The Therapeutic Milieu Project: Reflections on an Attempt to Change the Culture in an Acute Mental Health Service
| Published date | 01 June 2003 |
| Date | 01 June 2003 |
| Pages | 21-25 |
| DOI | https://doi.org/10.1108/13619322200300016 |
| Author | John Hook |
| Subject Matter | Health & social care |
The Therapeutic Milieu Project:
Reflections on an Attempt to
Change the Culture in an Acute
Mental Health Service
John Hook
Consultant Psychiatrist in Psychotherapy
Department of Psychiatry
Royal South Hants Hospital
Case Study I
Introduction
The problems in psychiatric wards are now well
documented (Sainsbury Centre for Mental Health,
1998). Similarly care in the community has not turned
out to be the success that was hoped. The reasons for
both are numerous. This paper describes some of the
problems we encountered in Southampton, no doubt
similar to those elsewhere, and the project that we set
up to try and tackle them.
This article is not the place to do justice to the
range and complexity of issues that have led to the
current state. The purpose is to describe the impact of
the problems on mental health staff and then suggest
that the core of training and workforce development is
to equip staff with psychological skills and
understanding that can be applied in various settings,
patient groups and to individual patients (Hook,
2001). The central construct is how to create and
sustain a therapeutic environment that provides
ongoing work satisfaction for the staff and optimal care
for patients.
The project
The project began over a lunchtime discussion
between the author and a ward manager, J Rawlins.
He was bemoaning how difficult it was to persuade
nursing staff to leave the ward office and spend time
with the patients. The author, a consultant
psychotherapist, was bemoaning the lack of group
work on the wards and in locality mental health teams.
We felt that our concerns reflected a wider malaise in
the hospital and the teams. We decided it was timely
to seek to remedy this.
We advertised an open meeting inviting staff from
all areas of the adult mental health service to come
and share their views. Prior to the meeting JR
informally surveyed staff opinion and the responses
made alarming reading:
■inadequate staffing levels/staff working too long
hours/use of inexperienced agency staff/poor
retention/increased sickness rates
■‘it’s a conveyor belt service’/greater turnover of
patients/not enough beds/staff becoming
deskilled by the constant need to focus on
admissions and discharges/too many clients on
caseloads/‘like fire-fighting all of the time’/too
much paperwork
■little attention to content of patients’ day/not
enough staff to take patients out/limited
therapeutic activities eg occupational and
psychological therapies/poor physical
environment/no money for improvements
■‘there is no time to talk’/no space/no community
meetings/no time for supervision/increased
training opportunities but no time available to
practice skills
■multi-consultant input to wards with conflicting
practice styles
■changing patient population/most patients have
dual diagnosis or personality disorders/staff
inadequately trained when working with dual
diagnosis/easy to access substances on and off
The Mental Health Review Volume 8 Issue 2 June 2003 ©Pavilion Publishing (Brighton) 2003 21
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