Developing multiprofessional cooperation and
milieu therapy within a Russian psychiatric
hospital context.
Vera Yashkovich,
Elvira Konoplenko,
Maria Leontyeva,
Tore Sørlie
Background
During the Soviet era psychiatry was influenced by following
features:
 Limitations in legislative regulations created
unpredictability in psychiatric care;
 The rights of the individual were not kept and guarded
properly;
 Psychiatry was used not only in medical, but also in
political purposes;
 Due to isolation during the Soviet period there were no
opportunities to obtain experience from other countries;
 The radical democratic changes of Perestroika and later
political instability reduced financial support of medical
institutions.
Background



Russian psychiatric health care services have been
traditionally focused on in-patient treatment in large
hospitals in suburbs of big cities.
Patients were hospitalized for long periods of time.
Psychiatry in Arkhangelsk county experience the
same problems, as psychiatry in Russia in general.
Background



In 1992 «A Law of the Russian Federation about
psychiatric care and guarantees of the rights of
citizens at its rendering» defining new standards for
a more humane and open psychiatry, demanded
extensive reorganization of the psychiatric services
in the Arkhangelsk region.
In 90-s reform process in Russian psychiatry started
A possibility to use the experience of Norwegian
colleagues occurred at that time.
Arkhangelsk regional clinical
psychiatric hospital



Arkhangelsk regional clinical
psychiatric hospital is the
largest institution providing
psychiatric care to the
population of the
Arkhangelsk region,
The hospital consists of two
hospital subdivisions
(Talagi-1, Talagi-2) for 1010
beds
Catchment area with 1.2 million
inhabitants (data for 2010)
Arkhangelsk regional clinical
psychiatric hospital


In-patient psychiatric care
for the male and female
population, resided in
Arkhangelsk, Arkhangelsk
region and Nenets
autonomous region.
In-patient psychiatric care
for children and adolescents
Arkhangelsk regional clinical
psychiatric hospital

Forensic psychiatric care
(expert examinations,
organizing and carrying out
involuntary treatment).
Arkhangelsk regional clinical
psychiatric hospital

Narcological care
(addiction treatment) treatment of alcohol
induced psychoses, all
kinds of substance use
dependency.
Arkhangelsk regional clinical
psychiatric hospital
Subdivision Talagi-1 consists of:
 2 female and 2 male acute wards (60 beds each)
 2 mixed wards: first psychotic episode and neurosis
(45/50 beds)
 Child (25 beds) and adolescent (30 beds) wards
 2 wards for addiction treatment (40/60 beds)
 Each ward staff: 12-15 nurses, 20 nurse assistants, 2-3
psychiatrists, 1 social worker
 Staff on a day shift: 4 nurses, 4 nurse assistants
 Staff on night shift: 2 nurses, 2 nurse assistants
Arkhangelsk regional clinical
psychiatric hospital
In 2002 a program of Russian Ministry of Health Care
was adopted. The program defined strategies of
organization and development of psychiatric care
services, which include:
 Planned decentralization of hospital and out-ofhospital psychiatric care, bringing it nearer to the
place of residence;
 Improvement of conditions of patients’ stay in
hospitals;
 Expansion of out-patient line network in highest
possible proximity to the population;
 Integration of psychiatric care into somatic network;
 Securing of continuity of psychiatric care provision.
Arkhangelsk regional clinical
psychiatric hospital
3000
2500
2635
2375
2000
2304
1930
1660
1500
1330
1494
1280
1000
1239
1050
1172
1010
500
0
1990
1995
2000
2005
2010
Number of beds in the hospital
Number of beds in Arkhangelsk region
2011
Aims


To develop milieu therapy and
multiprofessional team work within acute
psychiatric wards of Arkhangelsk psychiatric
hospital
To improve cooperation between the hospital
and out-patient clinic services (dispenser)
and primary health care
Methods

Each year from 2003 to 2010 group analysts from Lithuania,
who speak Russian fluently, conducted two two-week staff
training seminars with an emphasis on group supervisions of
participants’ own experiences.
Methods



Seminars consisted of theoretical material
concerning milieu therapy principles and
supervisions.
The daily structure included one theory lecture, one
supervision for “small” staff group (from one acute
ward) and a large group for all participants
Lectures covered psychodynamic aspects of mental
illness, milieu therapy, teamwork, group theory and
therapy
Methods


In the beginning, staff of the three acute wards took
part in seminars. In two years the project has been
expanded by inclusion of three more acute wards
and administrative group (N=70).
Small group supervision of practical experiences
with milieu therapy principles was experienced as
most fruitful.
Methods




During staff group meetings and the supervision
groups, participants for the first time experienced
that they were sitting in a multiprofessional team
discussing their professional life as equal partners
Previous culture had been dominated by “powerful”
doctors and “powerlessness” in remaining staff
By sharing openly how different roles had been
experienced, they realised their interdependency in
helping the patients
The basis for multiprofessional teams was emerging
Methods


Along with a strong emphasis on improving
multiprofessional and interagency cooperation,
participants from the out-patient psychiatric services
(dispensary) and primary health system were
included in 2008.
Six training seminars were conducted with teams
consisting of GPs, psychiatrists, psychologists,
social workers, nurses both from the hospital, and
dispensary to train cooperation and supervision
skills.
Methods



In addition, a multifamily psycho-educational
treatment program was conducted for 50
participants.
Training practices in Norway for members of the staff
of the hospital and dispensary were organized.
Participants of the project took part in different local
and international conferences
Results
Due to introduction of milieu therapy principles and
multiprofessional teams at the acute wards important
changes were marked:
 Cooperative relations among staff and between staff
and patients improved significantly
 Emotional climate in the wards turned to the better
 Personnel became more empathic and humane
 Material renewal of patients’ rooms created more
comfortable conditions for staying
Results




Higher creativity and job satisfaction in personnel.
Involvement of psychologist and social workers in the
treatment of the patients increased.
Role of nurses changed a lot.
Regular meetings of the staff and patients were
introduced (once a week).
Results



Mutual supervision in acute wards takes place
monthly where cases are presented and discussed
among staff from different wards.
Rest-rooms and small libraries in all acute wards
were established.
Group activities were established: art therapy,
occupational therapy, reading, artistic groups and
gymnastics conducted by nurses.
Results



Multiprofessional team work training
influenced everyday work:
Cooperative skills and attitudes improved
(confidence, openness for the opinions of
others, exchange and change)
Changes in routines and responsibilities
among the different professional groups
Results



Transition from biological model of treatment
to biopsychosocial;
Psycho educational work with patients and
their relatives were initiated;
The continuity of treatment between the
hospital and the dispensary improved
considerably.
Discussion



Initially, significant resistance was displayed towards
the new principles caused by low motivation and
unwillingness to incur new duties which demanded
stronger personal engagement and participation;
However, after realizing support from colleagues,
leaders and patients, resistance was turned into
engagement and higher job satisfaction;
It remains to see whether these changes will reduce
staff turnover.
Conclusion
Due to these educational programs:
 milieu therapy have been successfully put
into practice
 multiprofessional team work was introduced
at the acute wards
 interagency cooperation is developing
Thank you!