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Acute wards: problems and solutions

Acute wards: problems and solutions Holmes Acute wards: creating a psychotherapeutic culture Psychiatric Bulletin (2002), 26, 383^385 JER EM Y HO L ME S special articles Creating a psychotherapeutic culture in acute psychiatric wards There has been a curious linguistic shift in the use of the important role in improving quality of care in the in- word community in mental health (Holmes, 2001a). In the patient setting. 1950s and early 1960s community psychiatry was synon- First, there is the overwhelming evidence that psychosocial factors are relevant to the course of schizo- ymous with milieu therapy and the therapeutic commu- nity - that is, the attempt to create a vibrant community phrenia. In the home setting, high expressed emotion in carers is associated with increased risk of relapse (Leff & of patients and staff, in a shared space, working actively Vaughn, 1985). Similar findings apply to professional together to overcome disability, illness and stigma. The carers of patients living in hostels (Ball et al,1992). contrast was with insitutional psychiatry, caricatured as Although expressed emotion studies have not, to my the silent, soulless and, at times, abusive wards of the knowledge, thus far been undertaken in the in-patient Victorian mental hospital. The therapeutic community had setting, it seems likely that low levels of criticism and two main psychotherapeutic tools: group therapy and hostility in staff would also be associated with better creative therapies such as art therapy and psychodrama. outcomes in acute wards. This view is supported by These approaches were pioneered in specialist units such studies using the Ward Atmosphere Scale (Moos, 1996), as the Henderson hospital (Norton & Haigh, 2002) but, which suggest that patient satisfaction and reduced more generally, progressive acute units emphasised the readmission rates in patients with schizophrenia are use of ward groups and the importance of patients correlated with a ward atmosphere that strikes an playing an active part in decision-making. appropriate balance between structure and spontaneity With the end of incarceration and the replacement (Middelboe et al,2001). of large mental hospitals, those idealistic days seem far Second, there is the consistent finding in the away. User surveys tend to be highly critical of in-patient psychotherapy research literature that the quality of the care (Sainsbury Centre for Mental Health, 1998). In one therapeutic alliance is the best predictor of a good survey, 57% of patients said they would have liked more outcome in therapy (Roth & Fonagy, 1996). When patients contact with staff and 82% reported less than 15 minutes view their therapy in a positive light this predicts a low per day in face-to-face contact with staff (MIND, 2000). drop-out rate and significant reduction in symptoma- Indeed, today’s acute wards run the risk of being not so tology. Again, this finding is based mainly on out-patient much un-therapeutic as anti-therapeutic (compare Fagin, settings, but if translated into in-patient care, it would 2001), reflecting poor staff morale. Acute wards tend to suggest that skill in establishing a therapeutic alliance be seen as unattractive places to work compared with among ward staff would improve outcomes. This links community settings. There is rapid staff turnover and, with extrapolations from the attachment literature especially in the inner cities, extensive use of ‘bank’ staff (Holmes, 2001b), which suggest that a prime function of to make up numbers. The consequent lack of continuity mental health services is to provide a secure base for and commitment means that custodial rather than thera- patients. In an in-patient context, a secure base would peutic values prevail. represent a familiar person in a familiar place to whom the One way to survive the chaos and mental pain that patient can turn at times of threat or illness, charac- are the raw materials of mental health work is to batten terised by a combination of responsiveness and sensitivity down the hatches and to retreat into a defensive world with the capacity to set limits and help cope with of cynicism and mild paranoia, in which exploration of separation. feelings is considered to be disruptive and dangerous Third, there is evidence that difficulty in the when it happens. Psychotherapists are seen, at best, as staff-patient relationship is a significant predictor of woolly-minded idealists who have no idea about the in-patient suicide. Watts and Morgan (1994) found that, reality of acute psychiatric work and, at worst, as sinister prior to suicide, there is a marked deterioration in rela- psychoanalysts bent on disabling staff by laying bare their tionships between patient and staff, characterised by weaknesses to be exploited by managers and colleagues. increasing emotional