Community Mental Health Journal

, Volume 50, Issue 4, pp 415–421 | Cite as

Effects of a Recovery-Oriented Cognitive Therapy Training Program on Inpatient Staff Attitudes and Incidents of Seclusion and Restraint

  • Nadine A. Chang
  • Paul M. GrantEmail author
  • Lauren Luther
  • Aaron T. Beck
Original Paper


We investigated the feasibility of implementing a recovery-oriented cognitive therapy (CT-R) milieu training program in an urban acute psychiatric inpatient unit. Over a 1-month period, 29 staff members learned short-term CT-R strategies and techniques in an 8-h workshop. Trainees’ perceptions of CT-R, beliefs about the therapeutic milieu, and attitudes about working with individuals with psychosis were evaluated both before the workshop and 6 months after the workshop had been completed. Incidents of seclusion and restraint on the unit were also tallied prior to and after the training. Results indicate that staff perceptions of CT-R and their beliefs about the therapeutic environment significantly improved, whereas staff attitudes towards individuals with psychosis remained the same. Incidents of seclusion and restraint also decreased after the training. These findings provide evidence that CT-R training is feasible and can improve the therapeutic milieu of an acute psychiatric inpatient unit.


Recovery Schizophrenia Inpatient Milieu training Cognitive therapy 



We would like to thank Kathryn Byars, Aaron Brinen, Ashley Chambers, Marion Conneen, Katie Daly, Sarah Farash, Jody Foster, Reed Goldstein, Samantha Goodin, Spencer Kostinsky, Kerry McCole, Dimitri Perivoliotis, Susan Rappaport, Zach Rosenberg, Eren Semen, and Tony Zapisek for their assistance with this project. Study results were presented at the 2012 annual meeting of the American Psychological Association, Orlando.

Conflict of interest

Drs. Grant and Beck have received royalties from Guilford Press. The remaining authors have no interests to disclose.


