Psychiatric Nursing

Open access articles and resources on psychiatric nursing
Current
11/21/09

AMPHETAMINE AND RELATED SUBSTANCE USE DISORDERS

INTRODUCTION

Amphetamine and amphetamine related substances are the second most widely misused drug in Asia and many other countries. Metamphetamine, a congener of amphetamine has become more popular in the recent years.

HISTORY

Amphetamine was first synthesized in 1887 and was introduced in to the clinical use in 1932 as an over the counter inhaler for the treatment of nasal congestion and asthma. 1n 1937 onwards it used for the treatment of narcolepsy, depression, post encephalitic Parkinsonism. The current FDA approved indications for amphetamine are for the treatment of attention deficit hyperactivity disorder and narcolepsy. In some countries it also uses for the treatment of obesity, depression, chronic fatigue syndrome, AIDS, and dementia.

PREPARATIONS

The major amphetamine preparations are

  • Dextroamphetamine
  • Metamphetamine (Desoxyn)
  • A mixed detroamphetamine - amphetamine salt (Adderall)
  • The amphetamine like compound methylphenidate (Ritalin)

These drugs go by such street names as ice, crystal, crystal meth and speed. Amphetamines are referred to as stimulants, sympathomimetics, analeptics and psycho stimulants. These are used to increase the performance and to improve the euphoric feeling. (Students studying for the exam, truck drivers, athletes for the competition,by soldiers during war time etc)

Other amphetamines like substances are ephedrine, psuedoepedrine, phenylepropanolamine (PPA). Amphetamine like dugs with abuse potential are also include phendimetrazine and diethylpropion, benzphetamine(Direx), and phentermine(ionamine).

EPIDEMIOLOGY

Amphetamine use occurs in all socioeconomic groups. According to DSM IV TR the life time prevalence of amphetamine dependence and abuse is 1.5% and the male to female ratio is 1.

ETIOLOGY

The familial, social, and psychological factors are relevant in the etiology of amphetamine misuse. Two-thirds to three-quarters of drug misusers have an underlying personality disorder, usually of the antisocial type,

CLINICAL FEATURES

  • Amphetamine has a slower onset of action and a longer elimination half-life. Thus an amphetamine user may experience desired effects, unwanted mental effects, and withdrawal features over the course of a few days,
  • A single 5mg dose increases the feeling of wellbeing and induces elation, euphoria and friendliness. Small doses usually improve performance and concentration. An associated decrease in fatigue, nightmares, fears, reduction of pain perception etc also seen.
  • Mood is elevated, but these progresses to suspicion, in which true paranoid symptoms may be experienced and if use persists symptoms may become severe, or a more confused state develop.
  • After stopping the drugs there are typically withdrawal effects of depressed mood, hyperphagia, and hypersomnia; such features are viewed as 'rebound' symptoms,
  • It is commonly observed that amphetamine is non-addictive, or cause psychological but not physical dependence. It can be addictive' when individuals are injected amphetamine 10 or more times every day for many years,

Effects

Withdrawal effects

Increased energy

Hyperactivity

Euphoria

Reduced appetite

Insomnia

Paranoid symptoms

Confusion

 

Depression

Irritability

Agitation

Craving

Hyperactivity

Hyperactivity

Hypersomnia

 

NEUROPHARMACOLOGY

All the  amphetamines are rapidly absorbed orally(when compare to other stimulants like cocaine, its absorption rate is slow). And have rapid onset of action usually with in one hour when take orally. The classic amphetamines can take IV and the action will be very rapid in this route. Non described amphetamines and designer amphetamines can be inhaled (snorting). Tolerance develop with both classic and designer amphetamines. It is less addictive when compare with cocaine.

§  The classic amphetamines produce primary effects by causing the release of catecholamines, particularly dopamine from the presynaptic terminals. It has effect on the dopaminergic neurons projecting from the ventral tegmental area to the cerebral cortex and limbic areas. This path way has been termed as reward circuit pathway and its activation is the major addictiong mechanism for the amphetamines.

§  The designer amphetamines causes the release of the catecholamine's (dopamine and nor epinephrine) and of serotonin (the neurotransmitter implicated as the major neurochemical pathway of hallucinogens.). so the clinical effects of designer amphetamines are blend effect of classic amphetamines and those of hallucinogens.

DIAGNOSIS

DSM IV TR lists many amphetamine related disorders, but specific diagnostic criteria are available only for amphetamine intoxication, amphetamine withdrawal,  amphetamine related disorder not otherwise specified.

AMPHETAMINE (OR AMPHETAMINE-LIKE SUBSTANCE)-RELATED DISORDERS (DSM IV TR)

Amphetamine Use Disorders

304.40  Amphetamine Dependence a,b,c

305.70  Amphetamine Abuse

Amphetamine-Induced Disorders

292.89  Amphetamine Intoxication

Specify if: With Perceptual Disturbances

292.0  Amphetamine Withdrawal

292.81  Amphetamine Intoxication Delirium

292.xx  Amphetamine-Induced Psychotic Disorder

.11 With Delusions

.12 With Hallucinations

292.84  Amphetamine-Induced Mood Disorder,

Specify if: with onset during intoxication

: with onset during withdrawal

292.89  Amphetamine-Induced Anxiety Disorder,

Specify if: with onset during intoxication

292.89  Amphetamine-Induced Sexual Dysfunction,

Specify if: with onset during intoxication

292.85  Amphetamine-Induced Sleep Disorder

Specify if: with onset during intoxication

: with onset during withdrawal

292.9  Amphetamine-Related Disorder NOS

1. Amphetamine dependence and amphetamine abuse

Amphetamine dependence dependence can result in a rapid downward spiral of a persons ability to cope with work, and family related obligations and stress. A person who abuse this drug requires high doses of amphetamine to to obtain the usual high and physical signs of amphetamine abuse(decreased weight and paranoid ideas) almost develop with the continuous use.

2.      Amphetamine intoxications.

The symptoms of intoxication are mostly resolved after 24 hours and are generally completely resolved after 48 hours.

3. Amphetamine withdrawal

After amphetamine intoxication, a crash occurs with symptoms of anxiety, dysphoric mood, lethargy, fatigue, night mares, head ache, profuse sweating, muscle cramps, stomach cramps etc. it will be peak in 2-4 days and are resolved with in one week. The most serious withdrawal symptom is depression which can be severe after the continuous use of the drug and also associated with suicidal ideations

4. Amphetamine intoxication delirium

Delirium associated with amphetamine use generally result of high doses or of sustained use of the drug. The combination of amphetamine with other drugs and the use of amphetamine by the persons with pre existing brain damage also will lead to the development of delirium.

5. Amphetamine induced psychotic disorder

Amphetamine induced psychotic disorder are similar to the clinical presentation of paranoid schizophrenia. The hall mark of amphetamine induced psychosis is paranoia. The amphetamine induced psychosis can be distinguished from paranoid schizophrenia by the clinical features such as visual hallucinations, ambivalence, association disturbances which are evident schizophrenia. The treatment of choice for this condition is the use of antipsychotics such as haloperidol.