distance and hostility, a condition that is dubbed malignant alienation. A psychotherapeutic approach can help contain and detoxify the difficult feel- The case for psychological therapies ings that patients who are disturbed inevitably arouse in Hard evidence that psychological therapies can play a those who work with them. significant role in in-patient care is far from robust, Finally, there is the burgeoning literature on the perhaps because the attention of the research commu- efficacy of psychological methods in psychosis and other nity has been focused elsewhere. Nevertheless, the major psychiatric disorders (e.g. Drury et al,2000). research literature does provide some grounds for Cognitive-behavioural approaches to delusions, self- thinking that psychological approaches might play an management of hallucinations and other techniques have https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press Holmes Acute wards: creating a psychotherapeutic culture mainly been delivered in out-patient settings. However, Level two equipping ward staff with these psychological skills can An active programme of group therapy for patients is special strengthen the therapeutic alliance and provide the first also needed, run by ward staff (including psychiatrists) articles steps in a psychotherapeutic approach, which can then be and supervised by psychotherapists trained in group continued after discharge. Hostility and withdrawal on work. This may include a weekly or twice-weekly the part of staff often accompany a sense of being community meeting (or large group) for all patients and deskilled and unable to cope. Training in psychological staff, and/or regular small groups for selected patients, therapy can help overcome this. depending on their level of function and diagnosis. The purpose of such group work is to foster awareness of the life of the ward as a whole, and to begin to make connections between clinical events such as exacerbation Practical measures of symptoms, a violent outburst, deepened depression, How can these general principles be translated into prac- alcoholic relapse or suicide attempt, in an interpersonal context, that is as a response to events within the ward tical improvements in the in-patient environment? Given community. the rapid turnover and nature of clinical disturbance on An acute ward is potentially such a chaotic place, most in-patient wards, it would be unrealistic and inap- with such rapid turnover and intensity of psychotic beha- propriate to suggest that specific psychological therapies viour that this is no mean task. However, not to do so is become the mainstay of work on the ward - those are to abandon any attempt to understand or engage closely needed later in the care programme, in the day care or with ‘madness’ - surely for a psychiatrist, a dereliction of out-patient setting. However, three key sets of skills are primary duty. vital. First, there is the capacity to build a therapeutic Ward groups, however ‘sticky’ or apparently alliance with patients and their relatives. Second, self- mundane, can become an integral part of ward life and awareness and reflective practice should be developed, are able to deal with the inevitable resistance that they both at the level of the individual practitioner and in the arouse in patients and some staff, which is usually mani- staff team as a whole, thereby lowering expressed fested in non-attendance. Techniques directly transposed emotion and the likelihood of malignant alienation. Third, from long-term group analytic work may be inappropriate specific skills are needed in the management of person- in the in-patient setting. Developing an appropriate here- and-now, systemic, relevant and dynamic style for such ality disorder, eating disorder and psychological groups represents a major clinical and research challenge approaches to psychosis in the in-patient setting. The first (Mace, 2002). two are requirements for all who work on an in-patient ward; the third can be developed by selected staff members who can then act as mentors for the staff team Level three as a whole. There also needs to be specific expertise in and provision Ongoing training and detailed supervision of clinical of psychological therapies for in-patients with psychosis, work are integral to psychologically-informed practice; in eating disorders or personality disorders. Staff members the in-patient setting these are probably more important often do acquire additional training in psychological than any specific programmes. Regular supervision and therapies, for example by attending a course in cognitive- staff support are the crucial ingredients in improving the behavioural therapy (CBT). However, the acquired skills quality of psychological care on acute wards. tend to atrophy in the traditional ward setting. Insuffi- Three levels of psychological input into acute care cient thought is currently