From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services

From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services Edited by dint of Penelope Campling, Steffan Davies & Graeme Farquharson London: Gaskell (2004) ISBN 1-904671-07-1

When residential and inpatient settings in mental health services receive attention in print it is not always for positive reasons. As the title of this pioneering work suggests, such settings can fall into the grip of negative processe However, the title also recognises that residential environments can at hand opportunities that can be harnessed for therapeutic benefit.

Appropriately enough, there are numerous concerns to designated 'therapeutic communities' in which a certain number of of the underlying principles have been unraveled or find their fullest expression. There is also considerable use of insights from attachment and psychoanalytic perspectives, notably in the areas of relation wants and defence mechanisms that can affect patients and staff alike. Recurring recommendations range from a ne for greater involvement of patients in planning and decision-making, to the importance of supervision and support for staff.

The volume is intended for a multi-disciplinary readership and the range of contributors throw backs this. It is divided into four parts.

Part I is upon 'Understanding the problem'. It begins with a certain number of historical background, and in the constituent chapters a number of processe are described which might be involved in institutional toxicity. A theme that offers here and later, in more than single guise, is how for many patients the past can resonate with the at hand Staff can be cast into parts that reflect negative earlier experiences and internal conflicts, and previous crises (for example concerning rejection or abandonment) can be re-activated by means of present events. Other rewarding discussions include the contribution of attachment theory to understanding behaviour that is many times dismissed as manipulative. It is argued convincingly that failure to distinguish between impressed signs of patient in secure settings has l to sometimes contradictory recommendations in official inquiries, and to policies and practices based on one group that are contra-indicated for another.

Part II, 'Towards a better future' disentangles an understanding of how provision can be improved to make environments genuinely therapeutic. Attention is drawn to the potential symbolic meaning of the physical environment and activities. It is argued that provision emergencys to be tailored to the particular necessitys of users of services, of that kind as women and ethnic minorities. Effective leadership and management are essential, and a recurring theme is that the staff team should be a major affect Chapter 12 describes attachment to the team as 'the emotional bedrock upon which a therapeutic environment is built' (pi 21) The importance of the team in the prevention and management of aggression and violence is raised in the nearest chapter, as part of a framework of interacting factors. The final chapter builds upon an impressive history of research into measuring therapeutic environments, plenteous of it associated with the next to the first author (Rudolf Moos). Using the instruments outlined, programmes can be described and compared, monitored and evaluated, and the perceptions of different collections can be explored. Students of meta-analyses of treatment effectiveness might find particularly interesting the design of identifying associations between features of institutional programmes, patient characteristics and treatment issues

Part III is be of importance toed with 'Acute wards'. The chapters by dint of a user of services and a carer full number the chapter on users' experiences in Part I. Commenting that plane physical medicine is now beginning to operate a 'more co-operative negotiated approach to treatment' (pi 78) Chapter 17 notes that a tillage of blame, obedience and aversion to risk can still dominate in acute psychiatric wards, to the detriment of trust, autonomy and learning. The following chapter gives a certain quantity of useful pointers on training staff in a psychosocial approach, and another addresses the potential contribution and exhibition of psychologists and assistants. The chapter upon the implications of psychotherapy for improving ward tillage affirms arguments made elsewhere upon the importance to treatment consequence of the therapeutic alliance. Emphasis is given again to the utility of universals of attachment, the needs for supervision, reflective practice and assemblage cohesion, and for reduction of damaging 'express emotion' (critical and hostile comments) Other interesting recommendations include the use of a family therapy (rather than cluster therapy) approach to community issues.

Part IV addresses 'Specialist settings', focusing upon the needs of particular client clusters The specific issues share a useful deal of common ground and, unsurprisingly, there are echoe and elaborations of points made in earlier chapters. Thus adolescent residents bring to bear developmental issues on the other hand also, frequently, profoundly negative expectations of adult authority. The activities which for adolescents provide a vehicle for a great quantity [i]or[/i] amount of therapeutic work need to be more than usually stimulating, and staff must handle 'fierce projections' as well as 'high horizontals of distress and neediness' (p226) Chapter 22 not absents the views of some race with learning disabilities and underlines the importance of personal meanings and choice. The chapter upon secure psychiatric services describes a number of therapeutic communities for delinquents and develops further the arguments made in the author's earlier chapter about the ne to consider variations among residents in sure settings. The theme of adapting services to patients be founds again in the chapter upon older adults, while the final chapter advocates an active general [i]or[/i] abstract notion of recovery that emphasises personal discovery, autonomy and social inclusion rather than bare stabilisation.