6. Amphetamine induced mood disorder

According to DSM IV TR the mood disorders associated eith amphetamine are during the intoxication and withdrawal states. Intoxication is associated with manic or mixed mood states where as withdrawal is associated with depressive symptoms

7. Amphetamine induced anxiety disorders

Amphetamine induced anxiety disorders can also during intoxication and withdrawal periods. Amphetamines can induce symptoms which are similar to OCD, panic disorders, and phobia

8. Amphetamine induced sexual dysfunction

Amphetamines can be use as an antidote to the sexual side effects of serotonergic agents such as fluoxetine, but they often misuse to enhance sexual experience. High doses and long term use are associated with erectile problems and other sexual problems. It is more evident in the intoxication states also.

9. Amphetamine induced sleep disorder

Sleep disorders are present in intoxication as well as withdrawal states. Intoxication can cause insomnia and sleep deprivation and withdrawal can cause hyper somnolence and nightmares.

ADEVERSE EFFECTS

PHYSICAL

  • Can produce most serous adverse effects which include cerebrovascular, cardiac and gastro intestinal effects. The life threatening conditions like MI, severe hypertension, CVA, and ischemic colitis are more common among abusers
  • A continuum of neurological symptoms like twitching, tetany, seizures , coma, death etc can develop.
  • IV use of the drug can cause the transmission of infectious diseases like AIDS and hepatitis.
  • The non threatening adverse effects are flushing, fatigue, pallor, cyanosis, fever, bradycardia, palpitations, nausea, vomiting, bruxism, shortness of breath, tremor and ataxia.
  • Pregnant women who use this drug often have babies of low birth weight, small head circumference, early gestational age and growth retardation

PSYCHOLOGICAL

  • The adverse psycho logical effects include restlessness, dysphoria, irritability, hostility, confusion
  • Amphetamine use can also lead to disorders like anxiety disorders, panic disorders, ideas of reference, paranoid delusions, and hallucinations
  • Acute intoxication may present as a paranoid hallucinatory syndrome which closely mimic paranoid schizophrenia. The distinguish features of this are prominence of visual hallucinations, absence of thought abnormalities, presence of confusion.
  • Tactile hallucinations in clear consciousness may occur in chronic amphetamine intoxication

TREATMENT

Treatment of intoxication

  • Acute intoxication is treated by symptomatic management.(eg: hypepyrexia- cold sponging, seizures-diazepam, psychotic symptoms- haloperidol and hypertension-antihypertensives).
  • Acidification of urine with oral NH4CL 500mg every 4 hours facilitates the elimination of amphetamines

Treatment of withdrawal symptoms

  • The presence of suicidal depression requires hospitalization
  • The treatment includes symptomatic management, use of antidepressants and supportive psychotherapy. The management of withdrawal syndrome is the first step of treatment of amphetamine dependence.
  • Physicians should establish therapeutic alliance with the clients to treat the underlying depression and personality problems
  • Bupropion can be use once the patient recover from the withdrawal symptom to enhance the feeling of well being.

REFERENCES

  • Kaplan HI, Sadok BJ. Synopsis of psychiatry-behavioural science or clinical psychiatry.9th edn. Hong Kong.William and Wilkinsons publications. 1998.
  • GelderM,Gath D,Mayou R,Cowen P. New oxford text book of psychiatry. 4th edn.Oxford. Oxford university press.2004
  • Ahuja N.A short text book of psychiatry. 5th edn. New Delhi. Jaypee brothers medical publishers.2004.
  • Townsend MC. Psychiatric mental health nursing. 3rd edn. Philadelphia. FH Davis publishers.
Current
11/21/09

CAFFEINE-RELATED DISORDERS

INTRODUCTION

Caffeine is the most widely consumed psychoactive substance in the world. Psychiatric symptoms and disorders can be associated with its excessive use. DSMIV TR lists several caffeine related disorders, eg-caffeine intoxication, caffeine induced anxiety disorder and caffeine induced sleep disorder. Other caffeine related disorders are caffeine withdrawal and caffeine dependence.

EPIDEMIOLOGY

Caffeine is contained in drinks, foods, prescription medicines and over the counter medications. An adult consumes about 200mg of caffeine per day on an average and 20-30% of adults consumes more than 500mg of caffeine per day. A cup of coffee contains around 100 to 150mg of caffeine; tea about one third as much. Many over the counter medications contains one third to one half as much caffeine as a cup of coffee and some migraine medication and over the counter medicines contains more amount of caffeine than a cup of coffee.   Cocoa, chocolate and soft drinks also contain significant amount of caffeine, enough to cause some symptoms of caffeine intoxication in small children when they ingest a candy bar or cola drink.

Caffeine consumption also varies by age. The average daily caffeine consumption of caffeine consumers of all age is 2.79mg/kg body weight. A substantial amount of caffeine is consumed by small children also.

COMORBIDITY

Persons with caffeine related disorders are more likely to have additional substance related disorders than are those with out diagnosis of caffeine related disorders. About two third of those who consume large amounts of caffeine daily also use sedative and hypnotic drugs.

ETIOLOGY

After exposure to caffeine , continued caffeine consumption can be influenced by several factors, such as pharmacological effects of caffeine, caffeine's reinforcing effects, genetic predisposition to use caffeine and personal attributes of the consumer.

NEUROPHARMACOLOGY

Caffeine is more potent. The half life of caffeine in human body is 3-to 10 hrs, and the time of peak concentration is 30-60 min. Caffeine readily crosses the blood brain barrier. Caffeine acts primarily as an antagonist of adenosine receptors. Adenosine receptors activate an inhibitory G protein and thus inhibit the formation of the second messenger cyclic adenosine mono phosphate (cAMP). Caffeine intake result in an increase in intraneuronal cAMP concentrations in neurons with adenosine receptors. Three cups of coffee are estimated to deliver the amount of caffeine which occupy about 50% adenosine receptors

High doses of caffeine can affect the dopaminergic and noradrenergic system. Dopamine activity is enhanced by the caffeine activity, so it may be the reason of exacerbation of clinical symptoms in patients with schizophrenia in increased caffeine intake.

Subjective effects and reinforcement

Single low to moderate amount of caffeine can produce a subjective wellbeing in human beings and is generally indicated as pleasurable. caffeine causes increase in energy, motivation, capacity to work and concentration. Caffeine decreases the sleep and fatigue. 300-800mg of caffeine may lead to anxiety and nervousness. At low doses it act as a reinforce and this effect contribute to the regular use of caffeine.

Genetics and caffeine use.

Some genetic predispositions are present in caffeine use. Monozygotic and dizygotic twins have high concordance. It is more in monozygotic twins than dizygotic twins and heritability ranging from 33 to 77 percent.

Age, sex and race.

Studies suggest that middle age people use more caffeine, there is no much difference in caffeine use among male and females.

