Table 1 shows the demographic and clinical characteristics of patient and staff participants.
Table 1 Demographic and clinical characteristics of participants
To help protect the confidentiality of more specialist staff, we have grouped them into support workers (healthcare assistants, activity workers, and students); nurses (staff nurses and charge nurses); and senior staff (managers, doctors, and psychological and occupational therapists). Table 2 shows pseudonyms with gender and ethnicity by patient/staff group.
Table 2 Participant pseudonyms with gender and ethnicity by group
Patients on Apollo Ward generally had a significant level of functional impairment. Due to negative symptoms, many would spend their days in passive activity such as sleeping or watching television if left to choose. Many struggled with self-care. There was a wide range of ability when it came to shopping, preparing food, and cooking, but functional abilities in these domains were generally low. Motivation for engagement in activity groups and structured community integration was often very limited.
The majority of patients were detained for involuntary treatment under Sect. 3 of the Mental Health Act, meaning that they either did not agree to their hospitalisation or they lacked capacity to consent to it. While they had not been detained in the first instance by clinicians working on Apollo Ward, most patients did not perceive this to be an important distinction, and they understood that the ward’s consultant psychiatrist was now ultimately in charge of their treatment and discharge plans. The two participants who were informal patients had previously been detained but had subsequently agreed to stay on a voluntary basis, allowing them greater freedom to come and go from the hospital during the day. However, their engagement with staff did not differ radically from the rest of the sample, and they still had to abide by the ward’s general rules such as restrictions on potentially risky possessions, alcohol use, smoking, curfews, etc. This meant that their daily experiences were not starkly different either.
In general, despite their histories with involuntary detention, the patients did not actively object to the more medicalised interventions. For example, most accepted medications willingly—although few managed their own medication regimens, which were mostly left to the nursing staff to administer. What some patients disputed more frequently were the ward’s restrictions on their everyday movements and habits, for example their leave, personal possessions, or food choices. Still, this was highly variable: for some patients with severe negative symptoms like Alison, Hamza, and Jim, treatment involved supporting them to leave the hospital more, or to exercise greater agency in their daily routines.
Given that the concept of recovery assumes a degree of active input from patients, as well as broad alignment of treatment goals, this mix of passivity, avolition, and disagreement about treatment created myriad tensions and contradictions that had to be navigated carefully on the ward. Staff needed to find a way of balancing assertiveness with collaboration, structure and consistency with flexible person-centredness, and friendly familiarity with boundaried professionalism. Where staff did this effectively, it was overwhelmingly due to the skill and expertise with which they built and maintained therapeutic relationships with patients—what we term ‘relational engagement.’ This is demonstrated in the following quote from patient Tristan, reflecting on his time on Apollo Ward after he was stepped down to a community rehabilitation unit towards the end of fieldwork:
“Some of [the staff members] were just really nice. They tried to make you feel at home. […] I guess they gave people respect, which was good. Yeah, just, like, trying to get you involved in activities and stuff, like arts and crafts, exercise groups [pause] trying to get you out into the community. […] Like sometimes I feel like [pause] getting you medication is the main part of their job. But I think [pause] you know, the good ones try and encourage you in other areas [pause] which is, yeah, I think it makes you feel more positive.”
The centrality of staff in this quote captures the relational nature of recovery work on the ward. This relational engagement also stands out because most of the patients on Apollo Ward had few other social relationships: they had small social networks, few friends, and little engagement with family. The reasons for this appeared to be multifactorial, involving negative symptoms, stigma, and gradual social withdrawal driven by repeated psychiatric admissions—as Tristan himself put it, “it’s difficult to know where you stand with people.” On Christmas Day, for example, most patients remained on the ward and did not see family, despite the ward staff’s encouragement, either because it felt too stressful or they had lost contact. This social isolation, which presented further barriers to recovery-orientated treatment and community integration, stood in contrast to the best examples of relational engagement with staff. Our analysis here therefore focuses on (1) unpacking this relational engagement between staff and patients and (2) the structural/institutional relegation and de-prioritisation of this relational engagement on the ward, which ultimately meant that it was neither as prominent nor as consistent as it could have been.
