The International Journal of Psychosocial Rehabilitation

The Therapeutic Environment of Long-term Rehabilitation Units for Patients with Chronic Mental Illness: A Participant Observation Study in Four Hostels in Greece

Despina Sikelianou
Psychologist, Ph.d in Social and Community Psychiatry
Koumanioti 69, Patras, 26222, Greece

Venetsanos Mavreas
Professor of Psychiatry
Department of Psychiatry, University of Ioannina, Medical School, Ioannina, Greece

Sikelianou D & Mavreas V. (2011). Recovery and Self-EsteeThe Therapeutic Environment of Long-term Rehabilitation
Units for Patients with Chronic Mental Illness:  A Participant Observation Study in Four Hostels in Greece
.  International Journal of Psychosocial Rehabilitation. Vol 15(2) 59-68


The aim of this study was the detailed presentation and study of the factors regarding the organization of the therapeutic environment of four newly-established long-term units for the rehabilitation of patients with chronic mental illness, during their first year of establishment, within the framework of materialization of the ten-year European programme “Psychargos” 1st Phase 2000-2010 aiming at modernizing the mental health care system in Greece. The ethnographic method was used and the research was qualitative using participant observation, interviews and questionnaires. The research process was divided into three phases over one year (March 2001 – February 2002). The results have shown that factors such as good and proper implementation of internal and external supervision, continuous training of the therapeutic group, the application of clear and multidisciplinary roles of the caregivers, the positive attitudes and positively-expressed emotions of caregivers towards patients, etc. lead to a well-organized therapeutic environment within a new long-term unit for patients with chronic mental illness.

Key words: Quality of care, Mental Health Professionals, Organization, Long-term units, rehabilitation


The psychosocial rehabilitation of patients with chronic mental illness has begun to be realized over the last twenty years in Greece, initially with the materialization of the programmes Leros I and II aiming at deinstitutionalizing the chronic mental patients of the mental hospital at the island of Leros and now continuing with the implementation of the European programme “Psychargos” lasting 2000-2010. The aim is the gradual replacement of the institutional system of psychiatric care with a network of alternative preventive and therapeutic services and structures, on the basis of the principle of sectorization and developing community mental health services (MYP 2000). Within the framework of this programme, approximately three hundred sixty nine (369) rehabilitation housing units (104 Long-term units, 91 Boarding Homes and 174 protected appartments) for patients with chronic mental illness are currently available in the fifty-two (52) prefectures of our country. The therapeutic environment of a long-term unit provides appropriate conditions for the residents of these units to be able to regain the abilities and functions negatively affected by the institutional environment or mental illness.

The organization of a long-term unit comprises three developmental phases. In the first phase (Initial Stage), the therapeutic environment is characterized by flexible organization and concurrence of caregivers on objectives and a tendency towards self-administration of the unit while the relations between the therapeutic group and the main institution (mental hospital) are formal.
In the second phase (Expansion Stage), sub-groups are formed and there is a climate of optimism for successful rehabilitation. There is also competition between the sub-groups, and with other similar services and the main institution (mental hospital).

In the third phase (Establishment and Recognition Stage), the long-term unit becomes a decentralized unit. The members of the therapeutic group trust each other and express collective satisfaction, emphasizing on the organizational and social needs and objectives (Madianos 1994).