Special populations

Smokers consume more caffeine than non smokers. Studies shown that the higher rates of caffeine use in psychiatric patients populations than the general population. Patients who have anxiety disorders tend to use less amount of caffeine.

Effects on cerebral blood flow.

Caffeine result in cerebral vasoconstriction, with a resultant decrease in cerebral blood flow . cerebral blood flow improves after withdrawal from the caffeine. Many other studies reveals that caffeine can cause coronary artery constriction.

DIAGNOSIS

Diagnosis of caffeine related disorders and caffeine dependence are depend primarily on the comprehensive history of the patient. The history should cover whether the patient has experienced any symptoms, pattern of caffeine intake, whether the person had tried to stop the intake of caffeine etc.

The differential diagnosis of caffeine related disorders are anxiety disorders, panic disorders with or without agora phobia, bipolar II,  ADHD, and sleep disorder. The differential diagnosis should include the intake of OTC, anabolic steroids, and stimulants such as amphetamines. A urine sample is needed to screen for other stimulants.

CAFFEINE-RELATED DISORDERS (DSM IV TR CRITERIA)

Caffeine-Induced Disorders

305.90 Caffeine Intoxication

292.89 Caffeine-Induced Anxiety Disorder

292.85 Caffeine-Induced Sleep Disorder

292.9 Caffeine-Related Disorder NOS

I. Caffeine intoxication

Diagnostic criteria includes the recent consumption of caffeine, usually more than 250mg. common symptoms associated with caffeine intoxication are anxiety, psychomotor agitation, restlessness, muscle twitching, , psychophysiological complaints, nausea , dieresis, GIT upset, tingling in the fingers and toes. Consumption of more than one gram of caffeine can cause rambling of speech, confused thinking, cardiac arrhythmias, agitation, tinnitus and visual hallucinations.

DSM IV TR

A.      Recent consumption of caffeine intake usually more than 250 mg(more than 2-3 cups of brewed coffee)

B.      Five or more of following signs, developing during, shortly and after the caffeine use

ü  Restlessness

ü  Nervousness

ü  Excitement

ü  Insomnia

ü  Flushes face

ü  Dieresis

ü  GIT disturbances

ü  Rambling flow of thought and speech

ü  Tachycardia or cardiac arrhythmia

ü  Periods of inexhaustibility

ü  Psychomotor agitation

C.      The symptom in criteria B causes significant distress or impairment in social, occupational, or other important areas of functioning.

D.     The symptoms are not due to general medical conditions and are not better account for any other mental disorders.

II. Caffeine induced anxiety disorder

Caffeine induced anxiety disorder can occur during caffeine intoxication. The anxiety related to caffeine use can resemble the generalized anxiety disorder. The patient may be perceived ad wired, over talkative, and irritable. They may complaint of reduced sleep. Caffeine can induce and exacerbate panic attacks in persons with panic anxiety disorder.

III. Caffeine induced sleep disorder.

Caffeine induced sleep disorder can occur in acute intoxication. Caffeine is associated with delay in falling sleep, inability to remain in sleep, and early morning awakening.

IV. Caffeine related disorder not otherwise specified.

Caffeine dependence and caffeine withdrawal are not included in DSM IV TR. They are included in the classes- caffeine related disorder NOS

CLINICAL FEATURES

Signs and symptoms

After the ingestion of 50-100mg of caffeine , common symptoms includes increased alertness, a mild sense of wellbeing and a sense of improved verbal and motor performance. Caffeine ingestion is also associated with dieresis, cardiac muscle stimulation, increased intestinal peristalsis, increased gastric acid secretion and increased blood pressure.

Caffeine use and nonpsychiatric illness

§  There are significant risks from caffeine use. They are cancer, heart diseases, reproduction problems etc.

§  Caffeine use is contraindicated in generalized anxiety disorder, panic disorder, primary insomnia, pregnancy, gastro esophageal reflux disease.

§  Caffeine increases the blood pressure.

§  There is association between caffeine consumption and low birth weight babies.

TREATMENT

  • Analgesics such as aspirin can use to control the head ache because of caffeine withdrawal. Rarely patients need benzodiazepines to manage the withdrawal effects. If benzodiazepines use for this purpose it should use invery small doses for 4-7 days.
  • Person should recognize all sources of caffeine in his diet and control the caffeine intake. Because caffeine is use in the beverage form, it can be substituted with beverages which are noncaffenated. The patient should avoid stopping the caffeine intake abruptly, caffeine intake should taper first before proceed to the complete abstinence.

REFERENCES

  • Kaplan HI, Sadok BJ. Synopsis of psychiatry-behavioural science or clinical psychiatry.9th edn. Hong Kong.William and Wilkinsons publications. 1998.
  • GelderM,Gath D,Mayou R,Cowen P. New oxford text book of psychiatry. 4th edn.Oxford. Oxford university press.2004
  • Ahuja N.A short text book of psychiatry. 5th edn. New Delhi. Jaypee brothers medical publishers.2004.
  • Townsend MC. Psychiatric mental health nursing. 3rd edn. Philadelphia. FH Davis publishers.
Current
11/21/09

Therapeutic community

Introduction

The therapeutic community (TC) for the treatment of drug abuse and addiction has existed for about 40 years. In general, TCs are drug-free residential settings that use a hierarchical model with treatment stages that reflect increased levels of personal and social responsibility. The goals are to effect a complete change of lifestyle ,including abstinence from substances, to develop a personal honesty, responsibility and useful social skills and to eliminate antisocial attitudes and criminal behavior .

History

Under the influence of Maxwell Jones, Main, Wilmer and developed the  concept of the therapeutic community and its attenuated form - the therapeutic milieu - caught on and dominated the field of inpatient psychiatry throughout the 1960's. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. 'TC's have sometimes eschewed or limited medication in favour of group-based therapies.

Definition

"A therapeutic community is a drug-free environment in which people with addictive (and other) problems live together in an organized and structured way in order to promote change and make possible a drug-free life in the outside society. The therapeutic community forms a miniature society in which residents, and staff in the role of facilitators, fulfill distinctive roles and adhere to clear rules, all designed to promote the transitional process of the residents"  ( Ottenberg 1993)

Stuart and Sundeen defined therapeutic community as "a therapy in which patient's social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care and the daily problems of his community".

Objectives

  • To use patient's social environment to provide a therapeutic experience for him
  • To enable the patient to be an active participant in his own care and become involved in daily activities of his own community
  • To help patient to solve problems ,plan activities and to develop the necessary rules and regulations for the community
  • To increase their independence and gain control over many of their own personal activities
  • To enable the patient to become aware of how their behavior affects others

Elements of therapeutic community

Free communication

  • Shared responsibility
  • Active participation
  • Involvement in decision making
  • Understanding of the roles, responsibilities limitations and authorities

Components of therapeutic community

a) Daily community meetings

  • These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are not involved in the meetings.
  • Meetings should be held regularly for 60 minutes
  • Discussion should focus mainly on day to day life in the unit
  • During discussion patients feelings and behaviors are examined by other members
  • Frank discussion are encouraged ,these may take place with much out poring of emotions and anger

b) Patient Government or Ward council

  • The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning and privileges
  • A group of 5-6 patients will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients. Staff members should be always available
  • All decisions should be feedback to the community through the community meetings

c) Staff meetings or Review

A staff meeting should be held following each community meeting (patients are excluded and only staff are present). In this meeting the staff would examine their own responses, expectations and prejudice.

d) Living and learning opportunities

Learning opportunities are provided within the social milieu, which should provide realistic learning experiences for the patients.