Relational engagement on Apollo Ward
There were three aspects of this relational engagement that stood out. The first aspect was a microscopic attention to detail that allowed treatment to be as flexible, accommodating, and individualised as possible. While this was modelled by care reviews in which the team paid close attention to every aspect of the patient’s care and treatment plan, it was most present in innumerable moments of fleeting patient-staff interactions on the ward, seemingly of little significance individually but which collectively scaffolded the personalisation essential to recovery-orientated treatment. Here is one example from HJW’s fieldnotes, involving a support worker, Mateo, and a patient, Shepherd, in a smoothie-making group:
Mateo gets Shepherd to cut some of the fresh fruit; he says they’ll do one each, Mateo a pear and Shepherd an orange. Shepherd struggles with this. I notice his hands are trembling (perhaps extrapyramidal side effects). He is trying to cut the peel off and Mateo tries to show him the best technique, but he can’t help but make a bit of a mess of it. Juice is flowing over the table and the cut isn’t smooth, the orange pulp looks like it’s been attacked. After a few minutes of struggle Mateo comes to his aid and takes the knife and orange off him, completing the task while carefully demonstrating how, like a parent might to a child. It’s a moment I don’t think much of, but one that Mateo returns to after Shepherd leaves the room.
“I made a mistake there,” says Mateo, “I gave him the hardest one. I should have given him the pear. Luckily he took it well. These are the details that nobody thinks of, that you have to think about. It’s like when someone loses to someone of low status, it can cause problems.”
I ask him to clarify that last point.
“It’s like Hamza [another patient],” he says. “Everyone thinks of him as low status. But when we play games, sometimes he’s good at them and he wins. And when someone who thinks they are higher status loses to him, it’s a problem.”
“Like it’s humiliating?” I ask.
“Exactly. If you know the FA Cup, it’s like what they call a ‘giant killing’.”
Although a small example, this extract underlines Mateo’s thoughtfulness about the implications of even the most mundane interactions for patients, as well as how everyday events unfolding on the ward might affect group dynamics, confidence, and future engagement with staff. It is only through such close attention to detail, facilitated through relationship-building, that recovery-orientated treatment could unfold.
This attention to detail could also only be facilitated by having consistent staff who were given the time and space to nurture these long-term relationships actively. Illustrating the consequences of not meeting these requirements is the following quote, where support worker India admonished temporary bank staff for misunderstanding the details of Janet’s chronic delusions regarding ‘Queen Victoria,’ a prominent persecutory figure in her psychotic experience who she perceived to be responsible for almost all the unpleasant things that had happened in her life:
“Sometimes you’ll have bank staff come up and be like, ‘How are you, Queen Victoria?’ And it’s like, do you not understand how much she hates her?! You can’t call her Queen Victoria!”
Ethnographically, this attention to detail was not only important for thinking through treatment plans but communicated a level of respect and curiosity upon which deeper relations could be built.
A second aspect of relational engagement was an appreciation of the slow, barely perceptible progress that characterises psychiatric rehabilitation, which needs adequate time to unfold. As one staff member put it, “you have to remember about mental illness, the steps are so small and gradual that sometimes you almost can’t see them.” To be consolidated and sustained, this progress had to be noticed and appreciated by staff, and it then had to be encouraged and reinforced. Even the primary researcher, with the time and space to observe closely, often found his conscious awareness of the patients’ recoveries diminished in the daily bustle of ward life. Many staff members, however, were adept at this.
For example, one patient, Alison, had not showered, changed her clothes, or spoken to anyone for many months prior to admission. When she took her first shower, several months after moving onto Apollo Ward, HJW wrote in his fieldnotes that the staff celebrated it “as if they’ve just won a competition.” In her interview, support worker Karolina reflected on Alison slowly becoming more involved in changing her bedding:
“Like, Alison, now she’s coming to me and helping me to do the bed. And before [trails off then laughs]. You know, it’s slowly, slowly, slowly. And you need to involve them to—‘Oh, come’—if she’s just doing the pillow case, I said ‘Oh well done, you do good!’ And, you know, she’s happy, she starts to be happy, because ‘Oh, I did this.’”
