Inpatient Institutional Care: The Forced Social Environment

Abstract

The landscape of mental health recovery is changing; there have been calls for a shift from the clinical expertise being the dominant voice within mental healthcare towards a more personalised and collaborative service that supports those in need of mental healthcare to define what recovery is for the individual. Within this new recovery movement, there has been a recognition of the importance of the social environment in which individuals are situated and the relationship of this to mental health and wellbeing. Included in this is the importance of an individual’s role within society and the ways in which knowledge, such as experts by experience, can hold an important value. The argument then, is that social connectedness forms part of the recovery journey and that relationships can help us develop or re-connect with who we are in powerful ways. Such a view has only been strengthened by the recent and ongoing global COVID-19 pandemic. Within the UK, discussions of the importance of our wellbeing have become commonplace within the context of restricted social contact. With this heightened awareness of how the social contributes to wellbeing, it is important to consider the environments in which those in receipt of mental healthcare are situated. One of which is institutionalised care, where it is commonplace to restrict social contact. For example, by virtue of being within a locked environment, individuals’ freedom of movement is often non-existent and thus contacts with those not residing or working within the institution is restricted. While such restrictions may be deemed necessary to protect the individual’s mental health, such environments can be unintentionally toxic. Data are presented from an ethnography that was conducted within an inpatient forensic mental health hospital in the UK to highlight the problematic social environment which some individuals experience. Key interpersonal issues are presented, such as, trust, racism, the threat of physical violence and bullying that was experienced by staff and residents at the hospital. Consideration is given to the coping strategies enacted by residents and the pathologising of such behaviour. The consequences on interpersonal wellbeing are explored.

Is antipsychotic augmentation associated with improved functioning in patients on clozapine?

“…This may reflect this cohort's inherent struggle with social interaction due to positive and negative symptoms exacerbated by prolonged stays in psychiatric wards, an environment where social interactions are often restricted or constrained. 12,13 This study revealed a significant difference between full responders and partial responders who had an average clozapine daily dose of 466 mg and ongoing positive symptoms and were very similar to the clozapine-resistant schizophrenia patients defined by Chakrabarti. 3 The group of full responders had a notable absence of psychotic symptoms and better functioning while partial responders had ongoing positive symptoms and seriously impaired global functioning, particularly, in the social interaction domain.…”

“You Want Them Pretty, but Not Too Intelligent!”: Everyday Talk and the Continuum of Men's Violence Against Women in Forensic Institutional Care

“…The Therapeutic Community model creates an environment in which everyday constructions of hypermasculinity can be challenged and new constructions of hegemonic masculinity can be embraced and supported, by all community members including staff. Our previous paper advocated for the Therapeutic Community model within forensic environments in response to the challenging interpersonal environment in which racism, violence and bullying was observed by the ethnographer ( 4 ). Once again, this model is advocated for, particularly within the context where individuals are undertaking rehabilitative work related to sexual offending, so that everyday social encounters can be underpinned by an egalitarian ethic, one that challenges the gender inequalities which pervade social life and indeed our institutions, and contribute to the continuum and the continuation of VAWG.…”

“…A commitment to such notions of masculinity serves to marginalise those who do not fit the social norms of masculinity ( 83 ) and this commitment may indeed have been performed within the institutional community. Racial abuse experienced by staff and those in receipt of care is prevalent within the forensic mental health context ( 4 ), thus intersectionality would undoubtedly be relevant to the arguments presented within this paper.…”

“…The complex and sometimes toxic social environment can sharply contrast the positive and supportive therapeutic relationships that are integral to care practice which promote recovery. The complex social environment has been more thoroughly discussed within an earlier publication ( 4 ), however this paper focusses on misogynistic attitudes which are linked to Violence Against Women and Girls (VAWG) evidenced within the ethnographic data. The normalisation of values that subjugate women in a workplace setting can influence a setting's staff; this is doubly pertinent in secure services, as they're argued to instil emotional isolation from family, friends, and colleagues ( 3 ).…”

“…This paternalistic model is underpinned by a disparity between staff (who are deemed well) and those who are in receipt of care (who are deemed unwell) where the role of helper and helpless is commonly reinforced in care ( 26 ). Providing care within a custodial context is challenging ( 27 )-wherein it's integral to care that building and maintaining relationships occurs, however the environment is highly emotive ( 4 ). It is a long-standing position in medical sociology that medical knowledge “is socially contingent.…”