From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services Edited through Penelope Campling.

From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services Edited through 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 volume suggests, such settings can fall into the grip of negative processe However, the title also recognises that residential environments can existing opportunities that can be harnessed for therapeutic benefit.

Appropriately enough, there are numerous concerns to designated 'therapeutic communities' in which a of the underlying principles have been bring to maturityed or find their fullest expression. There is also considerable use of insights from attachment and psychoanalytic perspectives, notably in the areas of relation povertys 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 work is intended for a multi-disciplinary readership and the range of contributors cogitates this. It is divided into four parts.

Part I is forward 'Understanding the problem'. It begins with more [i]or[/i] less historical background, and in the constituent chapters a number of processe are described which might be involved in institutional toxicity. A theme that present itselfs here and later, in more than common guise, is how for many patients the past can resonate with the existing 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 from 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 originals of patient in secure settings has l to sometimes contradictory recommendations in official inquiries, and to policies and performances based on one group that are contra-indicated for another.

Part II, 'Towards a better future' cause to grows 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 straits to be tailored to the particular indigences of users of services, so as women and ethnic minorities. Effective leadership and management are essential, and a recurring theme is that the staff team should be a major bear upon 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 onward an impressive history of research into measuring therapeutic environments, a great deal of 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 clusters can be explored. Students of meta-analyses of treatment effectiveness might find particularly interesting the protoplast of identifying associations between features of institutional programmes, patient characteristics and treatment results

Part III is bear uponed with 'Acute wards'. The chapters according to a user of services and a carer deficiency the chapter on users' experiences in Part I. Commenting that unruffled physical medicine is now beginning to operate a 'more co-operative negotiated approach to treatment' (pi 78) Chapter 17 notes that a cultivation 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 progressive growth of psychologists and assistants. The chapter in succession the implications of psychotherapy for improving ward refinement affirms arguments made elsewhere in succession the importance to treatment result of the therapeutic alliance. Emphasis is given again to the utility of universals of attachment, the needs for supervision, reflective practice and arrange 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 in succession the needs of particular client form into groupss The specific issues share a pious 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 further also, frequently, profoundly negative expectations of adult authority. The activities which for adolescents provide a vehicle for to a great degree 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 at hands the views of some tribe with learning disabilities and underlines the importance of personal meanings and choice. The chapter onward secure psychiatric services describes a number of therapeutic communities for culprits and develops further the arguments made in the author's earlier chapter about the ne to consider variations among residents in insured settings. The theme of adapting services to patients come abouts again in the chapter forward older adults, while the final chapter advocates an active universal of recovery that emphasises personal discovery, autonomy and social inclusion rather than pond stabilisation.