Similarly, Mateo’s appraisal is captured in the following fieldnote:
We head up to the park, where Alison sits in silence, expressionless, on the bench. At some point Mateo leans into me and comments to me how much of a shift it is that Alison is even out here. “At the start, she wouldn’t even talk to anyone. Now, she’s having showers, she’s here. Incredible.”
A senior staff member’s reaction to Alison’s first attendance at a care review in person, nearly six months into her admission, was similar. The following fieldnote captures an exchange about 30 s into the review:
“Why are you doing this?” Alison asks him. “You’re a student.”
“I’m the doctor,” Michael replies gently.
“No you’re not, you’re a student,” mutters Alison, and abruptly stands up and walks straight out the door again.
Everyone looks at Michael, who smiles and shrugs. He’s very happy with the progress—she came into the review, even if it was for about 30 s. Those are the small gains.
Finally, a key ingredient of good relational engagement was a notable degree of affective bonding and mutual acceptance with patients. Several patients described staff members as “friends,” perhaps the only friends some of them had, and certain staff were highly skilled at treading the line carefully between maintaining professional boundaries and providing an affective warmth, curiosity, and reciprocity akin to friendship or even familial relations. Again, small, fleeting moments from HJW’s fieldnotes bring these relations to life, as in the tender father-son-like relationship of Mateo and Hamza, a severely disabled patient with prominent negative symptoms and hebephrenic features:
I sit with Hamza a while as he eats his chicken and chips.
Mateo pops into the dining area: “Don’t tell him all your secrets, Hamza,” he jokes. “Keep some for yourself.” Mateo looks at me. “Did he tell you about his dancing? He must have danced for about 1 hour. You know the song ‘500 miles’? ‘And I would walk 500 more!’ [singing]. This was on.” He points at the takeaway. “He deserves it today.”
Mateo leaves the dining room. I look at Hamza and he looks back at me and grins. He starts laughing. I laugh back and start singing the song, and he raises his hands above his head while he sits, moving them in time with the music.
The sisterly camaraderie of support worker India with patients Fiona and Janet, who she took out to a café for Fiona’s birthday, is another example:
We see Fiona, Janet, India, and Fiona’s befriender on the way down to the caff for Fiona’s birthday.
“’Eyy, happy birthday!” we chorus.
“We’re having a girly trip,” says India, smiling. “Hey, Jan! Wait for us!” she calls after Janet, who is off down the hill.
The combination of these ingredients of attention to detail, appreciation for slow progress, and genuine human connection created an environment frequently described by patients as calmer, more friendly, more welcoming, and more homely than acute psychiatric wards—which one patient described as “dark, tense, hard.” Crucially, the quality of these relationships, built up over time, also allowed staff to push patients more assertively towards greater independence and community integration without unduly irritating, frustrating, or upsetting them. When we went bowling in the local community, for example, Hamza was reluctant to go, before ultimately enjoying and gaining much from the experience:
Hamza takes some persuading. Initially a yes, he changes his mind when it gets closer to the time. The staff members each try to re-convince him in turn; Angela tries; even Magda tries. But in the end it is Imelda who gets there, by telling him that he doesn’t actually have to bowl. He can just sit there if he wants. So he relents and nods to her increasingly more assertive questions about whether he’ll go.
Similarly, here is senior staff member Angela’s report on patient Jim, prior to a care review:
“I think he has made improvements since he’s been on the ward. He does respond well to structured activity, for example the walking group, getting out and about. Now we want to focus on discharge and community activities.” She explains how she tried to raise the possibility of him going to a MIND group but he really shut her down. “I left it with him that I wasn’t going to give up,” she says with a grin.
These examples, both of which ultimately supported community integration in line with recovery-orientated treatment, would have been impossible without Imelda or Angela’s established relations with these patients, and their intimate knowledge of what the patients’ barriers might be and how far they could push them towards activity and independence. Accordingly, this relational engagement directly facilitated the recovery orientation.