The function of a long-term unit therapeutic environment is efficient when treatment of mental illness is in accordance with the social changes and developments and the personnel do not show signs of inactivity and passivity. The difficulty to deal with chronic mental illness faced by caregivers is due to their ‘fundamental fear of the insane’ (the threat posed to the mental health of caregivers themselves) with two predominant feelings, the feeling of intrusion of the mentally-ill patient on the personal inner space of the caregivers and the feeling of emptiness, leading to a significant distance from the psychotic patient. Consequently, patients show signs of institutional behaviour (Hochmann (2003). In accordance with Katz and Kirkland (1990) and Curtis and Hodge (1994), the presence of violence and institutionalized behaviour of the patients results from failure to apply clear and multidisciplinary caregiver roles. In accordance with Damigos (2003) and Anderson (2003), the absence of proper internal and external supervision of the unit leads to the inability of caregivers to play clear and multidisciplinary roles, whereas Foster (1998) points out that caregivers run a risk when playing multidisciplinary roles and behaving ‘in the same way as each other’. This can lead caregivers to experience burn out and failure of the therapeutic procedure.
Lack of empathy expressed by caregivers leads them to keep a distance from the patients (Minkoff and Stern 1985). The rejection and criticism of caregivers towards patients results in their receiving poor quality medical care services (Hastings et al. 1995, Morgan and Hastings 1998, Snyder et al 1994), while expression of negative attitudes and feelings towards the patients leads to bad relations between the caregivers and the patients and also to the failure of the latter to accomplish their rehabilitation tasks (Van Humbeek et al 2001, Tartan and Tarrier 2000, Bebbington and Kuipers 1994, Butzlaff and Hooley 1998, Kavanagh 1992). The implementation of training programmes for the personnel of a long-term unit is necessary and effective because it improves the communication skills between caregivers and patients and between caregivers themselves and offers caregivers a ‘clear comprehension of their own self-image and that of others’ and assists in the direct understanding of the actual therapeutic values of rehabilitation (Van Audenhove and Van Humbeek 2003, Piatt et al. 2002, Rabkin et al 1998, Neilsen et al 1985).
Aims and research hypotheses:
The aim of this research study is to explore the factors for the organization of the therapeutic environment in four newly-established long-term units for rehabilitation of patients with chronic mental illness, during their first year of establishment.

The evaluations from the European deinstitutionalization programmes Leros I and Leros II, regarding the communication of the caregivers, the presence or absence of the internal and external supervision of the long-term unit, the application of clear and multidisciplinary roles of the caregivers, the attitudes and expressed emotions of the caregivers towards the patients, the implementation of training programmes for caregivers at workplace, the relation of the unit with the Mental Hospital,  the level of the long-term unit independence and the handling of mental illness constituted the research questions of this study.
Research Design
Settings and Staff
The long-term units began operating in 2001 in accordance with the European programme “Psychargos” 1st Phase. Long-term units A and B are located in two cities in Western Greece, while long-term units C and D are located in the same city as the Mental Hospital of the area. All four long-term units were established at the same period of time. 46 mental health professionals worked in these long-term units.
Study Sample
The sample consisted of forty-six mental health professionals: thirty-eight women and eight men of various specializations (professional and non-professional staff), such as: Psychologists, Social Workers, Nurses, Occupational Therapists, Trainers and Auxiliary Staff. Long-term units C and D were also staffed with a Special Teacher and a Health Visitor. Ages ranged from 18-50 years old and the majority of professionals were women.

In long-term unit A, there were 11 mental health professionals, aged from 25-50 years old, and 15 residents. 12 mental health professionals worked in long-term unit B, the number of residents being 14. The majority of caregivers in both long-term units was between 18-25 years old and had no university education and all caregivers had no specialization and experience with regard to the rehabilitation of mentally-ill patients. The only difference between the two long-term units was that long-term unit A did not have an Occupational Therapist.

The number of caregivers in long-term unit C was 15 with 22 residents and, in long-term unit D, the caregivers totaled eight with five residents. The caregivers of both long-term units had experience of working with chronic mental health patients, all of them being ex-employees of the Mental Hospital. The personnel of long-term unit D worked simultaneously at the Day Centre of the hospital, which was in the same building as the long-term unit. The personnel of both units were not specialized in the rehabilitation of mentally ill patients. The nursing staff of both long-term units had no university education and did not include an Occupational Therapist.
Method and Data Collection
Qualitative Analysis
The ethnographic method was used for the implementation of this study, as it is the most appropriate method for qualitative research and in-depth investigation and analysis of issues studied for the first time. The approaches used in this study were participant observation and unstructured interviews. The entire research procedure and data collection was conducted from March 2001 to February 2002 and divided into three Phases (1st Phase – A’ trimester, 2nd Phase – B’ semester, 3rd Phase – C’ trimester), with visits taking place once a week during the morning shift from 09:00 am – 14:00 pm.  

