Search results

The concept of user participation is well accepted internationally. Nevertheless, studies show that both patients and health professionals find it challenging to maintain patient-centred ideals in the context of severe mental illness. The purpose of this paper is to explore how professionals deal with the ideals in light of patients’ right to participate in planning and decision making regarding milieu therapeutic measures and activities.

This is a qualitative study with an interactionist approach based on fieldwork at three district psychiatric centres in Norway during 2011-2012. The observations focused on patient-staff interaction in milieu therapeutic activities. Interviews were based on observed situations.

Adherence to treatment, rules and routines restricted patient autonomy. The professionals’ practical orientation towards routines overrode the ideals of patients’ rights. The staff regarded user participation primarily as participation in organised and mandatory activities. Refusal to comply was met with different sanctions, e.g. the prospect of being discharged.

Although user participation calls for patient-centred approaches, there is some debate about the challenges and premises for cooperation with persons suffering from severe mental conditions. This study adds insight into the everyday organisational context that facilitates or impedes user participation. It helps to explain why the user perspective can be overlooked, thus providing important information to both clinicians and policy makers who aim to fulfil the patient’s right to participate in planning and decision making regarding treatment and care.

The purpose of this paper is to review quantitative research since 1999 evaluating the effectiveness of democratic therapeutic community (DTC) treatment for individuals with personality disorders (PD) with reference to interpersonal and offending risk outcomes.

A systematic search resulted in the review of ten studies. All of the studies investigated DTCs treating PD in community, inpatient residential and forensic settings. Only peer-reviewed, English-language articles employing a quantitative design were included.

The majority of studies were conducted poorly and of low methodological quality, with limitations located in the representativeness of participants, limited use of control and comparison groups, follow up periods and controls for confounders. Heterogeneity remained in use of measures and limited consideration was given to the validity of interpersonal measures used. While improved interpersonal outcomes post DTC treatment were noted in forensic and residential settings, results were mixed in day and mini TC settings. Inconsistent findings in offending risk outcomes were also indicated. A study with increased methodological rigour indicated residential treatment had limited effects on interpersonal outcomes, when compared to combination treatment (residential TC and step-down treatment).

The study provided an evaluation of the limitations of DTC research across a range of settings and highlighted a combination of residential TC and step-down treatment may achieve superior outcomes to residential TC treatment alone in a community inpatient population. Recommendations are made for future research to contribute to the treatment of PD.

Forthcoming Reorganisations Inter‐Authority working parties develop programmes for forthcoming Local Government reorganisation. Elaborate Health Service reorganisation plans are formulated. Schools are merged to form comprehensives. Central Government reshuffles frequently involve merging or demerging whole departments, and Common Market entry will eventually lead to some synthesis of services and policies at continental levels of operation. Many European countries approach major Social Services mergers—for example, the Dutch are soon to take action on Seebohm‐style report called “Structural Perspective”, and the 1970 Danish Social Steering Act is equivalent to the 1970 British Social Services Act, except that it allows for a four‐year changeover period. The Swedes continue to test integrated service delivery at neighbourhood level along the lines of such famous experiments as the Tierp commune block in Uppsala. Many European countries are in throes of Maud‐type Local Government reorganisations, which Italy embarked on in April 1972, and Britain is to embark in April 1974. The public sector is evidently moving through a period of major mergers as scepticism about 1960s' industrial conglomeration prompts the Government's fair trading legislation promising new merger evaluation methods. General principles about merging public services begin to emerge. Relevant data derives from British Social Services' reorganisation following the Seebohm Report, London Local Government reorganisation, American and Australian state‐level experiments in service integration incorporated under Allied Services legislation and various service industry mergers. Merger theory is still in its infancy, even that part which derives from industrial experience the degree of potential upheaval in public services reorganisations demands that fullest possible use be made of our existing understanding of what may occur when two or more organisations merge.

The purpose of this paper is to discuss the clinical assessment of children and the development of a multi-disciplinary team in an established residential school for children aged five to 12.