  1. Bahareethan, M., & Shah, A. (2000). Aggressive behaviour, staff attitude and staff perception of patients on two continuing care psychogeriatric wards. Aging and Mental Health, 4(1), 66–71.CrossRefGoogle Scholar
  2. Baker, J. A., Lovell, K., & Harris, N. (2008). A best-evidence synthesis review of the administration of psychotropic pro re nata (PRN) medication in in-patient mental health settings. Journal of Clinical Nursing, 17(9), 1122–1131.PubMedCrossRefGoogle Scholar
  3. Barrowclough, C., Haddock, G., Lowens, I., Connor, A., Pidliswyj, J., & Tracey, N. (2001). Staff expressed emotion and causal attributions for client problems on a low security unit: An exploratory study. Schizophrenia Bulletin, 27(3), 517–526.PubMedCrossRefGoogle Scholar
  4. Beck, A. T., Rector, N. A., Stolar, N. M., & Grant, P. M. (2009). Schizophrenia: Cognitive theory, research and therapy. NY: Guilford Press.Google Scholar
  5. Bellack, A. S. (2006). Scientific and consumer models of recovery in schizophrenia: Concordance, contrasts, and implications. Schizophrenia Bulletin, 32(3), 432–442.PubMedCentralPubMedCrossRefGoogle Scholar
  6. Chakrabarti, A., Whicher, E., Morrison, M., & Douglas-Hall, P. (2007). ‘As required’ medication regimens for seriously mentally ill people in hospital. Cochrane Database Systematic Review, 3, CD003441.Google Scholar
  7. Chang, N. A., Farash, S. (2010). The CT-R interview. Unpublished test.Google Scholar
  8. Clarke, I., & Wilson, H. (2009). Cognitive behaviour therapy for acute inpatient mental health units: Working with clients, staff and the milieu. London; New York: Routledge.Google Scholar
  9. Davenport, S. (2002). Acute wards: Problems and solutions. Psychiatric Bulletin, 26(10), 385–388.CrossRefGoogle Scholar
  10. Davidson, L., Harding, C. M., & Spaniol, L. (2005). Recovery from severe mental illness: Research evidence and implications for practice (Vol. 1). Boston: Center for Psychiatric Rehabilitation of Boston University.Google Scholar
  11. Davidson, L., Harding, C. M., & Spaniol, L. (2006). Recovery from severe mental illness: Research evidence and implications for practice (Vol. 2). Boston: Center for Psychiatric Rehabilitation of Boston University.Google Scholar
  12. Davidson, L., Tondora, J., Lawless, M. S., O’Connell, M. J., & Rowe, M. (2009). A practical guide to recovery-oriented practice: Tools for transforming mental health care. Oxford, UK: Oxford University Press.Google Scholar
  13. Dean, A. J., Duke, S. G., George, M., & Scott, J. (2007). Behavioral management leads to reduction in aggression in a child and adolescent psychiatric inpatient unit. Journal of the American Academy of Child and Adolescent Psychiatry, 46(6), 711–720.PubMedCrossRefGoogle Scholar
  14. Department of Health and Human Services. (2003). Achieving the promise: Transforming mental health care in America. (DHHS Pub SMA-03-3832). President’s New Freedom Commission on Mental Health. Final Report. Rockland, MD: US Department of Health and Human Services.Google Scholar
  15. Forster, P. L., Cavness, C., & Phelps, M. A. (1999). Staff training decreases use of seclusion and restraint in an acute psychiatric hospital. Archives of Psychiatric Nursing, 13(5), 269–271.PubMedCrossRefGoogle Scholar
  16. Georgieva, I., de Haan, G., Smith, W., & Mulder, C. L. (2010). Successful reduction of seclusion in a newly developed psychiatric intensive care unit. Journal of Psychiatric Intensive Care, 6(1), 31–38.CrossRefGoogle Scholar
  17. Gilbody, S., Cahill, J., Barkham, M., Richards, D., Bee, P., & Glanville, J. (2006). Can we improve the morale of staff working in psychiatric units? A systematic review. Journal of Mental Health, 15(1), 7–17.CrossRefGoogle Scholar
  18. Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N. M., & Beck, A. T. (2012). Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of General Psychiatry, 69(2), 121–127.PubMedCrossRefGoogle Scholar
  19. Heresco-Levy, U., Ermilov, M., Giltsinsky, B., Lichtenstein, M., & Blander, D. (1999). Treatment-resistant schizophrenia and staff rejection. Schizophrenia Bulletin, 25(3), 457–465.PubMedCrossRefGoogle Scholar
  20. Holmes, J. (2002). Acute wards: Problems and solutions. Psychiatric Bulletin, 26(10), 383–385.CrossRefGoogle Scholar
  21. Howard, V., & Holmshaw, J. (2010). Inpatient staff perceptions in providing care to individuals with co-occurring mental health problems and illicit substance use. Journal of Psychiatric and Mental Health Nursing, 17(10), 862–872.PubMedCrossRefGoogle Scholar
  22. IBM Corp. (2010). IBM SPSS statistics for windows (version 19.0). Armonk, NY: IBM Corp.Google Scholar
  23. Kreyenbuhl, J., Nossel, I. R., & Dixon, L. B. (2009). Disengagement from mental health treatment among individuals with schizophrenia and strategies for facilitating connections to care: A review of the literature. Schizophrenia Bulletin, 35(4), 696–703.PubMedCentralPubMedCrossRefGoogle Scholar
  24. Laker, C., Rose, D., Flach, C., Csipke, E., McCrone, P., Craig, T., et al. (2012). Views of the therapeutic environment (VOTE): Stakeholder involvement in measuring staff perceptions of acute in-patient care. International Journal of Nursing Studies, 49(11), 1403–1410.PubMedCrossRefGoogle Scholar
  25. LePage, J. P., DelBen, K., Pollard, S., McGhee, M., VanHorn, L., Murphy, J., et al. (2003). Reducing assaults on an acute psychiatric unit using a token economy: A 2-year follow-up. Behavioral Interventions, 18(3), 179–190.CrossRefGoogle Scholar
  26. McLeod, H. J., Deane, F. P., & Hogbin, B. (2002). Changing staff attitudes and empathy for working with people with psychosis. Behavioural and Cognitive Psychotherapy, 30(4), 459–470.CrossRefGoogle Scholar
  27. Morrison, M. F., Grant, P. M., Cummings, W., Boyle, P. D., Simmons, W., Gardiner, G. C. (2013). Meeting the challenge of olmstead v. L.C.: A recovery-oriented pilot program to improve outcomes from long-term psychiatric inpatient care. Paper presented at the American Psychiatric Association’s Institute of Psychiatric Services, Philadelphia, PA.Google Scholar
  28. Nelson, H. (2005). Cognitive behavioral therapy with schizophrenia: A practice manual. Cheltenham: Stanley Thornes Ltd.Google Scholar
  29. Perivoliotis, D., Grant, P. M., & Beck, A. T. (in press). Recovery-oriented cognitive therapy for schizophrenia: A comprehensive treatment manual. New York: Guilford.Google Scholar
  30. Rogers, C. R., Gendlin, E. T., Kiesler, D. J., & Truax, C. B. (1967). The therapeutic relationship and its impact: A study of psychotherapy with schizophrenics. Madison: University of Wisconsin Press.Google Scholar
  31. Sharfstein, S. S. (2008). Reducing restraint and seclusion: A view from the trenches. Psychiatric Services, 59(2), 197.PubMedCrossRefGoogle Scholar
  32. Silverstein, S. M., & Bellack, A. S. (2008). A scientific agenda for the concept of recovery as it applies to schizophrenia. Clinical Psychology Review, 28(7), 1108–1124.PubMedCrossRefGoogle Scholar
  33. Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy: Training and practice. Chicago: Aldine.Google Scholar
  34. Wright, J. H., Thase, M. E., Beck, A. T., & Ludgate, J. W. (1993). Cognitive therapy with inpatients: Developing a cognitive milieu. New York: Gullifod Press.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Nadine A. Chang
    • 1
    • 2
  • Paul M. Grant
    • 1
    Email author
  • Lauren Luther
    • 1
  • Aaron T. Beck
    • 1
  1. 1.Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of PsychiatrySt. Luke’s-Roosevelt Hospital CenterNew YorkUSA

Personalised recommendations