How Does a Therapeutic Milieu Help Children who Need Treatment in Hospital for Mental Health Difficulties?

How does a Therapeutic Milieu in inpatient mental health treatment enable change for children? A realist process evaluation using ethnographic methods to develop programme theory. Background Inpatient mental health treatment is offered to children whose needs cannot be met in any other context and whose mental health difficulties significantly impact functioning in all areas of their life. During the stay on an inpatient ward the social, emotional and physical ward environment is not just the setting in which treatment takes place; it is the treatment. Staff work to create an environment which is an effective treatment for each child. The treatment provided by this environment is described as the 'Therapeutic Milieu'. Children accessing these services are highly vulnerable and under-served by research. Empirical research considering the working of the therapeutic milieu and in particular its application for children's mental health contexts needs further development. The complexity of the intervention and its implementation has been a barrier to research. Aims and Methods The aim of this research is to understand the change processes of the Therapeutic Milieu in highly specialised inpatient mental health services for children. The study is the first to consider inpatient mental health treatment for children within the framework of the UK Medical Research Council's guidance for evaluating complex interventions1 in a theory-based approach. This project is a realist process evaluation. Three workstreams are planned. 1. A qualitative meta-synthesis of existing studies exploring the experience of an admission for children, young people, their parents and carers. 2. A comprehensive mapping of the use of the Therapeutic Milieu in children's units in England An electronic tailored survey and a standardised measure of ward atmosphere will be sent to all staff working in the six children's mental health units in England. The survey will explore each unit's approach to the use of the therapeutic milieu. 3. Developing an in-depth understanding of how the Therapeutic Milieu is delivered and experienced in practice An ethnography, including participant observation and interviews with children, their parents/carers and staff from two children's units, will be completed. Interviews with each child and parent/carer will be completed at two time points; during admission and after discharge. Framework Analysis will be used. Patient and Public Involvement (PPI) PPI has supported development of the research questions and methods via consultation with experts by experience. Experts by experience will collaborate throughout the project with both an advisory group and specific working groups for key tasks. Impact and Dissemination Understanding this crucial component of inpatient treatment is central to improving care, reducing admission length and avoiding admission by identifying when it will not be helpful. Guidelines and training materials for practitioners about creating the optimal climate for therapeutic change will be shared in visits to all units and in national workshops. An animation to share the results of the study with children and families will be an impactful resource ensuring the research is accessible to all. A strong and clear foundation for future research will be established.