Using clinical examples the paper describes how assessment can identify different levels of therapeutic need, and then how the decision is made whether or not to offer milieu therapy, music therapy, dramatherapy or psychotherapy.

The paper suggests that children who have early histories of abuse and trauma have differing clinical needs.

The implication is that children will engage better with the therapy if the level of intervention is sensitive to their state of mind, which in turn will help them make better use of the environmental provision of the school.

The paper offers an original perspective on the possibilities and limitations of psychotherapeutic work with extremely vulnerable damaged children in a residential therapeutic setting, the Mulberry Bush.

The purpose of this paper is to describe and discuss interventions of stabilisation of emotions and behaviour in adults with post-traumatic stress disorder (PTSD). This topic is understudied in persons with intellectual disability.

The aim of this study was to investigate interventions of stabilisation in persons with more severe intellectual disability; i.e. persons with moderate or severe intellectual disabilities. Five patients in a specialised psychiatric inpatient unit for patients with intellectual disabilities were included. Information about treatment of the patients was collected through case files, observations, and interviews. The authors of this paper followed a training programme for trauma therapists in addition to the inpatient treatment of the five patients.

Six main areas of stabilisation of emotions and behaviour were identified: validation, anxiety relief, treatment of depressed mood, increased mastering of daily activities, protection against anxiety triggers, and facilitated staff communication. Protection from anxiety triggers seems to be a core element of milieu therapy interventions. Interventions for neurotypical PTSD patients, such as exposure therapy may be contraindicated for patients with more severe intellectual disabilities.

Research on interventions of stabilisation towards adults with more severe intellectual disabilities is still in its infancy. The case reports may help milieu therapists to facilitate interventions towards patients with moderate or severe intellectual disabilities.

The purpose of this paper is to provide an overview of the application of therapeutic community (TC) method in non-TC environments.

Milieu treatment is defined and differentiated from TC “proper”. Literature is reviewed covering attempts to use TC methods in inpatient wards, across hospitals, and more recently in the criminal justice system and more widely through the enabling environments initiative.

It is unclear whether TC milieu treatments proved helpful in acute ward environments in their heyday in the 1950s, 1960s and 1970s, in particular those involving people suffering from acute psychosis, and the changing landscape of psychiatric provision may make further investigation difficult. The reasons for this, and for the difficulties reaching a firm conclusion, are outlined. In contrast, TC milieu interventions appear to be demonstrating usefulness more recently in less mixed populations without the implementation of full TC “proper”.

Much of the research is old and the methodology poor, which limits the conclusions that can be drawn.

Recent innovations pick up in a more accessible way principles of therapeutic communities that can inform and improve care in a variety of contexts. They are sufficiently well defined to lend themselves to research, which should now be a priority.

After a gap in developments in the field, recent innovations are reintroducing elements of TC functioning to new contexts including criminal justice settings, inpatient wards, homeless shelters and city communities.

This article aims to analyze and discuss the role of moral development in treatment of behavior problems and, further, to describe differences and similarities between two different methods – milieu therapy (MT) and cognitive behavioral therapy (CBT) – in terms of addressing criminogenic needs and promoting moral development.

By performing a literature review, the study shows that even though there are both pros and cons using MT and CBT in institutional care, relationships strong enough to restructure a young person's moral reasoning require time, and involves not only the young person's parents and social network members, but also a genuine therapeutic alliance with clinical staff at the institution.

These are central factors articulated in both CBT and MT, but are more explicitly expressed in MT. The results presented in this article highlight some important practical implications: in order to redevelop moral self and societal values, an overly narrow focus on criminogenic needs might exclude other components or processes of treatment and behavioral change. Together with a treatment program that views close staff‐resident interactions as of secondary importance, this could impair the possibility to obtain positive and long‐lasting treatment results.

In practice, moral development itself should be considered as an overall treatment goal, integrated into the daily life at the institution, 24 hours a day. Finally, the possibility to work with moral development in institutional settings is discussed.