given to providing training can be envisaged, each of which adds to the preceding appropriate to the in-patient setting, and to the level. management structures that are needed to support it. Selected staff members who have had training in CBT approaches in psychosis need to become part of a Level one managed clinical network for psychosis services, and take the lead in supervising keyworkers who are helping their As a bare minimum, a weekly or fortnightly multi- patients to cope with hallucinations and to challenge disciplinary staff support group is required, facilitated by delusional ideas. Others are conversant with behavioural a psychotherapist with training in group dynamics, and and interpersonal approaches to severe eating disorders actively supported and attended by senior staff, including and can take the lead with such difficult patients when consultant psychiatrists and ward managers. These are they are admitted. Patients with personality disorder are multi-function groups where the impact of difficult cases among the most problematic of in-patient cases, invari- canbe discussed and staff tensions canbe exploredin ably arousing strong feelings among staff. Expertise in a safe and confidential setting. There is some evidence the combination of responsiveness and limit-setting that (Kho et al, 1998) that the existence of such a group is more appropriate for this patient group rarely comes serves to reduce the number of violent episodes on a without training and support. Here, too, having one or ward, presumably by reducing expressed emotion and more staff members who are part of a managed clinical enhancing cohesion within the group. network for personality disorder, who have received https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press Davenport Acute wards: a rehabilitation approach training in appropriate psychotherapy skills, can make a Declaration of interest significant difference to outcomes (Holmes, 1999). None. special articles Conclusion References Fostering a psychological approach to in-patient care will BALL, R. A., MOORE, E. & KUIPERS, L. LEFF,J.&VAUGHN,C.(1985) Expressed (1992) Expressed emotion in Emotion in Families. London: Guilford. require a shift in culture, management and training. There community care staff: a comparison of has to be a determined commitment from senior medical, MACE, C. (2002) Group therapy. In patient outcome in a nine month Integration in Psychotherapy: Models nursing and management staff to create change. An in- follow-up of two hostels. Social and Methods (eds. J. Holmes & A. Psychiatry and Psychiatric patient psychological therapies implementation group is Bateman). Oxford: Oxford University Epidemiology, 27,35-39. needed, with representatives from psychiatry (with one Press. DRURY,V., BIRCHWOOD, M. & member of the consultant group taking the lead in acute MIDDLEBOE,T., SCHEDT,T., BYRSTING, COCHRANE, R. (2000) Cognitive care), psychotherapy, nursing, psychology, occupational K., et al (2001) Ward atmosphere in therapy and recovery from acute acute psychiatric in-patient care. Acta therapy and management. Each professional grouping psychosis: a controlled trial: 3. Five- Psychiatrica Scandinavica, 103, 212- year follow-up. British Journal of needs to think through the implications for its own Psychiatry, 177,8-14. particular discipline. MIND (2000) Environmentally Friendly? FAGIN, L. (2001) Therapeutic and In spite of the important moves towards community Patients’ Views on Conditions in counter-therapeutic factors in acute care, the work of the consultant psychiatrist could, in Psychiatric Wards. London: MIND. ward settings. Psychoanalytic theory, centre on the in-patient ward. That is where the Psychotherapy, 15,99-120. MOOS, R. (1996) Ward Atmosphere most ill patients tend to be at any one time and the Scale: Developments, Applications, HOLMES,J.(1999)Psychodynamic Research. Redwood, CA: Mind Garden. greatest efforts of the consultants should be concen- approaches to the management and treatment of severe personality NORTON, K. & HAIGH, R. (2002) trated there. Sadly, this is often not the case. The disorder in general psychiatric settings. Therapeutic Community. In Integration consultant will come onto a ward, usually shared with CPD Psychiatry, 1,53-57. in Psychotherapy: Models and several other consultants, see his or her patients and Methods (eds. J. Holmes & A. (2001a) Psychotherapies. In depart. Maintenance of the ward culture and manage- Bateman). Oxford: Oxford University Textbook of Community Psychiatry Press. ment of the ward as a whole is left, by default, to the (eds. G.Thornicroft & G. Szmuckler). nurses, rather than being a collaborative therapeutic Oxford: Oxford University Press. ROTH, A. & FONAGY, P. (1996) What Works for Whom? London: Guilford. enterprise managed by a ‘combined parent’ of medical (2001b) The Search for the Secure Base: Attachment and Psychotherapy. SAINSBURY