Therapeutic Milieu Approaches within The State Hospital: A Qualitative Analysis of Patients' Experiences of Ward Talking Groups

Jacqueline Geddes

University of Edinburgh/The State Hospital

Developing “a positive therapeutic milieu”• Within forensic mental health services all staff

must be alert to physical and procedural structures/processes due to the increased likelihood of violence and aggression. This inevitably has an impact on the relationships between staff and patients.

• In an attempt to address this imbalance, the clinical model proposed the development of a ‘positive therapeutic milieu‘.

Developing “a positive therapeutic milieu”• In order to develop a positive therapeutic

environment, it was essential to identify therapeutic components within the evidence base that have been found to be effective.

Developing “a positive therapeutic milieu”• Vandevelde et al.’s (2004) retrospective account

of the democratic Maxwell Jones type Therapeutic Community (Jones, 1952, 1968) and the Hierarchical Concept-based Therapeutic Community (Yablonsky, 1965; Bratter et al, 1985) explores the similarities and differences between them.

Developing “a positive therapeutic milieu”Although both approaches are borne from thesediverse roots, Vandevelde et al. (2004) highlightsthe links between them with regard to:

• Social learning and behavioural modification • Permissiveness and modeling• Democracy and hierarchy• Communalism and community as method• Reality testing and acting as if

Developing “a positive therapeutic milieu”• Perry’s (2012) systematic review of successful

components of milieu approaches echoed Vandevelde’s account. The components found in the literature were:

• Using the community as a therapeutic tool• Social learning• Reality testing• Permissiveness• Patient participation• Psycho-education

Why ward talking groups?• To capitalise upon the evidence for these six

shared-components of successful milieus.

• The issue of high expressed emotion in community meetings.

This study

• Although these groups have been developed in an attempt to provide more opportunities for therapeutic interactions between staff and patients, it is recognised these groups are a novel therapeutic intervention. As a result of this, patient’s subjective experience of these groups is unclear. There is a need to explore these experiences in order to evaluate the processes in these groups and assist in service development.

Methodology• Interpretive Phenomological Analysis (IPA)• Recruitment• Inclusion and Exclusion Criteria• Participant Characteristics• Materials• Ethical Review• Data Collection

Why IPA?

•To provide insight into how services feel ‘from the inside’ (Rose, 2003, p.406).

•The importance of the subjective experience of offenders on their life changes (Farrall, 2002).

Findings

Relating to Others

Building & improving relationships

Being heard

Sharing experiences

Negotiating difficult social situations

Findings

Rights within the context of high security

Choice

Freedom of speech

Negotiating boundaries

Equality

Findings

The challenge of something new

Ambivalence towards new processes

Previous experiences shaping current understanding

The importance of information

Being open-minded

Findings

Breaking down barriers to social

interaction

Informal

Normalising

Negotiable boundaries

Versatility