The Most Important Thing - "Milieu"Document Transcript
36 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JANUARY, 1961 Experiences with Milieu Therapy in a General Hospital NATHAN L. COMER, M.D., HAROLD H. MORRIS, JR., M.D. and FRANK ORLAND, M.D. Departnient of Psychiatry of Mercy-Douglass Hospital and the School of Medicine of the University of Pennsylvania, Philadelphia, PennsylvaniaW E propose here to report our experiences Both floors contained two wings, separated by in setting up a particular type of milieu for a large sitting room or lobby. One wing was desig-psychiatric patients in a general hospital. nated as the Mens wing and the other as the PHILOSOPHY OF THE UNIT Womens. As a result, men and women mixed freely in the sitting rooms on both floors and also In August of 1956, an 85 bed psychiatric unit had meals together in the dining room. It waswas opened at the Mercy-Douglass Hospital in our impression that this arrangement reduced isola-Philadelphia with the intention of providing a tion and regression.place where certain ideals of psychiatric treatment The offices of all professional personnel andas applied to psychotic patients could be expressed. secretaries were also situated on the wards andIn view of recent studies1 2, 3, 4 there was some this seemed to facilitate communication at allfeeling that the milieu had as much effect upon levels.the outcome of psychiatric illness as did other typesof treatment more commonly considered as "psy- TYPE OF PATIENTSchiatric." Patients were admitted to this psychiatric service Attempts were therefore madc to appeal to after a brief preliminary screening at the Psy-the relatively intact portions of patients egos chiatric Reception Center at the Philadelphia Gen-through increasing their status and offering them eral Hospital, which examines all applicants forgreater responsibility and showing them respect public psychiatric hospitalization in the Phila-as persons. Freedom of communication at all levels delphia area and then refers them to three facili-and through many channels, formal and informal, ties. Thus, these patients were not screened bywas encouraged and distinctions between the hos- members of the staff who would ultimately bepital community and the wider outside one were responsible for their treatment.minimized. The great majority of patients admitted came DESCRIPTION OF THE UNIT from the lower middle class population of the At the time the hospital was constructed, a psy- city. Most had been ill for relatively short periodschiatric inpatient service was not contemplated, so of time before admission, and for many, the ex-the two floors assigned to the psychiatric depart- perience represented their first hospitalization. Wement were designed to accommodate general medi- accepted all types of mentally ill patients butcal patients in private and semi-private rooms patients presenting as addicts or sociopaths withoutrather than being specifically designed for psy- psychosis were not referred to the unit. In 1958,chiatric patients. As a result, each room contained 250 patients were admitted, of whom 137 weremirrors, lights, sinks, clothing cabinets, etc., which schizophrenics, 30 affective reactions, 19 acute orremained in the rooms. chronic brain syndromes, 48 neurotic reactions or One floor was equipped for disturbed patients personality disorders and the remainder unclassi-and was "closed" while the other floor was for fied.convalescing patients and was "open". Patients Although no absolute time limit was set, thewere admitted to the closed floor and when they unit was designated to provide a relatively shortachieved an adequate degree of personality re-or- period of in-patient treatment. The average dura-ganization, they were transferred to the open floor. tion of stay has been 85 days, although some
VOL. 53, No. 1 Experiences with Milieu Therapy in a General Hospital 37patients have remained as long as two years, where- treatment; nurses and attendants worked withas others have been transferred within a month patients as equals on problems of ward administra-to other settings providing a more prolonged treat- tion and house-keeping and the patients began toment program. feel that they had something positive to con- In addition to its service function, the unit has tribute to their own therapy and rehabilitation.also had important training and research functions Also, in line with our belief that the differenceas an integral part of the University of Pennsyl- between the hospital milieu and the outside com-vania Department of Psychiatry. Of course this munity should be minimized, we encouraged fre-has had a considerable influence on the milieu in quent visiting hours and home visits and severalthat there was a relatively high staff patient ratio public telephones were made available. Com-and a relatively frequent turnover in those seg- munity facilities such as provided by the neigh-ments of the staff that had come primarily for borhood recreation center and swimming pool astraining. well as the churches were utilized by the patients. Frequently patients who were convalescing would FUNCTIONING OF THE UNIT return to their jobs or to school while continuing As mentioned previously, the milieu was struc- to live in the hospital. An attempt was made totured to stress the relatively intact portions of the scale the scope of these various activities and in-patients egos. Patients were encouraged and ex- teractions to the individual patients ability to as-pected to assume responsibility for themselves and sume these responsibilities. Each extension of ac-for other members of their community. This was tivity was explained to the patient as a respon-facilitated through the establishment of patient gov- sibility rather than a privilege-a patient was givenernment groups5 which met weekly on each ward open-ward responsibility or week-end visit respon-under the direction of the resident in charge of the sibility rather than open-ward "privilege" or homewards. At these ward meetings, such subjects as visit privilege. These were also viewed as im-frequency and duration of visiting hours, avail- portant aids to the recovery process rather thanability of telephones and the planning of recrea- held out as rewards for getting well.tional activities were decided. In addition, suchemotionally charged subjects as the patients re- OBSERVATIONS AND CONCLUSIONSsentment toward the staff because of the death of The relative