The relegation of relational engagement
Yet, many staff members, in their interviews, described how they were unable to embody this relational engagement nearly as much or as well as they would have liked. This raised the important question of why they could not. In our analysis, three mechanisms stood out.
First, the dominant structures and discourses governing the psychiatric hospital (and wider mental health services) seemed to clash with those underpinning this relational engagement (and psychiatric rehabilitation in general). These dominant discourses and structures, which set the services up to support high-throughput acute treatment, conveyed that economically, hospitalisation is expensive; culturally, lengthy inpatient treatment is anachronistic; and clinically, risk management is the priority. There were many ethnographic examples attesting to these priorities, which clashed with the slower, more flexible, person-centred requirements of rehabilitation:
Magda [senior staff member] says that when she first arrived on the ward [from working on an acute ward], all she could think of was the cost to the hospital—a hangover from the dominant framings animating the acute wards: “This person is costing X hundred pounds a night for the bed, why are we just keeping them here? How much of a waste is this!” She says she’s come around from that way of thinking now, and adopted more of a ‘rehab mentality’, but it’s taken some time.
Nurse Isaac captured the difference: “On the acute ward, [the patients] are being prevented to do some things. On a rehab ward, [they] are allowed.” Many staff members’ training, however, had inculcated more comfort with the ‘preventing’ than the ‘allowing’. Nurse Tim described how during his early days on Apollo Ward he had had to reconsider the dominant logics he had been socialised into:
“There was certain things that I kind of thought, ‘God, should that be allowed?!’ […] I mean it’s good that she’s able to do that [knitting], but at the same time I just thought, that’s a risk.”
This speaks to the ‘default’ clinical framings prioritised by the wider institution, also seemingly reflected in the trust’s investment:
Magda calls this “the forgotten ward.” She explains how when she first arrived, the ward didn’t—and still doesn’t—have any of the benefits of investment that was provided to the acute wards. She gives the examples of big interactive patient flow screens in the nursing offices and individual laptops for staff. These were things that were given out to the acute wards, but not here. This ward, by contrast, is using “old-fashioned” white boards and old, slow, desktop IT systems.
The clashes between these dominant structures/discourses and those of rehabilitation had two important effects. First, relational engagement was effectively relegated to a quasi-optional ‘extra’, to be done when the more ‘core’ tasks of inpatient mental healthcare—documentation, risk assessments, observations, medication rounds, responding to other wards, escorting on leave, safety huddles, etc.—had been completed. As nurse Tim put it:
“A lot of the time [is spent] doing your documentation, doing your notes, then updating your care plans and your risk assessments. […] Having a one-to-one [with a patient] sometimes seems to be a difficult time. Because if I take a patient and sit [with them] […] then someone will want to know where I am or what I’m doing. […] And I really want to sit here and have this conversation, but then you feel like you can’t because something else happens that maybe is more of a priority.”
The second effect is that having to navigate the tensions created by this clash inevitably led to inconsistencies between staff members—e.g. one staff member might turn a blind eye to a patient coming back late from leave in the community if they felt their experience had been beneficial for independence and community integration, whereas another staff member might enforce the boundary more firmly. This was often experienced as confusing for patients and staff alike and sowed discord, which was usually resolved by retreating to and re-emphasising the boundary (to the detriment of a more flexible, person-centred approach).
Another important mechanism undermining relational engagement was the prominence of ‘audit culture’ on the ward, where doing and showing tended to be held in higher regard than relating and reflecting. At morning meetings, for example, the primary researcher was often struck by the importance given to discreet tasks that needed completing that day—as senior staff member Sharon put it, “feeling like it has to be kind of task-orientated, so, you know, there are things that need to be done on the wards.” While this is perhaps unavoidable to a degree, there were prominent ethnographic examples of how the bureaucratisation and standardisation inherent to this approach undermined the relational aspects of rehabilitation. Senior staff member Angela, for example, lamented that when she had started working on Apollo, her manager had told her the most important tasks were the standardised assessments of functioning done at admission and discharge to evidence improvement, which should constitute the bulk of her work. When it came to engaging with patients between those assessments, however—that is, the therapeutic work that would actually lead to the improvement—she was instructed to delegate to someone more junior.