CENTRE FOR MENTAL and nursing staff. London: Routledge. HEALTH (1998) Acute Problems: A The contention of this paper is that the re-discovery Survey of the Quality of Care in Acute KHO, K., SENSKY,T., MORTIMER, A., et of a psychological culture on the acute unit can produce Psychiatric Wards. London: Sainsbury al (1998) Prospective study into factors improved clinical outcomes, a reduction in untoward Centre for Mental Health. associated with aggressive incidents in events and increased staff and patient satisfaction. The psychiatric acute admission wards. WATTS, D. & MORGAN, G. (1994) acute ward can become a place of creativity and change British Journal of Psychiatry, 172, Malignant alienation. British Journal of 38-43. Psychiatry, 164,11-15. rather than of burden and threat. To achieve this requires a sustained research and management effort, but if successful, the positive impact on consultant morale Jeremy Holmes Department of Mental Health, University of Exeter, could be significant and rejuvenating. North Devon District Hospital, Barnstaple, Devon EX31 4JB Psychiatric Bulletin (2002), 26,385^388 SAR A H DAV ENP O RT A rehabilitation approach to in-patient care This paper describes rehabilitation principles and some The dynamics of in-patient settings specialised practice that could usefully inform the These are related to the dynamics of institutions, of provision of acute in-patient care. A low secure reha- psychosis and of abuse (Davenport, 1997). bilitation setting is described using a method of case There is a high prevalence of childhood sexual and formulation to embed an envelope of care around an physical abuse among psychiatric in-patients (Wurr & individual patient within a therapeutic ward milieu. This Partridge, 1996), with some responses being conditioned increases the collaboration and transparency around by previous abuse. Typical dynamics of abuse include individual care planning and the capacity for self- splitting, revictimisation, difficulties within power reflection within the multi-disciplinary team, in a relationships and sexualisation of relationships in general. manner that may be applicable to other in-patient Patients receive care within an institution that settings. operates social defences to reduce the anxiety, guilt, https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Psychiatric Bulletin Unpaywall

Acute wards: problems and solutions

Psychiatric BulletinOct 1, 2002

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Abstract

Holmes Acute wards: creating a psychotherapeutic culture Psychiatric Bulletin (2002), 26, 383^385 JER EM Y HO L ME S special articles Creating a psychotherapeutic culture in acute psychiatric wards There has been a curious linguistic shift in the use of the important role in improving quality of care in the in- word community in mental health (Holmes, 2001a). In the patient setting. 1950s and early 1960s community psychiatry was synon- First, there is the overwhelming evidence that psychosocial factors are relevant to the course of schizo- ymous with milieu therapy and the therapeutic commu- nity - that is, the attempt to create a vibrant community phrenia. In the home setting, high expressed emotion in carers is associated with increased risk of relapse (Leff & of patients and staff, in a shared space, working actively Vaughn, 1985). Similar findings apply to professional together to overcome disability, illness and stigma. The carers of patients living in hostels (Ball et al,1992). contrast was with insitutional psychiatry, caricatured as Although expressed emotion studies have not, to my the silent, soulless and, at times, abusive wards of the knowledge, thus far been undertaken in the in-patient Victorian mental hospital. The therapeutic community had setting, it seems likely that low levels of criticism and two main psychotherapeutic tools: group therapy and hostility in staff would also be associated with better creative therapies such as art therapy and psychodrama. outcomes in acute wards. This view is supported by These approaches were pioneered in specialist units such studies using the Ward Atmosphere Scale (Moos, 1996), as the Henderson hospital (Norton & Haigh, 2002) but, which suggest that patient satisfaction and reduced more generally, progressive acute units emphasised the readmission rates in patients with schizophrenia are use of ward groups and the importance of patients correlated with a ward atmosphere that strikes an playing an active part in decision-making. appropriate balance between structure and spontaneity With the end of incarceration and the replacement (Middelboe et al,2001). of large mental hospitals, those idealistic days seem far Second, there is the consistent finding in the away. User surveys tend to be highly critical of in-patient psychotherapy research literature that the quality of the care (Sainsbury Centre for Mental Health, 1998). In