Re-Thinking Acute Psychiatric Inpatient Care

Background : Reports of low staff morale and high levels of patient complaints suggest that acute psychiatric wards are not achieving their full therapeutic potential. Aims : This paper reviews some of the ‘therapeutic milieu’ literature to identify ways of construing ward functioning so as to maximise therapeutic and minimise destructive processes within inpatient units. Method : Relevant papers are reviewed, providing an understanding that permits the inpatient clinician to consider and apply the pertinent concepts. Results : Five key therapeutic functions of the ward environment are identified - containment, support, structure, involvement and validation. Four destructive processes are described, relating to: the isolated patient; group phenomena; the contribution of staff; and structural manifestations in the ward. Conclusions : The inpatient ward can be construed as a ‘whole’, embodying a range of therapeutic functions, which may need rapid deployment and dismantling, as dictated by changes in ward conditions. The ‘ward-as-a-whole’ construct complements individualised models of patient care and the practical implications of such thinking could engender a greater sense of agency and job satisfaction in staff.