In the first Phase (March-June 2001) of this study, we were interested in studying the formation of relations between the members of the therapeutic group, their efforts to develop a degree of cohesion and specific therapeutic goals. In accordance with the above-mentioned goals, only long-term units A and B were studied, because the personnel in these long-term units had no professional experience and were unacquainted with each other, unlike the professionals in long-term units C and D, who were skilled and knew each other from their previous employment in the same department of the Mental Hospital. The questions were addressed only to psychologists and nurses because the remaining staff needed time to adjust to their working environment.

The duration of the 2nd Phase (July 2001 – December 2001) was six months, divided into two terms to serve both the proper implementation of the research and the best possible data collection. Its aim was to investigate the maturing of already-existent and established relations among the members of the therapeutic group and those they had with the patients (expressed emotions, attitude of caregivers, the communication level among caregivers and that which they had with the patients, the decision-making procedure, professional boundaries, the level of satisfaction with the therapeutic work) and the emergence of new tendencies and needs. All four long-term units were studied, because at this stage all were progressing and could be studied simultaneously in terms of the objective of this phase. 46 professionals from all four long-term units participated in this phase.

The aim of the 3rd Phase (December 2001 – February 2002) was to investigate the characteristics for the establishment of the level of self-administration and independence of each unit from the implementing body, the ‘opening’ of the unit to the community and a review of therapeutic goals.
Research Results
Long-term Unit A
Regarding the development of relations among the members of the therapeutic group in the 1st Phase, strong conflicts and disputes were ascertained among members of the scientific and nursing staff. There was no clear designation of internal and external supervisor for the therapeutic group by the implementing body so that these problems could be dealt with. In the 2nd Phase, caregivers began to form three sub-groups, scientific, nursing and auxiliary staff. The conflicts between the members were significantly reduced because they were ‘transferred’ to the external environment and specifically to the research process. All the caregivers refused to continue to participate in the research process because they feared that “… the results of this study with regard to this particular long-term unit were to be made known to the Ministry of Health and they might lose their jobs…..”. The staff nurse, a dynamic and strong personality, undertook the responsibility and supervision for the proper function of the unit. The members of the nursing staff had developed very good co-operation, achieved a large degree of unity and showed flexibility in decision-making and therapeutic work co-ordination. On the other hand, the members of the scientific staff showed signs of fragmentation (groups of two or one) and also signs of a remote and isolated sub-group. In all three phases, it was ascertained that the therapeutic group of long-term unit A did not manage to achieve a large degree of cohesion. The members of the scientific group failed to act in a professional capacity, whereas the members of the nursing staff had adapted to their clear professional role (1st Phase). During the 2nd Phase, tendencies to re-determine and re-assign professional responsibilities were ascertained, a fact that led the members of the nursing staff to have a positive attitude towards expectations of the efficiency of their role, whereas the members of the scientific staff had a negative attitude and expectations (3rd  Phase)

Regarding the attitudes of caregivers towards the residents-patients, in all three phases, these were characterized by signs of rejection (scientific staff) and signs of acceptance (nursing staff). The members of the nursing staff showed positive attitudes towards the patients, whereas the members of the scientific staff showed negative attitudes as well as signs of distance and fear of the patients, resulting in some members of the latter presenting with symptoms of stress (2nd Phase). The activity groups working with the patients were introduced in the 2nd Phase and it was ascertained that they showed signs of not abiding strictly by the working hours, lack of specific roles and objectives and lack of a stable co-ordinator. This resulted in signs of violence and institutionalized behaviour from the patients. The therapeutic groups and the activity groups were assisted by a permanent co-ordinator (psychologist) during the 3rd Phase but still demonstrated the above-mentioned characteristics. The main emotions expressed by caregivers towards the patients were stress and insecurity (1st Phase), verbal negative expression of emotions (2nd Phase) and a slight reduction in negative emotions in the 3rd Phase.

All caregivers agreed that there should be training programmes, with the aim of improving their courage and strength. The attitude of the community was initially negative (1st Phase), while during the 2ndrd phases the attitude of the community was more positive, a fact that coincided with the ‘opening’ of the unit to the community (e.g. summer vacations in the wider region of the community, patient walkabouts, etc.). The caregivers showed signs of becoming independent of the administration of the general hospital in that region; however, independence was not ultimately achieved.
Long-term Unit B      
The relations between caregivers of long-term unit B were characterized by mutual trust, high level of cohesion and unity and very good co-operation. The caregivers were particularly flexible in their co-operation in all three phases, and the only difference was that traces of dissatisfaction on behalf of the nursing staff were ascertained during the 2nd Phase, because they believed that the scientific staff did not place due confidence in their group. At the end of the 2nd Phase, a training programme for a period of one (1) month took place within the staff working environment. After the completion of this training programme, the therapeutic group began functioning as a ‘cohesive group’.