one therapeutic alliance is the best predictor of a good survey, 57% of patients said they would have liked more outcome in therapy (Roth & Fonagy, 1996). When patients contact with staff and 82% reported less than 15 minutes view their therapy in a positive light this predicts a low per day in face-to-face contact with staff (MIND, 2000). drop-out rate and significant reduction in symptoma- Indeed, today’s acute wards run the risk of being not so tology. Again, this finding is based mainly on out-patient much un-therapeutic as anti-therapeutic (compare Fagin, settings, but if translated into in-patient care, it would 2001), reflecting poor staff morale. Acute wards tend to suggest that skill in establishing a therapeutic alliance be seen as unattractive places to work compared with among ward staff would improve outcomes. This links community settings. There is rapid staff turnover and, with extrapolations from the attachment literature especially in the inner cities, extensive use of ‘bank’ staff (Holmes, 2001b), which suggest that a prime function of to make up numbers. The consequent lack of continuity mental health services is to provide a secure base for and commitment means that custodial rather than thera- patients. In an in-patient context, a secure base would peutic values prevail. represent a familiar person in a familiar place to whom the One way to survive the chaos and mental pain that patient can turn at times of threat or illness, charac- are the raw materials of mental health work is to batten terised by a combination of responsiveness and sensitivity down the hatches and to retreat into a defensive world with the capacity to set limits and help cope with of cynicism and mild paranoia, in which exploration of separation. feelings is considered to be disruptive and dangerous Third, there is evidence that difficulty in the when it happens. Psychotherapists are seen, at best, as staff-patient relationship is a significant predictor of woolly-minded idealists who have no idea about the in-patient suicide. Watts and Morgan (1994) found that, reality of acute psychiatric work and, at worst, as sinister prior to suicide, there is a marked deterioration in rela- psychoanalysts bent on disabling staff by laying bare their tionships between patient and staff, characterised by weaknesses to be exploited by managers and colleagues. increasing emotional distance and hostility, a condition that is dubbed malignant alienation. A psychotherapeutic approach can help contain and detoxify the difficult feel- The case for psychological therapies ings that patients who are disturbed inevitably arouse in Hard evidence that psychological therapies can play a those who work with them. significant role in in-patient care is far from robust, Finally, there is the burgeoning literature on the perhaps because the attention of the research commu- efficacy of psychological methods in psychosis and other nity has been focused elsewhere. Nevertheless, the major psychiatric disorders (e.g. Drury et al,2000). research literature does provide some grounds for Cognitive-behavioural approaches to delusions, self- thinking that psychological approaches might play an management of hallucinations and other techniques have https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press Holmes Acute wards: creating a psychotherapeutic culture mainly been delivered in out-patient settings. However, Level two equipping ward staff with these psychological skills can An active programme of group therapy for patients is special strengthen the therapeutic alliance and provide the first also needed, run by ward staff (including psychiatrists) articles steps in a psychotherapeutic approach, which can then be and supervised by psychotherapists trained in group continued after discharge. Hostility and withdrawal on work. This may include a weekly or twice-weekly the part of staff often accompany a sense of being community meeting (or large group) for all patients and deskilled and unable to cope. Training in psychological staff, and/or regular small groups for selected patients, therapy can help overcome this. depending on their level of function and diagnosis. The purpose of such group work is to foster awareness of the life of the ward as a whole, and to begin to make connections between clinical events such as exacerbation Practical measures of symptoms, a violent outburst, deepened depression, How can these general principles be translated into prac- alcoholic relapse or suicide attempt, in an interpersonal context, that is as a response to events within the ward tical improvements in the in-patient environment? Given community. the rapid turnover and nature of clinical disturbance on An acute ward is potentially such a chaotic place, most in-patient wards, it would be unrealistic and inap- with such rapid turnover and intensity of psychotic beha- propriate to suggest that specific