permissiveness and fluidity of thea patient were ventilated. non-authoritarian milieu had its advantages and We stressed quick and direct communication disadvantages, which seemed dependent in largerather than "going through channels". This ap- part on the type of psychopathology reacting with-proach was assisted by the locating of adminis- in it. Interestingly enough, the milieu seemed to betrative physicians and nurses offices on the floors most beneficial to those patients classified as psy-alongside patient rooms and recreation areas. chotic depressions and the clear cut schizophrenicPatients could then call a physician for a nurse syndromes and was much less effective with theas well as a physician calling a nurse for a patient. "actor-outers" such as the adolescent turmoil states,An attendant could request a conference as readily the hysterical personalities and the anti-socialas the chief of service. Patients and staff parti- delinquents.cipated as equals in many conferences and recrea- The latter groups seemed to need more externaltional activities. control and discipline than was provided by this Temporarily, this last point created some con- milieu. On the other hand, the patients who hadfusion among both patients and personnel as to had difficulties in interpersonal relationships bytheir relative roles; it was a new experience for reason of withdrawing from relationships wereboth groups. However, as both groups came to de- helped. However, it became quickly apparent thatpend less upon rigidly defined roles as part of their with this type of personality there was a dangerdefensive armamentarium, less therapeutically in- of fostering of dependency needs which werehibiting defenses were substituted. Physicians came satisfied by the institution rather than throughto accept the attitude that their ministrations to the meaningful relationships with people, individualspatients were not the sum total of psychiatric and groups. Not infrequently, we had the problem
38 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION JANUARY, 1961of "weaning" the patients from the hospital so patients, perhaps another for actor-outers, etc.that they would be willing to return to their homes. However, it should be borne in mind that the In general, the milieu allowed the patients to milieu is never constant and is continually chang-establish their own social structure (within limits) ing, depending on the patient population, make-rather freely, which often led to important re- up and the personalities of the staff which alsovelations of intra-psychic pathology, which could change with turnover in personel. Actually, wethen be recognized and dealt with individually if have not discussed the role played by the hospitalindicated. Although, by deliberate intent, author- staffs personalities but we believe this not to be in- itarianism was not stressed, authority figures were considerable. We hope to explore this further andautomatically and inevitably set up by the patients. report on it in a later paper.Transference phenomena developed spontaneouslyin the milieu. No attempt was made to control SUMMARYtheir direction, the attempt was to recognize their This paper reports experiences in setting up aemergence. One result of this situation where relatively non-authoritarian milieu for psychoticstrong parental figures were not stressed was that patients in a general hospital. First, there is asibling rivalry problems were expressed much brief discussion of the philosophy of the unit andmore commonly than parent-child relationships. then a description of the unit and how it functions. We have emphasized the importance of the The techniques utilized to structure the milieu aremilieu because of our conviction that disturbed in- delineated and then some of the problems resultingterpersonal relations represent a factor of major from the techniques are examined. Finally, thereimportance in mental illness. It was therefore our is a discussion of the advantages and disadvantagesgoal to make as much of the total interpersonal of the milieu and some recommendations are madeinteraction that went on with regards to the patient on the basis of the experiences.as ego syntonic as was possible. It is impossiblehowever, to completely individualize the milieu in LITERATURE CITEI)a hospital or institution. Therefore, it would seem 1. STANTON, A. H. and M. S. SCHWARTZ. The Men-practical, once the effectiveness of a particular tal Hospital, New York Books, 1954.milieu has been assessed, to try to select patients 2. CAUDILL, WILLIAM. The Psychiatric Hospital as a Small Society, Harvard U. Press, Cambridge, 1958.that would be most likely to be benefited by that 3. GREENBLATT, YORK, BROWN. From Custodial toparticular milieu. Our experiences have led us to Therapeutic Patient Care in Mental Hospitals, Rus-believe that a milieu which benefits one type of sell Sage Foundation, New York, 1955.patient may be of little value to other types of 4. HOLLINGSHEAD, A. B. and F. C. REDLICH. Socialpatients. For that reason, we believe that the pos- Class and Mental Illness-A Community Study. New York, John Wiley and Sons, Inc., 1958.sibilities should be explored as to what type of 5. DOWNING, ROBERT W. and N. L. COMER. Patientmilieu is best for different types of patients so that Government in a Psychotic Population, Mental Hv-possibly a certain milieu be utilized for senile giene. April 1960. FLYING STRESS AND URINARY 1 7-HYDROXYCORTICOSTEROID LEVELS Fatigue caused by intensive flying involves the adrenal glands. The urinary excretion of 17-hydroxycorti- costeroid in four B-25 crews flying 24 missions was studied in relation to stress. The mean increase in urinary steroids for all personnel ranged from 38 to 48 per cent. The time of the mission in relation to the normal rest period influenced the 17-OH-CS- output. The highest increase occurred during missions flown furthest from the normal sleep cycle. Aircraft commanders showed the highest excretion and this was correlated with increased responsibility and critical flight conditions. It was concluded that urinary excretion of 17-OH-CS served as a favorable index for evaluation of stress in flying personnel. These experimental results are in agreement with similar findings in studies on oarsmen before and immediately after performance. From MARCHBANKS, V. H., Jr. Flying Stress and Urinary 17-Hydroxycorticosteroid Levels During Twenty-hour Missions. Aerospace Medicine, 31:639-643, 1960.