Long-term unit B had an internal supervisor (psychologist), who was designated by the administration of the local General Hospital the unit belongs to, according to his scientific qualifications. The main characteristic of the internal supervisor was that he applied himself to flexible co-ordination of actions by taking direct decisions and developing initiatives and innovations to solve problems (3rd Phase).

The direct self-assignment of the caregivers according to their professional roles, the application of their professional and multidisciplinary roles and the positive expectations of their role efficiency in the therapeutic work were also ascertained.

The attitudes of caregivers towards the patients of the long-term unit were generally positive. In particular, the scientific staff maintained formal and positive attitudes, while the nursing staff expressed feelings of fear and a distant attitude (1st and 2nd Phases). After completion of the training programme, more positive attitudes and expectations of all members of the therapeutic group were ascertained (3rd Phase).

The implementation of the therapeutic programme was strictly enforced through the operation of therapeutic groups and activity groups (1st Phase). The groups had clear goals and the patients expressed socially acceptable forms of behaviour. At the same time, caregivers participated in joint activities with patients (e.g. joint walks into the city for shopping, having lunch with them, going for a coffee together in the city, etc.) (3rd Phase). The caregivers agreed on the necessity of training programmes, with the aim of improving the efficiency of their professional and therapeutic roles. Initially, attitudes of the community towards the unit were negative (1st Phase). Later, (2nd and 3rd Phases) it was ascertained that attitudes changed into positive (‘opening’ of the unit to the community). In conclusion, tendencies of the caregivers to become independent of the administration of the general hospital of the city were ascertained and the long-term unit could be characterized as an independent unit.
Long-term Unit C
Co-operation between the caregivers was excellent; they developed trust in each other and complemented one another’s role.  The therapeutic environment was organized according to the standards of organization of the mental hospital and caregivers continued to be dependent on the Mental Hospital. The chain of command between the members of the therapeutic group was the same as that of the mental hospital, with the staff nurse designated as internal supervisor.

The relations of caregivers with patients were good, especially on the part of the nursing staff. The scientific staff maintained more formal relations with the patients. The therapeutic programme of the therapeutic and activity groups was consistent and strictly enforced. The nursing staff may possibly have experienced feelings of frustration regarding the effectiveness of their therapeutic work and had reservations about the progress of patients (2nd and 3rd Phases), expressed through an indirect distant or spurning attitude towards the patients. In contrast, the scientific staff expressed more positive and formal attitudes. All caregivers expressed a desire for the implementation of training programmes and were looking for scientific motivation in order to improve their professional roles.

The attitude of the community was negative regarding the presence and operation of the unit in all study phases of the long-term unit (2nd and 3rd Phases). Finally, no tendency for independence (decentralization) of the unit from the administration of the mental hospital was ascertained.
Long-term Unit D
The therapeutic group had developed good relations of co-operation and trust in each other, showing a high level of cohesion. However, the pressure put on the members of the therapeutic group by the administration of the mental hospital to work simultaneously in two units (Day Centre and long-term unit D) led to a situation characterized by fragmentation within the group. The fact that on the whole the caregivers were obliged to render their services to both units simultaneously caused them to feel discontent with and to spurn the patients in this unit.  The nursing staff reacted more negatively to working simultaneously in the Day Centre and in a therapeutic environment where the work resembled that of a mental hospital. The scientific staff did not show negative attitudes as they worked fewer hours in the long-term unit, while the nursing staff expressed more negative and distant attitudes towards the patients of the unit. The patients of the unit demonstrated strong negative behaviour resulting in isolation, as they refused to participate in the activity groups. The resistance of patients reduced significantly during the 3rd Phase and this coincided with the simultaneous reduction in the ‘opposition’ of caregivers to working in both units simultaneously as they complied with the orders of the mental hospital (3rd Phase).