Length of treatment in a therapeutic community

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit. Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model .For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more.

In the TC, the level of treatment engagement and participation is related to retention and outcomes. Treatment factors associated with increased retention include having a good relationship with one's counselor, being satisfied with the treatment, and attending education classes. Important attributes linked to treatment retention include self-esteem, attitudes and beliefs about oneself and one's future, and readiness and motivation for treatment. Retention can be improved through interventions to address these areas.

Structure of the therapeutic community

TCs are physically and programmatically designed to emphasize the experience of community within the residence. The residential capacity of TCs can vary widely; a typical program in a community-based setting accommodates 40 to 80 people. TCs are located in various settings, often determined by need, funding sources, and community tolerance. Some, for example, are situated on the grounds of former camps and ranches or in suburban houses. Others have been established in jails, prisons, and shelters. Larger agencies may support several facilities in different settings to meet various clinical and administrative needs.

The treatment process: therapy, education and training

The elements of treatment at the TC typically include substance abuse treatment, education (General Equivalency Diploma or, in some cases, university courses), primary medical and dental care, vocational skills training (e.g. culinary arts, carpentry, general maintenance, mechanical systems, general contracting, computer skills, or substance abuse counseling), on- and off-site job placement, and in rare cases, on-site resident-run businesses. Other supports include legal services, advocacy, and life skills counseling. There is no formal religious component to treatment, education or training. In fact, experts caution against the introduction of religion as an aspect of daily life in the TC .

TC treatment can be divided into three major stages.

Stage 1. Induction and early treatment : This phase typically occurs  during the first 30 days to assimilate the individual into the TC. Once the intake process of interviews and assessments is complete, new arrivals to the TC are often housed in rooms with six to eight bunkmates. It is generally expected that new residents must be medically detoxified prior to beginning the program. Leader who is responsible for the orientation of the new resident to the rules and expectations of the TC.

Work is often identified as one of the central components of the therapeutic approach. As such, job assignments or "functions" begin immediately for new residents, usually with basic housekeeping or maintenance chores. The work-centered approach is intended to serve multiple purposes.

  • First, by beginning with general maintenance work, the resident acquires knowledge of the facility's physical layout and organizational structure.
  • Second, daily work is believed to instil an ethic of discipline and hard work that is desirable according to the TC treatment model.
  • Third, putting new residents to work immediately reinforces the broader nature of the TC as a structured, merit-based program, where residents earn privileges and seniority by complying with all rules and behavioural expectations. In this case, the implied goal for the new resident is to move up a strict hierarchy of jobs and departments to more desirable positions.
  • Lastly, the work is often physically demanding, leaving residents physically tired at the end of the day so that they have no time to think about leaving and returning to their previous lifestyle.

Progression from phase one to phase two is be made on the recommendation of staff members and, to a lesser extent, the broader peer group, and  is typically judged on the basis of the individual resident's attitude, work competence and peer relations.

Stage 2. Primary treatment

In Phase two the resident is expected to take on more responsibility for the welfare of others, particularly newcomers. At this stage, he or she is normally introduced to three vocational training areas. Training takes place during the daytime hours, with expected  study time in the evening. Residents typically begin courses to improve literacy, develop  computer skills and achieve a General Equivalency Diploma (GED). Residents are also typically expected to continue with their encounter groups, with the goal of adopting positive beliefs and attitudes toward themselves and others. By the end of phase two,  residents are normally expected to have completed their GED, choose one vocation training area in which to specialize, participate in encounter groups, deal with more daily responsibility, and adhere to the rules and regulations of the facility. Often  uses a structured model of progression through increasing levels of prosocial attitudes, behaviors, and responsibilities. The TC may use interventions to change the individual's attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3

Entry into phase three normally begins when the resident has applied for, and has been accepted to train in a vocational area on a full-time basis, with the intention of completing a certificate in the program or trade, and finding related work outside of the facility after leaving. Residents may be reimbursed nominally for their vocational work. The money is saved so they will have money to begin their new lives once they exit the program. During this phase, residents may be encouraged to attend social activities outside of the facility accompanied by other members, as well as re-establish contact with their   families of origin. A family reunification program is sometimes established.

Stage 4. Re-entry At this point residents typically share accommodations and bathrooms with a smaller number of residents in a more home like setting. It is believed that by this phase, residents have acquired skills and coping abilities to allow them to "re-enter" society.These skills often include a GED, vocational training, computer literacy, and relationship and coping skills. If any money has been saved for the resident, these funds will be released with the expectation that a bank account will be opened for living expenses.

Staffing

TCs are often staffed by a carefully chosen group of professionals who receive training in the specifics of the TC model. Experts suggest that program staff should comprise a mix of self-help recovered professionals and other traditional professionals (e.g.  nurses, physicians, lawyers, case workers, counselors) 8). An average resident to staff ratio was cited as approximately 15:1.

Resident profile and special populations

Many residents have been drug addicted for years and have a history of criminal activity or other legal problems. Other common factors include multi-generational poverty and homelessness. most TCs stipulate that residents must be healthy enough to undertake physical labor and participate in training programs and other group-related activities. Potential residents are generally deemed inadmissible in the case of a history of kidnapping, rape, arson, child molestation, suicide attempts.

The screening and intake process for TC residents is rigorous, typically involving an initial visit or phone call, admission to a waiting list, an orientation process, one or more intake interviews, medical, legal and psychological assessments, and consent to treatment. A thorough intake process is considered to be particularly critical in light of the high rate of drop-out which commonly reaches 50% within the first 30 days.

The daily regimen

A typical TC day begins at 7 a.m. and ends at 11 p.m. and includes morning and evening house meetings, job assignments, groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society, work is a distinctive component of the TC model.

In the TC, all activities and interpersonal and social interactions are considered important opportunities to facilitate individual change. These methods can be organized by their primary purpose, as follows:

* Clinical groups (e.g., encounter groups and retreats) use a variety of therapeutic approaches to address significant life problems.

* Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC.

* Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training.

Community and clinical management activities (e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.

