Scales for assessing the therapeutic milieu in psychiatric inpatient settings: A systematic review

The therapeutic milieu is widely regarded as an important factor influencing experiences and outcomes of psychiatric inpatient treatment. Appropriate scales are needed to assess the milieu. The aim of this review is to identify and describe scales established for that purpose.

A systematic search of electronic databases was carried out. Scales used in two or more studies were identified, and data was extracted on key characteristics.

Scales for assessing the therapeutic milieu were used in 78 studies. Five scales were identified that were used more than once. Four scales originate from 1964 to 1986, one was originally published in 2008. The Ward Atmosphere Scale (WAS) is the most frequently used scale and its psychometric properties have been reported as good. When tested alongside each other, the scales are weakly to moderately correlated.

Few scales have been established to assess the therapeutic milieu. All scales capture aspects of relationships on the wards. The most commonly used scale (WAS) has 100 items and was developed more than 50 years ago. Given the changes in the practice of inpatient care over the last 50 years, new, briefer and psychometrically robust scales should be developed.