The relational institution: an ethnographic study of recovery orientation and relational engagement on a psychiatric rehabilitation ward in London.

backgroundIn the UK, inpatient psychiatric rehabilitation services for complex psychosis aim to provide recovery-orientated treatment to patients, with the goal of supporting sustained stepdown into community living. The extent to which rehabilitation services uphold this recovery orientation is associated with better outcomes. However, few studies have been able to ascertain what promotes or prevents recovery orientation in inpatient settings.

methodsWe conducted an ethnographic study of treatment on a National Health Service (NHS) psychiatric rehabilitation ward in London over six months during August 2022-February 2023. Data were collected through participant observation and semi-structured interviews with 9 patients and 14 staff members. Fieldnotes and interview transcripts were analysed using situational analysis.

resultsOur analysis highlights the importance of what we term 'relational engagement' between staff and patients to nurture and sustain recovery-orientated treatment. This relational engagement was embodied through small acts of genuine human connection grounded in mutual acceptance and affective bonding; close attention to detail that communicated curiosity and respect; and recognition, appreciation, and encouragement of the slow and gradual progress that characterises recovery in complex psychosis. Yet, this relational engagement was often limited or foreclosed by the social environment of the ward and the wider institutional context. Limiting elements included the dominance of hospital logics geared towards high-throughput acute treatment and risk management; the presence of audit culture that led to a level of standardisation curtailing more genuine human connection; and staff demoralisation driven by events on and off the ward, including system-wide crises and more localised conflicts and disturbances. Some of these conflicts involved discrimination, most prominently anti-Black racism and homophobia, reflecting wider structural inequalities that characterise inpatient psychiatric populations and the healthcare workforce.

conclusionRelationships, often under-prioritised in mental health services, were a key cornerstone of recovery-orientated treatment on a psychiatric rehabilitation ward. The shaping of therapeutic relationships amounted to an active process of relational engagement, which may be afforded or constrained by complex social elements requiring careful consideration in inpatient psychiatry. These social elements go beyond more surface-level factors such as staff training, knowledge, or attitudes and may require structural and system-level interventions.