Advantages of therapeutic community

  • Patient develops harmonious relationships with other members of the community
  • Gains self -confidence
  • Develops leadership skills
  • Learns to understand and solve problems of self and others
  • Becomes socio-centric
  • Learns to live and think collectively with the members of the community
  • It provides opportunity to participate in the formulation of hospital rules and regulations that affect patient's personal liberties like bedtime, meal time, weekend permission, control of radio or T.V, social activities, late night privileges

Disadvantages of therapeutic community

·         Role blurring between staff and patient

  • Group responsibility can easily become nobody's responsibility
  • Individual needs and concerns may not be met
  • Patient find the transition to community difficult

Role of the nurse

  • Providing and maintaining a safe and conflict free environment through role modeling and group leadership
  • Sharing of responsibilities with patient
  • Encouraging patient to participate in decision making functions
  • Assisting patients to assume leadership roles
  • Giving feedback
  • Carrying out supervisory functions

Conclusion :

Several studies have found that this approach to treatment is successful in substantially improving the quality of life for members. A study of patients at the Cassel Hospital showed that 98% of patients are too disturbed on admission to find employment, but that five years later 90% have jobs. Re-admission and re-conviction rates have been found to drop considerably after treatment in a therapeutic community.

References :

1.   Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral Sciences/ Clinical Psychiatry .9th ed. Hong Kong :William and Wilkinson Publishers ;1998.

2.  Dr. Bimla K. Text Book of Psychiatric Nursing vol. II. Ist ed. New Delhi: Kumar Publishing House; 2006

3. Sreevani R. A Guide to Mental Health and Psychiatric Nursing .New Delhi:Jaypee Brothers Medical Publishers;2006.

Current
11/20/09

Milieu Therapy

Introduction:

In psychiatry, therapy involving the milieu or the environment may be called milieu therapy, therapeutic community or therapeutic environment. The goal of milieu therapy is to manipulate the environment so that all aspects of the client's hospital experience are considered therapeutic. Within this therapeutic community setting the client is expected to learn adaptive coping, interaction and relationship skills that can be generalized to other aspects of his or her life.

Meaning: The word milieu is French for "middle". The English translation of the word is surroundings or environment. Milieu therapy is the scientific planning of an environment for therapeutic purposes.

 

Definition: A scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual( Skinner, 1979).

Historical overview:

Late 1700 s: Pinel coined the term "moral treatment" to describe his new approach to psychiatric care, which included removing chains, using attitudes, and setting examples of appropriate behavior and humanitarianism.

Early 1800 s: Tuke established the York retreat based on atmosphere of kindness, meaningful employment of time, regular exercise, family environment, and the treatment of clients as guests.

Late 1800 s: the predominant service pattern in psychiatric institutions was the domestic service pattern in which care was custodial and the staff performed essentially house keeping tasks.

Early 1900 s: attention to hospital atmosphere declined, resulting in the development of environments that were benignly custodial or more destructively controlling, much like a prison.

1930: Sullivan began to experiment again with varying the treatment milieu by selecting the staff members who were sympathetic and interacted well with the patient.

1939: Menninger and others developed prescribed attitudes based on psychoanalytical principles that determined staff interaction patterns.

1940 s: the predominant service patterns was the medical intervention pattern in which staff, including nurses, served as the physicians agents in providing care.

1946: Main 'coined the term "therapeutic community" to describe the approach of resocialization of neurotic individuals through social interactions.

1948: Bettleheim' coined the term Milieu therapy to describe his use of the total environment for treatment of disturbed children.

1953: Jones used the therapeutic community approach in two experimental units for the treatment of antisocial personality disorders in which the social environment was seen as the primary treatment modality.

1990s: the development of milieu therapy based on research to identify the milieu structure most effective for specific treatment groups.

Future: Better integration of hospital and community psychiatry will provide for more efficient and   more effective care for the mentally ill in the community.

 

Basic assumptions:

Skinner outlined seven basic assumptions on which a therapeutic community is based:

1. The health in each individual is to be realized and encouraged to grow: all individuals are considered to have strengths as well as limitations. These healthy aspects of the individual are identified and serve as a foundation for growth in the personality and in the ability to function more adaptively and productively in all aspects of life.

2. Every interaction is an opportunity for therapeutic intervention: within this structured setting, it is virtually impossible to avoid interpersonal interaction. The ideal situation exists for clients to improve communication and development relationship skills. Learning occurs from immediate feedback of personal perceptions.

3. The client owns his or her own environment: client makes decisions and solves problems related to government of the unit. In this way personal needs for autonomy as well as needs that pertains to the group as a whole are fulfilled.

4. Each client owns his or her behavior: Each individual within the therapeutic community is expected to take responsibility for his or her own behavior.

5. Peer pressure is a useful and a powerful tool: Behavioral group norms are established through peer pressure. Feedback is direct and frequent, so that behaving in a manner acceptable to the other members of the community becomes essential.

6. Inappropriate behaviors are dealt with as they occur: Individuals examine the significance of their behavior, look at how it affects other people, and discuss more appropriate ways of behaving in certain situations.

7. Restrictions and punishment are to be avoided: Destructive behaviors can usually be controlled with group discussion. However, if an individual requires external controls, temporary isolation is preferred over lengthy restriction or other harsh punishment.

 

Goals of milieu therapy:

1. Manipulate the environment so that all aspects of client's hospital experience are considered therapeutic.

2. Client is expected to learn adaptive coping, interaction and relationship skills that can be generalized to other aspects of his or her life.

3. Achieving client autonomy

 

Principles of milieu therapy

±  To promote a fundamental respect for individuals (both clients and staff).

±  To use opportunities for communication between client and staff for maximum therapeutic benefit.

±  To encourage clients to act at a level equal to their ability and to enhance their self esteem.

±  To promote socialization.

±  To provide opportunities for clients to be part of unit management.

The nurses function is to act in ways that consistently promote these goals.

 

Characteristics of milieu therapy:

The concept of milieu therapy developed from a desire to counteract the negative, regressive effects of institutionalization: reduced ability to think and act independently, an adoption of institutional values and attitudes, and loss of commitments in the outside world.

 

Several strategies have been developed to counter these negative effects. They include

  • Distribution of power
  • Open communication
  • Structured interactions
  • Work- related activities.
  • Community and family involvement in the treatment process
  • Adaptation of the environment to meet developmental needs.

Distribution of power: the milieu therapy approach involves "flattening" the control hierarchy so all participants have a voice in decision making. This process may include the whole population of the treatment unit, or a governing council may take the final decisions based on input from various smaller groups of clients and staff members.

 

The ultimate goal of any treatment program is client autonomy. This may be achieved through a stepwise progression through a number of treatment programs or by gradually increasing independence within a given program. Consciously incorporating a plan for increasing independence is a means to achieve client autonomy.

Open communication: although the importance of open communication has been widely recognized in literature, it is still not a reality in many settings. One reason for this may be the insecurity of persons in the authority. Open communication requires risk taking. Questioning and criticism may be threatening, where as there is little to risk if no feedback is allowed. Cultural norms, personal defenses and established communication patterns may block the communications.

In the therapeutic milieu, treatment decisions are often made by the clients themselves, who therefore need information to make effective decision. It is not necessary to communicate personal information but clients and staff need to be aware of individual treatment goals to ensure everyone is working towards the same goal. In this atmosphere, exclusive confidentiality is replaced by mutual trust, honesty and open communication.