psychological therapies viour that this is no mean task. However, not to do so is become the mainstay of work on the ward - those are to abandon any attempt to understand or engage closely needed later in the care programme, in the day care or with ‘madness’ - surely for a psychiatrist, a dereliction of out-patient setting. However, three key sets of skills are primary duty. vital. First, there is the capacity to build a therapeutic Ward groups, however ‘sticky’ or apparently alliance with patients and their relatives. Second, self- mundane, can become an integral part of ward life and awareness and reflective practice should be developed, are able to deal with the inevitable resistance that they both at the level of the individual practitioner and in the arouse in patients and some staff, which is usually mani- staff team as a whole, thereby lowering expressed fested in non-attendance. Techniques directly transposed emotion and the likelihood of malignant alienation. Third, from long-term group analytic work may be inappropriate specific skills are needed in the management of person- in the in-patient setting. Developing an appropriate here- and-now, systemic, relevant and dynamic style for such ality disorder, eating disorder and psychological groups represents a major clinical and research challenge approaches to psychosis in the in-patient setting. The first (Mace, 2002). two are requirements for all who work on an in-patient ward; the third can be developed by selected staff members who can then act as mentors for the staff team Level three as a whole. There also needs to be specific expertise in and provision Ongoing training and detailed supervision of clinical of psychological therapies for in-patients with psychosis, work are integral to psychologically-informed practice; in eating disorders or personality disorders. Staff members the in-patient setting these are probably more important often do acquire additional training in psychological than any specific programmes. Regular supervision and therapies, for example by attending a course in cognitive- staff support are the crucial ingredients in improving the behavioural therapy (CBT). However, the acquired skills quality of psychological care on acute wards. tend to atrophy in the traditional ward setting. Insuffi- Three levels of psychological input into acute care cient thought is currently given to providing training can be envisaged, each of which adds to the preceding appropriate to the in-patient setting, and to the level. management structures that are needed to support it. Selected staff members who have had training in CBT approaches in psychosis need to become part of a Level one managed clinical network for psychosis services, and take the lead in supervising keyworkers who are helping their As a bare minimum, a weekly or fortnightly multi- patients to cope with hallucinations and to challenge disciplinary staff support group is required, facilitated by delusional ideas. Others are conversant with behavioural a psychotherapist with training in group dynamics, and and interpersonal approaches to severe eating disorders actively supported and attended by senior staff, including and can take the lead with such difficult patients when consultant psychiatrists and ward managers. These are they are admitted. Patients with personality disorder are multi-function groups where the impact of difficult cases among the most problematic of in-patient cases, invari- canbe discussed and staff tensions canbe exploredin ably arousing strong feelings among staff. Expertise in a safe and confidential setting. There is some evidence the combination of responsiveness and limit-setting that (Kho et al, 1998) that the existence of such a group is more appropriate for this patient group rarely comes serves to reduce the number of violent episodes on a without training and support. Here, too, having one or ward, presumably by reducing expressed emotion and more staff members who are part of a managed clinical enhancing cohesion within the group. network for personality disorder, who have received https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press Davenport Acute wards: a rehabilitation approach training in appropriate psychotherapy skills, can make a Declaration of interest significant difference to outcomes (Holmes, 1999). None. special articles Conclusion References Fostering a psychological approach to in-patient care will BALL, R. A., MOORE, E. & KUIPERS, L. LEFF,J.&VAUGHN,C.