The Relational Institution: An Ethnographic Study of an Inpatient Psychiatric Rehabilitation Ward

AIMS: Inpatient psychiatric rehabilitation services for people with complex psychosis promote independent living and reduce readmissions through multidisciplinary recovery-based practice. Yet, little research has explored how these services are experienced by patients and staff, partly due to the difficulties of conducting qualitative research in such settings using interviews and focus groups. We therefore lack an in-depth understanding of how inpatient rehabilitation operates on the ground, including which aspects are experienced as helpful/unhelpful and which factors determine the feasibility/success of recovery-based practice. METHODS: We conducted an ethnographic study of a 16-bed inpatient rehabilitation ward in London comprising six months of participant observation followed by 20 semi-structured interviews with patients (n = 7) and staff (n = 13). For participant observation, over 200 pages of fieldnotes were taken contemporaneously. Semi-structured interviews were audio-recorded and transcribed verbatim. Data were analysed using grounded theory and situational analysis. RESULTS: Our analysis highlights the fundamental importance of relationality in inpatient rehabilitation. Specifically, complex psychosis is characterised by relational impairments and divergences that lead to significant disability. Working with this complex patient group therefore requires nuanced and specialist relational skills. On the ward, these skills were actively nurtured by staff, especially those at lower pay grades, to provide the essential scaffolding for recovery-based practice. Yet, ward staff were often prevented from prioritising therapeutic relations by prevailing structural and institutional arrangements. For example, greater importance was attached to completing technical and bureaucratic interventions; patient contact was reduced for more experienced staff; and staffing levels and material resources for rehabilitation activities were limited. Already feeling underequipped, staff members described how their motivation to cultivate therapeutic relations was further reduced by experiences of structural inequalities inside and outside the ward and, more proximally, by limited psychological and occupational support structures. The consequent undermining of recovery-based practice led to patients experiencing treatment as more restrictive and less therapeutic than it could have been. CONCLUSION: Relationality is a key determinant of the experience of treatment within psychiatric units, and yet the subversion of therapeutic relations identified in this study reflects prevailing currents in psychiatry and mental health systems nationwide and beyond. Recovery-based practice and the cultivation of rich therapeutic relationships have among the strongest evidence bases of any interventions for people with complex psychosis. Therefore, to fulfil its clinical potential, inpatient rehabilitation requires investment in the expertise, well-being, and availability of its frontline staff who make or break these relations. This must be facilitated by broader structural and institutional commitments.