The therapeutic staff made efforts to change the therapeutic environment of the long-term unit from that of the Day Centre. This contributed to re-determining how therapeutic roles should be applied, aiming to achieve the best possible performance and efficiency of the therapeutic goals for each unit separately. Moreover, caregivers deemed it necessary to improve their therapeutic roles through implementation of training programmes. The relations of dependency maintained between the members of the therapeutic group and the administration of the mental hospital did not lead to tendencies towards self-administration of the long-term unit.
Stagnation in the therapeutic environment of long-term unit A and improper function in terms of the organization of the therapeutic group made it difficult for caregivers to undertake specific responsibilities regarding the organization of the therapeutic programme of the unit according to the needs of in-patients. Flexible organization in combination with the absence of designated internal and external supervisors of the unit, the problems in the relations among staff members, lack of collective effort in therapeutic planning, ambiguity of therapeutic roles and failure in the application of defined professional and supplementary roles led to unavoidable problems for both the smooth operation of the programme in the unit and the achievement of rehabilitation therapeutic goals (Katz & Kirkland 1990). The distance kept by the scientific group between themselves and their patients and the negative expectations for the therapeutic outcome (Cottle  et al 1995, Herzog 1998, Stark et al 1992, Kuipers & Moore 1995) led to the development of negative attitudes and emotions (e.g. critical remarks, incorrect arbitrary evaluations of patients, defensive attitude – resistance) (Ball et al 1992, Van Humbeek & Van Audenhove 2003, Snyder et al 1994, Moore et al 1992, Oliver & Kuiper 1996, Finemma et al 1996, Van Humbeek et al 2002). The loose application of therapeutic activities (Watson et al 1980) – and the indifference of patients to what these entailed – led to the development of institutional and violent behaviour by patients (Butzlaff & Hooley 1998, Wearden et al 2000, Van Humbeek et al 2001, Barrowclough et al 2001, Tattan & Tarrier 2000, Weigel & Collins 2000). The expression of negative behaviour by the staff towards patients may be associated with the possible experience of intrusion and emptiness of emotions by the staff itself (Hochmann 2003).

In contrast, the effectiveness of the therapeutic programme in long-term unit B enabled the caregivers to be more flexible and ready to meet new needs resulting from the changes in the social environment of the long-term unit.

The social sufficiency of the long-term unit environment was evident by: i. the direct attention paid by the therapeutic group to patients and ii. the positive interaction between caregivers and patients. The prompt designation of an internal supervisor for the therapeutic group on the basis of scientific qualifications contributed to the maintenance of good relations of co-operation among the staff members, development of therapeutic goals and efficiency of therapeutic work (purposive system thinking) (Foster & Roberts 1998, Adair 1983, Hinshelwood 1989, Rushton & Nathan 1996).

The therapeutic environment of long-term unit B was based upon a well-organized therapeutic plan with the following main characteristics: i. individualized therapeutic intervention and strict application of the therapeutic programme (Curtis & Hodge 1994), ii. encouragement of patients to become independent and express their personal choices (Lavender 1985, Shepherd 1984), iii. positive expectations of staff for a therapeutic outcome together with positive attitudes and positively-expressed emotions towards patients and, finally, iv. socially-acceptable forms of patient behaviour (Betz 1969, McCarthy & Nelson 1991, Hull & Thompson 1981, Kruzich 1985 and Van Humbeek et al 2001). The presence of capable internal and external unit supervisors, the organization of the chain of command in the therapeutic group, the implementation of training programmes and strictly-prescribed therapeutic goals all appeared to contribute to the development of positive characteristics in the therapeutic environment of the unit.
The traditional form of administration of units C and D, based on the standards of administration of the Mental Hospital, was largely due to relations of dependency that had developed between the caregivers and the Mental Hospital but also because they had adopted the ‘way of thinking of the mental hospital’. The fixed views of caregivers on chronic mental illness, the continuous interventions by the administration of the Mental Hospital in the organization of the unit and the absence of substantial internal and external supervision of the unit did not help the therapeutic group of unit C to promote their therapeutic work for rehabilitation of patients substantially. Consequently, the members did not use therapeutic techniques and methods for the rehabilitation of patients and did not proceed to any substantial changes in the therapeutic environment of the long-term unit, the organization of which resembled that of the Mental Hospital (Astrachan et al 1970). The therapeutic group of unit D showed signs of inactivity, passivity and lack of initiative because of other reasons, too, such as the pressure applied by the Mental Hospital to work simultaneously in both units (unit D and Day Centre) and the preference of the therapeutic staff members to work only in the Day Centre. Such negative attitude and behaviour probably reflects emotions of intrusion and emptiness experienced in the past due to frequent contact between caregivers and chronic patients (Searles 2003, Hochmann 2003).
The well-organized therapeutic environment of a long-term unit for rehabilitation of chronic mental patients is a significant prerequisite for both normal development of chronic mental illness and efficiency of rehabilitation of patients. A long-term unit should not be isolated from the social and cultural developments of its time and the patients should feel that they are part of the community in which they live and work.