(1985) Expressed (1992) Expressed emotion in Emotion in Families. London: Guilford. require a shift in culture, management and training. There community care staff: a comparison of has to be a determined commitment from senior medical, MACE, C. (2002) Group therapy. In patient outcome in a nine month Integration in Psychotherapy: Models nursing and management staff to create change. An in- follow-up of two hostels. Social and Methods (eds. J. Holmes & A. Psychiatry and Psychiatric patient psychological therapies implementation group is Bateman). Oxford: Oxford University Epidemiology, 27,35-39. needed, with representatives from psychiatry (with one Press. DRURY,V., BIRCHWOOD, M. & member of the consultant group taking the lead in acute MIDDLEBOE,T., SCHEDT,T., BYRSTING, COCHRANE, R. (2000) Cognitive care), psychotherapy, nursing, psychology, occupational K., et al (2001) Ward atmosphere in therapy and recovery from acute acute psychiatric in-patient care. Acta therapy and management. Each professional grouping psychosis: a controlled trial: 3. Five- Psychiatrica Scandinavica, 103, 212- year follow-up. British Journal of needs to think through the implications for its own Psychiatry, 177,8-14. particular discipline. MIND (2000) Environmentally Friendly? FAGIN, L. (2001) Therapeutic and In spite of the important moves towards community Patients’ Views on Conditions in counter-therapeutic factors in acute care, the work of the consultant psychiatrist could, in Psychiatric Wards. London: MIND. ward settings. Psychoanalytic theory, centre on the in-patient ward. That is where the Psychotherapy, 15,99-120. MOOS, R. (1996) Ward Atmosphere most ill patients tend to be at any one time and the Scale: Developments, Applications, HOLMES,J.(1999)Psychodynamic Research. Redwood, CA: Mind Garden. greatest efforts of the consultants should be concen- approaches to the management and treatment of severe personality NORTON, K. & HAIGH, R. (2002) trated there. Sadly, this is often not the case. The disorder in general psychiatric settings. Therapeutic Community. In Integration consultant will come onto a ward, usually shared with CPD Psychiatry, 1,53-57. in Psychotherapy: Models and several other consultants, see his or her patients and Methods (eds. J. Holmes & A. (2001a) Psychotherapies. In depart. Maintenance of the ward culture and manage- Bateman). Oxford: Oxford University Textbook of Community Psychiatry Press. ment of the ward as a whole is left, by default, to the (eds. G.Thornicroft & G. Szmuckler). nurses, rather than being a collaborative therapeutic Oxford: Oxford University Press. ROTH, A. & FONAGY, P. (1996) What Works for Whom? London: Guilford. enterprise managed by a ‘combined parent’ of medical (2001b) The Search for the Secure Base: Attachment and Psychotherapy. SAINSBURY CENTRE FOR MENTAL and nursing staff. London: Routledge. HEALTH (1998) Acute Problems: A The contention of this paper is that the re-discovery Survey of the Quality of Care in Acute KHO, K., SENSKY,T., MORTIMER, A., et of a psychological culture on the acute unit can produce Psychiatric Wards. London: Sainsbury al (1998) Prospective study into factors improved clinical outcomes, a reduction in untoward Centre for Mental Health. associated with aggressive incidents in events and increased staff and patient satisfaction. The psychiatric acute admission wards. WATTS, D. & MORGAN, G. (1994) acute ward can become a place of creativity and change British Journal of Psychiatry, 172, Malignant alienation. British Journal of 38-43. Psychiatry, 164,11-15. rather than of burden and threat. To achieve this requires a sustained research and management effort, but if successful, the positive impact on consultant morale Jeremy Holmes Department of Mental Health, University of Exeter, could be significant and rejuvenating. North Devon District Hospital, Barnstaple, Devon EX31 4JB Psychiatric Bulletin (2002), 26,385^388 SAR A H DAV ENP O RT A rehabilitation approach to in-patient care This paper describes rehabilitation principles and some The dynamics of in-patient settings specialised practice that could usefully inform the These are related to the dynamics of institutions, of provision of acute in-patient care. A low secure reha- psychosis and of abuse (Davenport, 1997). bilitation setting is described using a method of case There is a high prevalence of childhood sexual and formulation to embed an envelope of care around an physical abuse among psychiatric in-patients (Wurr & individual patient within a therapeutic ward milieu. This Partridge, 1996), with some responses being conditioned increases the collaboration and transparency around by previous abuse. Typical dynamics of abuse include individual care planning and the capacity for self- splitting, revictimisation, difficulties within power reflection within the multi-disciplinary team, in a relationships and sexualisation of relationships in general. manner that may be applicable to other in-patient Patients receive care within an institution that settings. operates social defences to reduce the anxiety, guilt, https://doi.org/10.1192/pb.26.10.383 Published online by Cambridge University Press

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Psychiatric BulletinUnpaywall

Published: Oct 1, 2002

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