To illustrate the extent to which this standardisation can sap the genuine human curiosity from patient-staff interactions, consider the following fieldnote regarding the standardised form to establish the ‘patient view’ carried out before care reviews:
Imelda comes over and asks to go through the patient sheet with Andrew, ahead of his care review. Andrew barely engages. She persists, but he keeps losing attention, and it’s clearly a pretty meaningless exercise for him. In the end they arrive at the following:
How are you feeling?
“Like shit.”
How are you getting on with other people?
“Like a cunt.” (When prompted ‘with staff?’ specifically: ) “Acceptable. They raped me.”
Are your physical needs being met?
“Yeah alright.”
Are plans going ok for your social needs?
“Yeah alright.”
What about treatment?
“I just want to take it with me.”
Are there enough activities each day to make good use of time without overwhelming you?
“I don’t want to.”
What are your (the patient’s) own views and plans?
“I don’t have any, I’ll wait for them to sort it out for me.”
Has a carer’s assessment been offered or completed?
“Yeah.”
None of these answers provide much clinically useful information, nor do they authentically reflect who Andrew is or what his perspectives were at that time. Yet, if the emphasis had been on Imelda to find out this information more organically, she likely could have done so in a manner more empowering for Andrew.
Another notable example was the weekly community meeting, held ostensibly to ensure that patients had an opportunity to voice their opinions about life on the ward and contribute meaningfully to its programmes. The hospital hierarchy, who considered this important material for regulatory inspections, had mandated that it be done in a rigid format for audit purposes. Senior staff member Emma explained:
“We have to have community meetings every week, and they have to be minuted, and they have to be actioned, and when people don’t do that, it looks like we’re very uncaring, and we’ll get marked down for that, it looks like we’re not following what people want. […] So, when you try to say to staff, you know, ‘Can you do this because it does make an impact?’ I think, I understand, they think it looks very tick-boxy, you know?”
Meanwhile, this was nurse Imelda’s opinion on the community meeting:
“It’s one of the saddest things I’ve ever seen. […] It’s so tired. But like, if you’d hold a community meeting, I think, like [pause] what do they [the patients] want to talk about? Like most of it, really, the running theme for me, is it’s more of what we want to talk about, it’s more of what we want to do, it’s more of what we think is best for them. As opposed to what their concerns are, what they’re passionate about. […] They’re not interested! Because we don’t talk about things they’re interested in! So they don’t want to participate!”
A final mechanism undermining relational engagement, and perhaps the most prominent during fieldwork, was the demoralisation of ward staff. Much of this was shaped by the post-pandemic context of the wider NHS, with fieldnotes reflecting the ongoing “nursing strikes, paramedic strikes, and upcoming ballots for junior and senior doctors. The overall feeling is that people are fed up, short-staffed, and underappreciated.” However, more proximally, demoralisation arose due to feeling undervalued and having little opportunity to process or reflect on the challenges of working with complex psychosis. During fieldwork, HJW asked nurse Imelda whether the staff had any space to process their emotions:
“Absolutely zero,” she says.
I remark that this is maybe why I get the impression some people feel burnt out.
“Err, yep!” she says, laughing at how obvious that is.
Again, there were wellbeing checklists during ward meetings every morning, but their standardisation undermined any sense of genuine care for staff, as captured in HJW’s fieldnote:
At the end of the meeting, the staff go through their usual checklist. “Is everyone feeling safe?” “Yes,” they chant in unison. “Does everyone know where the ligature points are?” “Yes,” etc. It strikes me, in the light of all that’s happened recently, how meaningless these routines become if they’re repeated ad nauseum. Multiple staff have told me how they often haven’t felt safe—and yet every morning they’re asked if they feel safe, and I’ve never heard anyone say anything other than, “Yes.”