This study showed that the primary and principal factor in a well-organized long-term unit environment was prompt designation of internal and external supervisors for the unit by the implementing body, with regard to not only newly-established long-term units with inexperienced therapeutic staff but also those employing expert mental health professionals. The internal supervisor should be a member of the therapeutic group and be designated only by the implementing body on the basis of his scientific and organizational qualifications. The presence of an internal supervisor is significant because any problems and conflicts that may arise within the therapeutic group can be settled or prevented through regular and weekly meetings with staff. The presence of an internal supervisor encourages caregivers to understand precisely their clearly-defined therapeutic and supplementary roles and apply them. In this way, role ambiguity of caregivers is avoided. Moreover, the presence of a supervisor serves as a ‘protective umbrella’, because this can help him take decisions after having ‘listened to’ the needs of the caregivers.

The second yet basic factor in a well-organized long-term unit environment is the continuous training of the staff. Most mental health professionals, including skilled ones, have neither undergraduate nor postgraduate level-specific knowledge in terms of rehabilitation of patients. Of course, it is undeniable that the training programmes that do take place occasionally and unsystematically aim only at the provision of knowledge and skills regarding the treatment of mental illness, based on psychotherapeutic methods and techniques, not enabling caregivers to develop more positive attitudes and behaviors towards chronic mentally-ill patients. The implementation of continuous training programmes within the working environment can help caregivers to: i. deal much more easily with the intensity of their feelings and negative emotions developed in their inter-therapeutic relations, ii.  be able to identify and settle possible signs of frustration that may be evident in their inter-therapeutic relations, thus avoiding burn out, iii. have a positive attitude and show empathy for the patient and iv. ‘listen to’ the needs of the patients. Consequently, the therapeutic work becomes more substantial and resident-oriented.

The third factor in achieving a well-organized long-term unit environment involves the attitude of the implementing body towards the staff of the unit. The presence of the implementing body in the therapeutic environment of the long-term unit should be substantial, its role being a subsidiary and supportive one, not interventional. This can be achieved by: i. prompt designation of internal and external supervisors for the unit, ii. organization and implementation of training programmes for the staff members, iii. staffing of a well-organized therapeutic group, in which all members should be professionally ready to work in such an environment, either applying their current specialization skills to the rehabilitation of psychiatric patients or using their experience from the sector of psychiatric rehabilitation, iv. substantial rotation of staff to various psychiatric units in order to prevent the appearance of burn out syndrome, v. promotion of unit independence and self-administration, vi. substantial support that meets the needs of patients and caregivers, but which does not serve financial interests such as: absorption of funds and unequal allotment of resources.

The fourth factor concerns the rotation of staff to various psychiatric units, in order to prevent the appearance of burn out syndrome. Rehabilitation is difficult and therefore administration has to use this method with the assistance of the internal supervisor of the unit.

The fifth and last factor to play a significant role in a well-organized long-term unit environment concerns the organization of the chain of command. The therapeutic group of the long-term unit functions better when there is a clear-cut chain of command. The members of staff are each separately oriented in accordance with the function of their particular role and feel safe in complementing one another’s role.

The above-mentioned findings cannot be put into general use, as they only constitute indicative data with regard to the long-term units studied in this research. However, they could be taken as an impetus for new qualitative and quantitative research.


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