 

Structured interactions: K.A Menninger pioneered the concept of structured interaction patterns in the form of attitude therapy. An advantage of the structured interaction approach is that all staff members approach the client in a consistent manner, acknowledging specific diagnostic areas, thereby shortening treatment time. The difficulty with this approach is that once a diagnosis is made and an attitude prescribed there is little flexibility in the interaction pattern. Day- to day fluctuations in the client's condition may not be accounted for, and some staff members sometimes seem stilted in their response to clients.

 

Work related activities: the focus of these activities is on benefits to the client rather than to the agency. Work under realistic circumstances and for appropriate rewards is probably the best central activity for all clients. Several factors contribute to effective work therapy programs.

 

  • First, clients need to choose the type of work they wish to perform
  • Second, work activities should be geared toward developing skills that will be useful in actual job situations. The current trend is to place clients on the job and provide funds for staff support in the work environment.
  • Third, a variety of activities provides the opportunity to test different areas for future job interests.

Community and family involvement: as a result of more effective medications and humane treatment philosophies, community mental health centers emerged. Hospitalization is considered desirable only for acute illnesses. For easy accessibility, mental health centers are placed conveniently within a neighborhood.

According to milieu therapy approach, clients are kept in their usual environment, for example, a day treatment center or halfway house, and continue most of their routine activities while receiving treatment. If one family member is hospitalized, an attempt is made to continue family involvement. This is an effective way to improve family interaction and minimize the isolation resulting from hospitalizing one family member.

Adaptation of the environment to meet the developmental needs: to develop his full potential an individual must have an environment adapted to his current needs. Adapting the environment to meet these multiple needs is challenging due to the extension of milieu therapy to all age groups and the inclusion of family members with individuals of varying ages within the treatment milieu.

1. Children: the most apparent environmental change necessary to accommodate children is a    change in size of furnishings. Beds, chairs, tables, dressers and play equipment that are designed for changing sizes facilitate a positive relationship with the environment and encourage activity and exploration.

Initially infants appear to respond better to black and white designs and patterns than to colors. As they mature, they recognize brighter colors first, with examples of contrasting colors being more easily comprehended.

Meaningful sound is important, even to a newborn. The most valuable sound is that of human voices directed to the child. Excessive sound is harmful to concentration, whereas silence results in sensory deprivation.

Play equipment is important for children because toys can counteract sensory deprivation, relieve tension and feelings of hostility and aggression and provide an avenue to work through problems and conflicts. Blocks, puzzles, and games, as well as crayons, paint, chalk, clay, scissors, and paper encourage skill development and creative self expressions.

 

2. Adolescents: one of the major needs of the adolescent population is a communal area for interaction with peers. Decreasing the level of noise in this area is important but should not be so great as to diminish sensory output. Individual bulletin boards encourage the display of personal items, soft drinks and simple foods promote social interaction, and participation in food preparation encourages responsibility. Other accommodations include stereo systems, advanced creative materials such as oil paint and canvas, games and cards appropriate to their level, and sports equipments to encourage expenditure of excess energy.

3. Adults: differences in the amount of responsibility granted to various types of psychiatric clients have been identified. Clients who are regressed or who are overwhelmed need more structure and support; other clients benefit from a program that promotes autonomy and responsibility. A program that provides stepwise increase in responsibility would be an effective solution.

Progressive levels of responsibility according to client's self care capacity:

Level I Displays a destructive behavior to self, others, or the environment.

Disoriented to time, place and person.

Unable to function in group therapy.

Exhibits poor personal hygiene.

Level II Does not display destructive behavior.

Knows the current time, date and place.

Attends at least one therapeutic group daily.

Attempts to maintain good personal hygiene and grooming.

Level III Attends All Therapeutic Activities.

Participates actively in the Community Meetings and serves on at least one client                         committee.

Develops a self-directed behavior plans to change or resolve a personal problem.

Knows the names of all medications and the times they are to be taken.

Participates in a family session.

Level IV Takes an active role in assisting other clients to gain level changes.

Demonstrates willingness to serve as an officer on the client committee.

Assumes a leadership role in the community, acts as a positive role model, and                             ensures that other clients are prompt in their attendance of regularly scheduled                              activities and group meetings.

Initiates discussions with the mental health team concerning discharge planning.

One approach to differing levels of responsibilities is to divide the clients into small groups according to their developmental needs. More regressed clients focus on physical and safety needs, and more advanced individuals concentrate on social, esteem and self- actualizing needs. Individuals progress to more advanced levels as their needs indicate.

4. Aged persons: Environmental alterations that promote safety and orientation are of primary importance for the aged. Adequate lighting, nonskid surfaces, color coding of doorways, and curved mirrors at the junction can assist the elderly to safely maintain orientation and mobility.

Diminished visual ability requires the use of brighter colors and 25% more illumination. This can be provided by natural light, additional reading lights, and indirect nonglare artificial lighting. The aged have decreased ability to accommodate sudden increases in light, therefore windows needs to be well shaded and artificial lighting placed on a dimmer switch so that a gradual change in lighting is possible.

Older individuals have a decreased ability to distinguish meaningful sound. Rather than increasing the volume on televisions, radios, and sound systems, earphones may be used to improve hearing without increasing environmental noise.

Often contact with the outside world is limited; therefore special attempts are made to improve input. Windows are valuable in maintaining visual contact with outside world, and the weather provides a common topic of conversation. For those who are bedridden, the ceiling can be treated as a fifth wall and designed to enhance sensory input. Furniture arrangements that provide face-to face contact or round table discussions promote social interactions.

It is most desirable for the elderly to remain in a familiar neighborhood so they feel safer and have an established support system.

Settin contended that freedom of choice, appropriate sensory stimulation, physical activity, social interaction and social status contribute to a sense of control and environmental mastery.

Characteristics of the milieu therapist:

A productive therapist

ä  Shares problems within a context that will benefit others.

ä  Recognizes the risks involved in honest communication and works to minimize these risks.

ä  Communicates an empathetic understanding of others problems.

ä  Is warm and supportive without excessive attachment.

ä  Accepts responsibilities for own actions and admits mistakes.

ä  Works to solve problems independently, asks for assistance when problems exceed own scope or resources.

ä  Is self- directed in selecting activities that contribute to organizational goals.

ä  Believes that others enjoy work and responsibility when given the opportunity to participate in goal setting.

ä  Sees their contribution in terms of the whole, not only on the task.

ä  Works with others to achieve consensus in decision making.

ä  Shares information at the appropriate time and with the appropriate people.

ä  Acknowledges anxiety and uses resources to cope effectively.

ä  Seeks feedback about abilities and performance.

ä  Has a sense of self- worth and self- respect.

ä  Readily adapts to change.

ä  Functions comfortably in various roles, acts as either a leader or a follower as the situation dictates.

