User participation when using milieu therapy in a psychiatric hospital in Norway: a mission impossible?

Abstract

In the past decade, the Norwegian government has emphasized user participation as an important goal in the care of mentally ill patients, through governmental strategic plans. At the same time, the governmental documents request normalization of psychiatric patients, including the re-socialization of psychiatric patients back into society outside the psychiatric hospital. Milieu therapy is a therapeutic tool to ensure user participation and re-socialization. Based on an ethnographic study in a long-term psychiatric ward in a psychiatric hospital, we identified how staff tried to implement user participation in their milieu-oriented therapy work. We have identified three major tensions and challenges in implementing user participation in milieu-therapeutic work. First, it is difficult to implement individual-based user participation and at the same time take collective house rules and codes of conduct into consideration. Second, user participation proved a difficulty when patients' viewpoints challenged staff judgements on proper conduct and goals for which patients might aim. Third, user participation becomes a challenge when trying to establish relationships based on equality when using milieu therapy in a biomedical hierarchical hospital structure. These tensions and challenges are seen in light of paradoxical political frames and demands on one side, and milieu therapy as a complex tradition anchored in different ideologies on the other.

Patients' participation in decision‐making in the medical field – ‘projectification’ of patients in a neoliberal framed healthcare system

“…Sahlsten et al, 2009;Omeni et al, 2014). That is, patient participation is both anchored in a democratic and humanistic ethos underscoring patients as active participants (Oeye et al, 2009), as well as anchored in a neoliberalistic ethos underscoring patients as 'customers' (Mol, 2008;Holen, 2011;Fotaki, 2013;Powers et al, 2013). However, there is no consensus on how to interpret 'participation' (Faerch & Harder, 2009;Lyttle & Ryan, 2010;Olesen, 2010;Cribb & Entwistle, 2011).…”

“…On the other hand, respect for patient autonomy has to be balanced with knowledge of the patient's literacy and ability to understand information, both of which affect the patient's ability to give informed consent (Rossel, 1985). However, research has shown that attempts by physicians and nurses to secure patient involvement in decisionmaking often end up supporting the professionals' agenda based on the dominating medical model of the right choice of treatment or care (Glasdam, 2003;Whitney, 2003;Dahlager, 2005;Oeye et al, 2009;Knutsen et al, 2011;Upton et al, 2011;Glasdam et al, 2013aGlasdam et al, , 2013b.…”

Ethical Dilemmas of Participation of Service Users with Serious Mental Illness: A Thematic Synthesis

“…Professionals state that sometimes they have difficulty involving service users in decisions due to the lack of time to engage in dialogue (Graneheim, Slotte, S€ afsten, & Lindgren, 2014). Professionals feel service users can be limited by their symptoms to engage in decision-making as sometimes the users do not respond to the provider's efforts to engage them in dialogue, or have unrealistic ideas about their own capacity (Oeye, Bjelland, Skorpen, & Anderssen, 2009). In other cases, professionals lacked the resources to follow up on decisions, for instance, in assisting service users in activities they chose to engage in (Pelto-Piri et al, 2013).…”

Cross-national mixed-methods comparative case study of recovery-focused mental health care planning and co-ordination in acute inpatient mental health settings (COCAPP-A)

“…135 Tensions were identified when patients' views challenged staff judgments. Establishing symmetrical therapeutic relationships generally proved difficult.…”