The most junior staff, who often did the most relational engagement, also faced all the challenges inherent to this work: the sustained effort it requires to support people with severe avolition to engage in activities, for example, or the emotional fallout of managing low-level irritability that erupts into violence from time to time. They felt poorly recognised and remunerated for the thought they put into their work and consequently relied on more intrinsic motivations to sustain relational engagement. A sense of demoralisation was often bubbling beneath the surface, however, as captured in this quote from Mateo in reference to the NHS trust hierarchy:
“They may think Band 3 is not intelligent, is not educated [pause] the way they email or order us or treat us. But we are able to see things. And we are able to judge. And we are able to see injustices.”
The experience of India, who at recruitment had spoken very fondly of her job, demonstrates the precariousness of this situation. The following fieldnote was taken around Christmas time:
India doesn’t seem herself. She seems dazed and frantic at the same time, like an image of helplessness—patients in the corridor keep shouting her name because they want things, and it’s like she has to be in several places at the same time. She doesn’t seem herself, like she’s on the edge of giving up altogether. […] Ten minutes later and she comes back in the room, looking like she’s been crying. […] “I’m burnt out. I’m so burnt out. I’m working so much. They ask for so much, all of them [patients and other staff]. And I’m just overworked. All these long days, and my coursework, and then I get home, and guess what? I’m a single mum [starts crying]. There’s no one to wash my fucking pants, do you know what I mean? I feel like I’m gonna quit. I can’t do it anymore.”
This demoralisation also intersected with wider structural inequalities, eroding motivation to engage even further for those affected. From time to time, the irritability and occasional violence on the ward was inflamed with discriminatory language or targeted towards staff members with particular protected characteristics. During the fieldwork, the most prominent examples in this regard involved anti-Black racism, and there were also several homophobic incidents. Sometimes these aggressions were primarily driven by psychosis and sometimes they were not, but they were always inevitably complicated by the patients’ own feelings of powerlessness around admission and restriction. This complexity is captured in the following quote, which one of the patients said to HJW:
“The staff here never listen to you, the Black nurses. They’re horrible people, the Africans—do nothing but hold you down and inject you. It takes two days training to be a support worker, it’s a joke.”
Without much reflective space to process them, these incidents stoked tensions on the ward, contributed to divisions between groups of staff members (some of whom felt unsupported by others), and undermined people’s motivation in their work. For some Black staff, this was further aggravated by the moral injury of having to restrain what they perceived to be a disproportionate number of Black patients in the wider hospital when on duty. Nurse Ana described the consequences for relational engagement:
“I’ve seen it loads, discrimination against staff and patients, it’s the same. And it causes harm. Like for me, there’s the physical harm, but also I believe it causes real psychological harm. Like, if you’re not gonna look after my mental health, then that’s why some people are just gonna come to work, do their job, go. They’re not gonna talk to the patients.”
Sharon, one of the senior staff members, described how she thought this erosion of relational engagement ended up playing out on the ward in psychological terms:
“Once you’re in threat mode, you know, it’s hard to be broadly thoughtful about people, because once that system’s going, the whole of your attentional focus is very narrow. And it’s all that, you know, ‘better safe than sorry,’ quick decisions, you know, make your mind up very quickly. So I think it gets a bit circular really, because I think sometimes that can lead to [staff] responses that put or keep the people [patients] who are on the ward in that mode as well, and that can lead to all sorts of interactions that might be less helpful.”
Collectively, then, swimming against more dominant structures and discourses in the hospital, audit culture, and staff demoralisation seemed to undermine the relational engagement so thoughtfully curated at other times. This was not lost on the patients. Fiona remarked to HJW mid-conversation one day, “see, you stop me and talk to me. If you can do it, I don’t know why none of the other staff can?” Similarly, Janet remarked, after seeing a particular staff member:
“She’s too professional, too emotionally detached. She doesn’t give anything to her patients! Lots of them are in this place. There has to be some basic human contact! They’re too professional and too frigid.”
And clinically, when these therapeutic relations were significantly undermined, recovery-orientated treatment on Apollo Ward proved difficult. “I feel like I do these assessments and find out exactly what [the patients’] interests are and what activities they need,” senior staff member Angela told HJW, “and then [shrugs] nothing happens.”