An ethnographic study of an inpatient rehabilitation ward for complex psychosis in London

Inpatient psychiatric rehabilitation services support people with complex psychosis to begin their recoveries towards community living. While a recovery-based approach in these services is associated with better outcomes, we have little in-depth understanding of what this looks like on the ground: what is important to patients and staff, and what are the barriers and facilitators? To investigate these questions, I conducted six months of ethnographic research on a psychiatric rehabilitation ward in London, using participant observation and semi-structured interviews with patients and staff. Data were analysed through situational analysis, a recent elaboration on grounded theory. My analysis elucidates the careful relational engagement of frontline ward staff with patients, which laid the foundations for a person-centred approach on the ward. This comprised several key features, including: extremely close attention to detail regarding what encourages or discourages individual recoveries; active appreciation of the slow day-to-day progress that characterises psychiatric rehabilitation; and engaging with patients with a striking degree of curiosity, acceptance, and respect. However, on the other hand, this careful relational engagement was often deprioritised on the ward, relegated to an afterthought or quasi-optional extra by the structural and discursive arrangements dominating the wider psychiatric institution. For example, the institutional structures of the hospital and clinical orientations of staff naturally elevated risk management and discharge planning over face-to-face time with patients; quantifiable tasks and standardised assessments were prioritised ahead of more natural human interactions; and the underappreciation of junior staff members' relational expertise and a lack of reflective space for staff to process their countertransference contributed to staff demoralisation. The resulting relegation of relational engagement was experienced negatively by staff and patients alike. The findings reinforce recent calls to emphasise the relational practice at the heart of psychiatry in general and psychiatric rehabilitation in particular.