How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 58
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Milieu therapy and modified therapeutic communities
A rather different stream of psychiatric practice that has permeated acute inpatient psychiatric nursing practice
was that of therapeutic communities, a British innovation associated with the work of Maxwell Jones in the
1940s (Jones & Bonn 1973). The common attributes of such communities are (Kennard 1998): an informal and
communal atmosphere; group meetings central as fora for sharing information, decision-making, feedback, and
generating cohesion; shared work of maintaining and running the community; shared authority and a flattened
hierarchy; a therapeutic role for residents; and underpinned by moral values and beliefs about the interpersonal
and social nature of psychiatric difficulties, therapy as a learning process, and basic equality. Therapeutic
communities have had a major impact on the care and treatment of people with personality disorders, drug and
alcohol dependencies, and criminal behaviours. However for a period they were also adopted by some leading
acute psychiatric wards in a modified form. Certain elements of the therapeutic community ideal spread to
nearly all acute psychiatric wards for a period, especially the notion of a weekly community meeting with some
shared governance and therapeutic learning responsibility, coupled with the idea of egalitarianism between staff
and patients and evidenced by the abandonment of nursing uniforms.
Attempts to implement this approach on acute psychiatric wards are not without major difficulties, particularly
in relation to acutely psychotic patients. Acutely ill patients are often not able to communicate easily, and are
not in a fit condition to assume responsibilities towards running a community. In the case of psychosis, the idea
of social causation, and social learning as an effective therapeutic method, are both open to serious question.
Nevertheless, acute psychiatric wards in the UK are populated by more than just those suffering from acute
psychosis, and even those patients usually make a recovery during their stay making them fit to engage with
therapeutic community activities to some degree. Thus the therapeutic community notion continues to be
present in psychiatric nursing practice to some degree, and from time to time is rediscovered and reimplemented or re-energised (Mistral, Hall, & McKee 2002).
Similar and parallel innovations in the US came to be known as milieu therapy (Gunderson, Will, & Mosher
1983). The concept of milieu and milieu as a form of treatment was broad and never completely fixed, and drew
on multiple sources. Patient involvement was drawn from therapeutic communities proper; validation or being
with the patient was drawn from Mosher and Laing; finally the idea of structure encompassed rules, routines,
hierarchy, herding or group care (in the Goffman sense, but non-pejoratively), and behavioural modification
systems of every hue, and drew on a similarly wide range of sources, from Bettelheim, through Menninger to
the work of Ayllon and Azrin, and Paul and Lentz. There was thus a sense in which milieu therapy ‘meant
everything to everyman’, incorporated a wide range of treatment modalities, and therefore specific
recommendations on practice or on interaction with acutely psychotic patients were rare. The literature argues,
with a degree of weak research support, that intensive milieus with high levels of staff-patient interaction,
patient involvement in decisions and responsibilities, and with an ideology that psychosis was meaningful and
needed to be worked through, had good outcomes for non-chronic sufferers of schizophrenia. However none of
this literature gets down to the actual detail of the nature of staff-patient interactions.
Psychotherapy, solution focused therapy, person-centred therapy and pre-therapy
The psychotherapy literature might be thought to offer some helpful indicators on how to interact with acutely
psychotic patients. Unfortunately the vast majority of the psychotherapy literature of any sort has been written
about the treatment of non-psychotic people and about outpatients. There is little specific writing or advice
about the inpatient care of people with acute psychoses.
In the sole book about inpatient group psychotherapy (Yalom 1983), the main potential therapeutic processes
are identified: instillation of hope, universality, imparting of information, altruism, corrective recapitulation of
the family group, development of socialising techniques, imitative behaviour, catharsis, existential factors
(death, freedom, isolation and meaninglessness), cohesiveness and interpersonal learning. Although his work is
now of some vintage, being over 25 years old, it continues to be rediscovered and applied from time to time
(Grandison et al. 2009). While Yalom does talk about offering patients support, valuing them, respecting and
understanding their experience, all applicable to interactions with psychotic patients, the therapeutic processes
he identifies are all considered to be the way in which group psychotherapy operates for ‘higher-level’ (i.e. not
acutely psychotic) patients. Of this 312 page book, only 12% is devoted to talking about group therapy with
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