ä  Accepts conflicts and confrontation as normal aspects of life and handles them effectively.

ä  Believes that all people can change, grow and function more effectively.

The inter disciplinary treatment team

Care of the clients in the milieu therapy is directed by an interdisciplinary treatment team. They include:

Psychiatrist:

Credentials: medical degree with residency in psychiatry and license to practice medicine.

Responsibilities: serves as the leader of the team. Responsible for diagnosis and treatment of mental disorders. Performs psychotherapy; prescribes medication and other somatic therapies.

Clinical psychologist:

Credentials: Doctorate in clinical psychology with 2-3 year internship supervised by a licensed clinical psychologist. State license is required for practice.

Responsibilities: conducts individual, group and family therapy. Administers, interprets and evaluates psychological tests that can assist in the diagnostic process.

Psychiatric clinical nurse specialist:

Credentials: registered nurse with a minimum of a master's degree in psychiatric nursing. Some institutions require certification by national credentialing association.

Responsibilities: conducts individual, group and family therapy. Presents educational programs for nursing staff. Provides consultation services to nurses who require assistance in the planning and implementation of the care for individual clients.

Psychiatric nurse:

Credentials: registered nurse with hospital diploma, associate degree or baccalaureate degree. Some psychiatric nurses have national certification.

Responsibilities: provides ongoing assessment of client condition, both mentally and physically. Manages the therapeutic milieu on a 24- hr basis. Administers medications. Assists clients with all therapeutic activities as required. Focus is on one- to- one relationship development.

Mental health technician (psychiatric aide or assistant or psychiatric technician)

Credentials: varies from state to state. Requirements include high school education, with additional vocational education or on the job training. Some hospitals hire individuals with baccalaureate degree in psychology in this capacity. Some states require a licensure examination to practice.

Responsibilities: functions under the supervision of the psychiatric nurse. Provides assistance to the clients in the fulfillment of their activities of daily living. Assists activity therapists as required in conducting their groups. May also participate in one- to- one relationship development.

Psychiatric social worker:

Credentials: Minimum of master's degree in social work. Some states require additional supervision and subsequent licensure by examination.

Responsibilities: conducts individual, group and family therapy. Is concerned with client's social needs such as placement, financial support and community requirements. Conducts in depth psychosocial history on which the needs assessments is based. Works with client and family to ensure that requirements for discharge are fulfilled and needs can be met by appropriate community resources.

Occupational therapist:

Credentials: baccalaureate or master's degree in occupational therapy.

Responsibilities: work with clients to help to develop independence in performance of activities of daily living. Focus is on rehabilitation and vocational training in which clients learn to be productive, thereby enhancing self esteem. Creative activities and therapeutic relationship skills are used.

Recreational therapist:

Credentials: Baccalaureate or master's degree in recreational therapy.

Responsibilities: Use recreational activities to promote clients to redirect their thinking or to rechannel their destructive energy in an appropriate manner. Clients learn skills that can be used during leisure time and during times of stress following discharge from treatment.

Music therapist:

Credentials: graduate degree with specialty in music therapy.

Responsibilities: encourages clients in self expression through music. Clients listen to music, play instruments, sing, dance and compose songs that help them get in touch with feelings and emotions that they may not be able to experience in any other way.

Art therapist:

Credentials: graduate degree with specialty in art therapy

Responsibilities: uses the client's creative abilities to encourage the expression of emotions and feelings through artwork. Helps client to analyze their own work  in an effort to recognize and resolve underlying conflict.

Psyhcodramatist:

Credentials: graduate degree in psychology, social work, nursing or medicine with additional training in group therapy and specialty preparation to become Psyhcodramatist.

Responsibilities: directs the clients in the creation of a drama that portrays real life situations. Individuals select problems they wish to enact, and other clients play the roles of significant others in the situations. Some clients are able to act out problems that they are unable to work through in a more traditional manner.

Dietitian:

Credentials: Baccalaureate or master's degree with specialty in dietetics.

Responsibilities: plans nutritious meals for all clients. Works on consulting basis for clients with specific eating disorders such as anorexia nervosa, bulimia nervosa, obesity and pica.

Chaplain:

Credentials: college degree with advanced education in theology, seminary or rabbinical studies.

Responsibilities: assess, identifies and attends to the spiritual needs of clients and their family members. Provides spiritual support and comfort as requested by client or family. May provide counseling if educational background includes this type of preparation.

NURSING PROCESS

The physical, intellectual and social aspects of the environment all contribute to the emotional atmosphere.

Physical dimension: the physical aspects of the treatment environment include all concrete features of the external world. These features include the organization, structure and interaction of many spatial components. The study of this interrelationship, called proxemics, is subdivided into three aspects: fixed feature space, semi fixed feature space and informal space.

Fixed feature space: the internal and external design of a building and its relationship to other buildings and environmental factors constitute the fixed or permanent elements in space. The arrangements of these elements strongly affect interactions that strongly affect interactions that influence therapeutic outcomes.

Semi fixed feature space: objects that have some degree of mobility are regarded as semi fixed. These are the props that promote a certain degree of freedom within the environment such as furniture, partitions, folding doors, and planters.

Certain furniture arrangements (long bunches found in railway stations), while others (tables at a side walk café) tend to pull people together. Those who sit at the corners of a table at right angles to each other tend to speak more than those sitting next to each other and more than those sitting across the table from each other.

Informal space: informal space, or personal distances maintained in interpersonal encounters, is probably the most significant use of space for the individual. The proper distance between persons varies by culture.

Nurse's role: A nurse participating in the design or renovation of the setting can greatly affect the therapeutic physical environment. A nurses input concerning the number of activities and interactions that occur in a dayroom can determine if the design is functional. Shower curtains, lockers for personal items, bulletin boards to display personal art work and pictures, and bed side lamps can be added at little costs.

Intellectual dimension: the intellectual aspects of the environment are an extension of the physical properties. They include color, sound, texture, temperature, odor and taste. The clarity of the intellectual environment is determined by the amount and clarity of sensory stimulation. The number of stimuli becomes a problem at either end of the continuum- excessive stimuli (sensory overload) or lack of stimulation (sensory deprivation).

Design features: several design features can be used to promote orientation. Patterns in floor coverings and furnishings may be used to identify personal space. These can serve as orientation supports to assist confused individuals in identifying their special relationship to others. Perceptual clarity is especially important for stairways to prevent accidents resulting from confusion.

Nurse's role: the nurse may interpret the needs of the client population for design experts with knowledge of color, texture and lighting. All these factors combine to promote perceptual clarity and orientation. The nurse is often responsible for making referrals, encouraging client participation and coordinating the team members involved.

Social dimension: the social system of a treatment milieu includes the roles of individual members, the organization of these roles into a social system based on leadership style, communication patterns that develop, and staff/ client ratio. The function of the care giver is to respond to the needs of the client who is seeking assistance. Although each of the care giver roles described has separate functions, many of them overlap. The delegation of specific functions is largely determined by the social structure and leadership style of the treatment setting.

