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: 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-of- hospital 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

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 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

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