LECTURE ON INPATIENT PSYCHIATRY
Joseph Matta, MD
HARDSHIPS OF INPATIENT WORK
1. Aborted Intimacy
2. Primary Process Immersion
3. Orality and hunger: the demanding patient
4. Aggression and anger: the threatening patient. The seclusion room incident with
security: Limit setting? Containment? Rape?
5. Intractable Illness
6. Limit Setting
7. The fishbowl phenomenon.
Looking deskilled (the psychological process where one loses skills that are a
normal part of ones professional behavior).
The impact of a patient suicide. See Sacks: When Patients Kill Themselves.
8. Projective identification.
9. Impact on the significant other (spouse, child…).
MILIEU AND MILIEU THERAPY. THERAPEUTIC COMMUNITY
Definition 1. Milieu is a geographic reference to an environment in which one lives – for
example, the work place or a place where the mentally ill are treated.
Definition 2. We will use it to refer to the culture of this environment with specific
values, expectations and roles that can be therapeutic or antitherapeutic. In Milieu
Therapy, there is an effort to prevent bad antitherapeutic things from happening and to
foster good therapeutic things. See Sacks: The Psueodtherapeutic Community, An
Examination of Antitherapeutic Forces on Psychiatric Units.
The contention: The social environment (this includes friends, spouse, family, work
environment and most important for today: the psychiatric unit) is important in all aspects
of psychopathology and treatment. The role of the social environment is significant as a
source of:
1. self-esteem
2. appreciation
3. guilt regulation (he/she loves me, stays with me, etc, how bad can I be?)
4. misery (not unimportant in paradoxical ways for those with masochistic traits)
5. monitoring (taking medications, getting to work, getting out of bed in the am)
6. reason or purpose in life (should we include pets?)
Additional relevance: Is there a social environment that will maximize the resources and
minimize the likelihood of decompensation that you can arrange for discharge?
Some examples:
Mr F. is an HIV+ 65 year old man admitted with the delusion that he does not have
AIDS. He is impossible in a contemptuous irritable, demanding manner. It is learned that
the latter is his basic personality and his partner of 30 years had died. The partner
mediated between the patient and the rest of the world enabling the patient to function
marginally as a commercial and creative artist.
Ms. A. is a chronic delusional schizophrenic woman who is the unofficial diva of East ?
Street. She cleans the street regularly. The neighbors recognize her as harmless crazy
lady. She is admitted because her apartment becomes flooded. Her apartment is such a
mess that social services try to obtain the patient alternative housing. While this is going
on, the patient is evicted. She ends up in a shelter.
In milieu therapy the interaction between the patient and the social environment is used to
effect change. Each unit will have its own therapeutic philosophy. Hence one finds token
economy milieus, psychotherapeutic milieus, pharmacological milieus, etc. In general,
milieu therapy units will show a sensitivity to and awareness of group processes that can
prove beneficial or adversely effect the outcome of treatment. Most milieu units have the
following qualities:
1. humanistic
2. reality oriented
3. educational
4. providing living-learning situations
5. foster self understanding or at least an understanding of illness
6. provide a progressive increase in autonomy, etc.
More General Characteristics of a Therapeutic Milieu. See articles by Sacks and
Gunderson.
1. containment: provide safety
2. support: support self esteem
3. structure: provide predictable organization of time and privileges
4. involvement: encourage patients to interact and participate in environment
5. validation: recognizing the uniqueness of a patient
Therapeutic Community. A concept developed by Maxwell Jones in the 50s. It
emphasizes the important role that patients play in their own treatment and shifts the
responsibility for much to the therapeutic milieu to the patients. There is an emphasis on
democratic processes with minimization of the barrier between society, staff and the
hospital unit. There is an effort to avoid total institutional aspects (see below) in favor of
a decentralized democratic one. It was originally organized for the treatment of character
disorders but expanded rapidly until it became a catchword in the 60s and 70s when
every treatment center called itself a therapeutic community.
A vital influence on thinking about milieu treatment and the therapeutic community
during the organization of psychiatric units from the 60s onward was social psychiatry.
This was part of the general culture milieu of permissiveness, democratization,
autonomy, etc.
The area of social psychiatry is now more or less dead. (perhaps not with those
psychiatrists who deal with the disenfranchises such as the homeless, prostitutes,
chronically mentally ill, etc). The medicalization of the discipline has eliminated it as a
topic of significant relevance. Hard (expensive) to study. It is commonly argued that the
amount of variance it contributes to the onset and outcome of illness is small and
therefore it is scientifically not relevant. However, for a period it was vital.
Historical Digression: Early history. Pinel removes the chains. Tuke a Quaker opens
retreats in England in 1800s, Called Moral Treatment. In Italy, Chiarugi. Movement
comes to USA at turn of the century (Hartford Retreat).