Communication patterns: several patterns have been identified: fan, chain, ring, wheel, and all- channel.

  • In the fan pattern messages originates at one source and are directed downward to several receivers who do not interact with each other. They may only respond to the central message sender.
  • In the chain pattern messages are initiated at one point and are passed from one receiver to the next until the messages reaches the end of the chain. Feedback must receive through the reverse sequence of receiving.
  • The ring pattern is similar to the chain pattern except that the last receiver reports to the sender. Messages and feedback follow a cyclical pattern
  • In the wheel pattern messages originates at a central position. Interaction may occur between the message sender ad any one of the receivers positioned next to each other.
  • In the all channel patterns, messages may originate at any point and all members may interact.

The fan network is most likely to develop in groups with autocratic leadership, chain and ring networks are common with laissez-faire leadership and wheel and all- channel communications are most common in demographic groups.

The network communications also affects the roles within a group. Group morale is affected by communication networks. As part of communication process it is important to distinguish between constructive and destructive conflicts and to intervene to promote to promote constructive conflict resolution.

Staff/client ratio: a concrete factor that affects social interaction in a treatment setting is the staff/ client ratio. Moos "found that more clients per staff member on a psychiatric ward, the more emphasis that was placed on staff control and less on support and spontaneous communication. He concludes that a decreased number of staff members and an increased number of clients will have several negative effects:

1.    There is greater pressure to develop a more rigid structure.

2.    Staff members need to control and manage is increased.

3.    The degree of client independence and responsibility, the amount of support given, and the involvement of staff members with clients are decreased.

4.    There are fewer spontaneous interactions between clients and staff.

5.    There is decreased understanding of client's personal problems and less open handling of angry feelings.

Thus the staff/ client ratio is extremely significant in developing positive social interactions.

Nurse's role: intervening communication pattern effectively is the most significant role of a nurse.

Emotional dimension: the emotional atmosphere can be sensed almost immediately when one enters a treatment setting.

Types and characteristics of emotional atmosphere.

  • Rewarding: when members have worked together well on the task they set for themselves, they feel that they have gained from the experience. The members may feel rewarded if they have accomplished something; even though the task is still incomplete.
  • Sluggish: often members try hard to deal with the tasks at hand but 'just can't get going.
  • Cooperative: members work together harmoniously. Members seem to share goals and support one another in attaining goals.
  • Competitive: several members seem out to win their own points, with the result that the action can only proceed out of a win- lose approach.
  • Play: play is the opposite of being task oriented. It exists when the members avoids the tasks and cannot seem to shake off a light hearted, nonserious attitude long enough to get anything done.
  • Work: when the members devote themselves to task in a purposeful manner, the atmosphere is one of work. This may be true regardless of what other impressions results as well; for example it is possible to fight or not accomplish the task and still work hard.
  • Fight: often members find themselves in a complete disagreement regarding the topic to be discussed, decision to be made or action to be taken.
  • Flight: members pursue inappropriate or outside topics, horseplay, or a bull session as means of avoiding the real task at hand., which may be threatening or at hand.
  • Tense: members feel pressures from limited time, conflict between members, or personally threatening topics.
  • Relaxed: members work together in a harmonious manner with little tension or conflicts.
  • Cold: insensitivity to emotional needs is apparent. Defense mechanisms are used to avoid contact.
  • Warm: an emotionally support climate that promotes appropriate expression of feelings and the development of mutual trust.

Nurse's role: in the treatment setting all the group members can be motivated to work toward the common goal of improved mental health.

Spiritual dimension: although providing a specific place for worship is important, the entire treatment environment can provide the background for meeting the spiritual needs. Important in this assessment is the provision of quiet spaces and opportunities relating to nature and other people.

Nurse's role: The nurse must make sure that physical environment is structured to provide both private places for contemplation and reflection and larger areas for group interaction.

EVALUATION OF A THERAPEUTIC MILIEU:

Evaluation of a therapeutic milieu is based on observation of observation of desired outcomes. Several scales have been developed to objectify observations. These can be effective in both assessment and evaluation. Some of the scales for evaluation of therapeutic environment includes: behavioral mapping by Ittleson, Rivlin, and Proshansky, which consists of eighteen categories of observable behavior.

Ward atmosphere scale by Moos. (Order and organization, clarity of expectations, staff control, autonomy, practical orientation, personal problem orientation, involvement support, spontaneity, anger, aggression.)

RESEARCH HIGHLIGHTS

  1. The ward milieu and its effect on the behavior of psychogenic patients.

The study was based on the previous research that showed that relatively minor changes in the environment can result in significantly improved psychosocial functioning in psycho geriatric patients. In this study following questions were examined. 1) What was the role of planned activities versus purely environmental changes? (2) Are there subgroups of patients who respond differently to such interventions? (3) What role does the attitude of nursing staff play in the process? The sample consisted of 36 psycho geriatric patients in a 400 bed mental hospital. The average age was 75.8 years. The setting was a geriatric unit that consisted of a long tiled hall flanked by rooms on both sides with a locked door at one end and a sunroom at the other. The stark institutional environment with its bare walls and basic chrome furniture was replaced by a country kitchen look using a wooden table with a tiffany lamp overhead, rockers and planters. Observations were made of patients use and behavior while in the country kitchen. Findings of the study showed that patients looked relaxed and happy, behaved more appropriately and some preferred to sit with visitors in the room.

  1. social skill training for acute inpatients:

The purpose of this study was to explore the feasibility of conducting social skill training with a mixed population of psychiatric in patients hospitalized for treatment of an acute symptom exacerbation. The sample consisted of 115 patients. most had diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Social skills group were led by two therapists who conducted 1- hr sessions three times a week. Following each session, each therapist completed rating of each patient's social skills, performance, attention and cooperation using a five point likert scale. Patients who engaged in more than five role plays demonstrated greater improvements in social skill performance than those who engaged in fewer role plays. Males improved their performance more than females.

REFERENCES:

  1. Kay j, Tasman A & Lieberman J A .Text book of Psychiatry. Vol II.( 3 RD EDN). Newyork: John Willey & son's ltd. 2003.
  2. Fortinash K M, Patricia A and Worret H. Psychiatric mental health nursing (3 rd edn) Mosby publications. 2001.
  3. Kaplan and Sadock j Benjamin. Synopsis of Psychiatry-Behavioral Science, clinical approach. (6thedition).Williams & Wilkins Publishers; Baltimore: 1998.
  4. Townsend M C. Psychiatric Mental Health Nursing-concepts of care. (3 rd edition). F.H Davis Publishers; Philadelphia: 2000.
  5. Minde R, Haynes E and Rodenberg M . The ward milieu and its effect on the behavior of psychogenic patients. Candn jnl of psy. 35(2)
  6. Mueser K et.al. Social skill training for acute inpatients. Hospital and community psychiatry. 41(11).
Current
11/19/09

Clinical Practice Guidelines: Indian Psychiatric Society

 

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