients with placement.
An effective MDT approach contrasts with that of the conventional inpatient team, which is led by a psychiatrist and whose members are usually only involved when their assistance is requested by the psychiatrist. In the conventional model the psychiatrist assumes sole responsibility for assessing, admitting and discharging clients, and prescribing the treatment to be carried out. The extent to which the MDT assumes some of these traditional functions varies (see, for example, Barker & Walker 2000). An MDT approach requires collaboration among its members.
The principles outlined above remain current in contemporary mental health settings, although modifications and additions have been made in order to meet modern challenges to the provision of psychiatric care. Since Maxwell Jones, there have been numerous and farreaching changes within the mental healthcare sys tem. The drivers of these changes are multiple and include: attempts to increase efficiency and reduce costs; the rise of community mental health; increasing numbers of seriously ill, dangerous and difficult patients; new psychotherapeutic agents; and greater professionalisation of mental health workers. When the original model of the therapeutic milieu was developed, inpatients stayed for a minimum of 6–8 weeks (Jones 1953, cited in Watson 1992). The average length of stay now is about two weeks. Furthermore, brief hospitalisation is considered an appropriate method of treatment for some clients. A consequence of these changes to the length of stay is rapid patient turnover and more inpatients with complex needs. The next section considers the goals of the therapeutic milieu in contemporary inpatient psychiatric settings.
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