There are few publications on personality disorder in adults with intellectual disability (ID), and on borderline personality disorder (BPD) specifically. Publications concerning treatment are sparse, despite the high symptom burden in these patients. This paper aims to discuss these issues.

Six patients with BPD and ID were recruited from the same inpatient unit. Behaviour problems and mental health symptoms were scored on admission and discharge. Information about treatment, length of stay, etc. was taken from case files.

Both mental health symptoms measured by the SCL-90-R, and behaviour problems measured by the Aberrant Behaviour Checklist were significantly reduced on discharge. In the active treatment period, the two main aspects of treatment were validation and practicing new solutions when emotional and behavioural problems occur, i.e. skills training.

The limitations related to this study are that the study is conducted in one milieu only. Another limitation is that the patients were admitted over a five-year period, where, some changes were made in the treatment approach.

Inpatient treatment of this patient group seems to be effective if individually adjusted to the patient’s psychopathology, ID and communication style. Close co-operation between the individual therapist and milieu therapists is essential.

There is a need for intervention studies on BPD in ID. This study may be a valuable contribution.

The purpose of this paper is to inform readers and researchers about the use of a “lived experience” of therapeutic community work as an effective intervention for severely emotionally troubled children.

An explanation of the main developmental influences and how the Mulberry Bush School is continuing to incorporate new theories and approaches.

How the Mulberry Bush as a specialist therapeutic residential provision can bring about excellent outcomes for severely emotionally troubled children.

The paper explores the work and legacy of the school's founder Barbara Dockar-Drysdale and of her collaboration with Donald Winnicott to create a lived experience of community as an agent of therapeutic change. The paper also provides descriptions and a case study of the current multi-disciplinary work of the school, including how neuroscientific research is influencing the evolution of the therapeutic task with traumatised children.

The paper shows how a highly evolved model of integrated provision can support excellent outcomes for traumatised children and young people.

To broaden and deepen knowledge about the use of therapeutic community principles in the treatment of severely emotionally trouble children and young people.

The purpose of this paper is to construct a genealogy of therapeutic communities (TCs), with the espoused commitment to flattened hierarchies and democratic ideologies, the paper considers the lineage of the Frankfurt School of Social Research and its influence in setting a frame for TC ideology, with a particular focus on Herbert Marcuse and Eric Fromm. This genealogy provides further context to the contribution of two other key Frankfurters, Karl Mannheim and Michael Foulkes, who progressed therapeutic democracy in the UK and shaped the early days of the TC as a group-based treatment paradigm.

Discourse analysis and collective biography based on biographical details, texts and witness accounts.

The works of Marcuse and Fromm provide a hybrid psychosocial post-Freudian schemas that beckoned philosophic reconciliation between the state and the personal psyche culminating in new left psychoanalytic academic sectors. Eric Fromm's contribution is situated squarely in the clinical sphere in the USA dating from the 1930s after he fled from Germany and settled in the USA where he became a well-known lecturer at Chestnut Lodge during a time when it was developing its approach under the rubric of “milieu therapy”. Marcuse's influence on psychiatry is tracked through the development of ideas and writings emerging from his reading of Freud, finally intersecting with the emergence of TCs and anti-psychiatry when he delivered the keynote address at the Dialectics of Liberation Conference in London in 1967. Held at the height of the first generation of TCs, Joe Berke, R.D. Laing and colleagues considered Marcuse as someone to headline the Dialectics Conference because; “Marcuse was the Grandpapa of Flower Power” (Joe Berke said).

A rapprochement between milieu therapy in the USA, influenced by Fromm and Marcuse and the European tradition of TCs, influenced by Mannheim and Foulkes is demonstrated. The Frankfurt Institute of Social Research can be seen as an ideological corner that transcends Atlantic divides, and provides a sturdy and lasting intellectual cornerstone for the history of ideas in the field of social psychiatry.