Hurting and healing in therapeutic environments: How can we understand the role of the relational context?

Building and sustaining therapeutic relationships across treatment settings: a qualitative study of how patients navigate the group dynamics of mental healthcare

BACKGROUND

Therapeutic relationships are vital for patients with complex and long-term psychosocial needs, yet such patients often face fragmented and unstable relationships within mental healthcare. These patients are more often than others moved between treatment settings and caregiving teams. Statutory obligations strain the relationships with frequent hospitalizations adding to the burden This study explores how these patients perceive and navigate therapeutic relationships, highlighting both positive and negative experiences across various treatment settings.

METHODS

This is a qualitative study with a narrative approach utilizing in-depth interviews focusing on participants personal experiences and perceptions. We utilized purposive sampling to recruit patients with extensive hospitalization experience, operationalized as more than four admissions within one year or more than four successive weeks of hospitalization. Our sample consisted of 16 participants, twelve women and four men. The interviews were analyzed using a holistic-content approach.

RESULTS

We found that therapeutic relationships were built on healthcare professionals recognizing and addressing patients' needs and advocating for their interests within the service system. Participants described therapeutic relationships as sources of collaboration, stability, and support but found them challenging to sustain due to fear of rejection and institutional barriers. Successful relationships worked as a vital buffer, offering protection against malpractices and depersonalized care.

CONCLUSION

Therapeutic relationships play a crucial role in supporting patients with complex needs, but relational dilemmas and malignant group dynamics often impede their development. Mental healthcare services have an ethical responsibility to foster and maintain therapeutic environments and professional cultures that enable personalized care, while maintaining boundaries through reflective practices.

Supporting Aging-in-Place: Drivers and Desired Outcomes of a Healing Environment for Older Adults in Block Spaces of High-Density Cities

Aim: The objective of this study was to develop a comprehensive multidimensional framework by identifying the key drivers and components associated with the health of older people in healing environments, and to apply this framework in high-density city block spaces, creating opportunities for aging in place. Background: Effective theoretical and practical research frameworks are necessary to determine how to best support older adults in high-density city areas as they face aging-related challenges. Methods: The methodological approach involved bibliometric analysis (SciMAT) and systematic literature review of approximately 4446 articles related to rehabilitation settings and older adults. The review focused on literature that developed concepts and research frameworks and provided an empirical foundation. Results: The review identified four types of drivers for a healing environment for older individuals in high-density city blocks (HEOI-HCBs): self-environment, interpersonal, physical, and informational environments. These drivers were linked to eight desirable outcomes: initiative acquisition, shared vision, trust, empathy, integrity, systematicity, networking, and perceived usefulness. Conclusion: The drivers and outcomes formed the HEOI-HCBs framework, each representing a distinct dimension of the HEOI-HCBs concept. This study and the resulting framework facilitate the application and understanding of healing environments.

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

The forensic setting houses persons with offence convictions who are also in receipt of ongoing mental healthcare-a criminal justice system and healthcare meeting-point. Extant literature highlights how this context is laden with interpersonal and institutional difficulties unique to a secure context that must provide care and custody concurrently. Our central argument is that the intertwining and interdependent cultural and custodial elements of forensic healthcare environments are integral and influential to care, culture, and conduct within such institutions-including concerning misogynistic everyday talk and the continuum of men's violence against women therein. We argue that the institution is a continuation of contemporary social issues experienced within community life (e.g., misogyny), as the boundaries of such institutions are porous-polis values traverse physical brickwork. This paper analyses ethnographic data from two male wards that are situated within a UK inpatient forensic mental health hospital. Ethnographic fieldwork occurred over 300 hours-overtly participating in, exploring, and recording the daily life of the community. Five excerpts of ethnographic data are presented, which evidence the gendered ward environment and highlight a series of encounters pertaining to problematic social life, which are the upholding of heteronormative gender roles, hegemonic masculinity, and misogyny. These views are problematised within the sexual offending rehabilitative context by considering the clinical risk associated. Further, we argue that to only focus on the end of the continuum often viewed as most serious (e.g., rape) ignores a pervasive cultural landscape of the polis in wider community, beyond the institution, that facilitates the more commonly experienced end of the continuum related to misogynistic values, encounters, and talk. We evidence how social norms and habitualised gendered actions permeate the institution, which bring into question the rehabilitative efficacy of the hospital. This paper embraces a feminist lens to explore everyday social interactions and the embodied experience of the female ethnographer within a male-dominated forensic setting. We contribute to the literature by newly theorising the influences of hierarchical heterosexual gender roles, violent language in forensic settings, and misogynistic attitudes and practice, on the care for, and rehabilitation of, patients.

Inpatient Institutional Care: The Forced Social Environment

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.