Risk and protection: the discourse of confinement in contemporary mental health policy

Architecture as change-agent? Looking for innovation in contemporary forensic psychiatric hospital design

History suggests that departures from accepted design practice can contribute to positive change in the delivery of mental healthcare, the daily experience of hospitalised patients and public perceptions of mental illness. Yet the question of how architecture can support the therapeutic journey of patients remains a critical one. The availability of evidence-based design literature to guide architects cannot keep pace with growing global demand for new forensic psychiatric hospital facilities. This article reports a global survey of current design practice to speculate on the potential of three new hospitals to positively improve patient experience. A desktop survey was conducted of 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. This was supplemented by advisory panel sessions with clinical/facilities staff, alongside architectural knowledge obtained through workshops with architects from the UK and the USA, and the inclusion of Australian architects on the research team. Data analysis draws on knowledge from architectural practice, architectural history and environmental psychology, arguing that there is a responsibility to integrate knowledge from across these disciplines in respect of such a pressing and important problem.

Policing mental illness: Police use of section 136 - Perspectives from police and mental-health nurses

Ideological shifts in mental health-care policy such as deinstitutionalisation have meant police have had to make decisions about the care of persons with a mental-health crisis. This study examines how police in five English counties respond to crisis calls when employing the powers afforded in section 136 of the Mental Health Act 1983, and the effectiveness of the national Street Triage pilot scheme. Qualitative interviews with 30 police officers and mental-health nurses were collected as data sources. The analysis shows that police have previously struggled with the significant number of crisis calls, whilst also finding mental-health services inadequately sourced, leading to some detentions in police cells as alternatives to health-based places of safety. However, the scheme has made positive changes in alleviating these issues when mental-health nurses are co-located with police, highlighting the need to strengthen their partnership by facilitating the sharing of information, responsibilities and decision making in order to ensure police cells continue to be avoided as alternative places of safety.

"The expert and the patient": a discourse analysis of the house of commons' debates regarding the 2007 Mental Health Act

BACKGROUND

The Mental Health Act 1983 was amended in 2007. This legislation appears to be predicated on the assumption that an entity of "mental disorder" exists and that people who are designated mentally disordered require medical treatment, administered by force if necessary.

AIMS

To explore the ways in which mental disorder is constructed and the possible practical effects of these constructions in the House of Commons' debates regarding the Mental Health Act 2007.

METHOD

Verbatim transcripts from the House of Commons debates on the Mental Health Act were studied through a discourse analysis.

RESULTS

Two primary discursive constructions were identified: "The Expert" and "The Patient."

CONCLUSION

Mental disorder and associated roles, such as "The Expert," were constructed through particular selective rhetoric, which taken together, made particular psychiatric practices and the need for legislation, such as compulsory detention, seem normal, and necessary.

Studies regarding supported housing and the built environment for people with mental health problems: A mixed-methods literature review

Places where people live are important for their personal and social lives. This is also the case for people with mental health problems living in supported housing. To summarise the existing knowledge, we conducted a systematic review of 13 studies with different methodologies regarding the built environment in supported housing and examined their findings in a thematic analysis. The built environment of supported housing involves three important and interrelated themes: well-being, social identity and privacy. If overregulated by professionals or located in problematic neighbourhoods or buildings, the settings could be an obstacle to recovery. If understood as meaningful places with scope for control by the tenants or with amenities nearby, the settings could aid recovery.

Forensic psychiatry and general psychiatry: re-examining the relationship

Something is going wrong with forensic psychiatry, as a concept and as a service. Beds in medium secure units are logjammed, and relations with general adult services increasingly fraught with disputes over resources and responsibilities. Despite a remarkable investment in buildings, and the 300% growth of the forensic specialty (Goldberg, 2006), offending behaviour by individuals with mental illness shows no sign of decline, either in terms of prison numbers (at record high levels in the UK) or the countless demands for risk assessment (Duggan, 1997; Moon, 2000).

Therapeutic Landscapes in Hospital Design: A Qualitative Assessment by Staff and Service Users of the Design of a New Mental Health Inpatient Unit

This pilot research project sought to provide a postoccupation assessment of a new mental health inpatient unit in East London, built under the Private Finance Initiative scheme. Qualitative discussion groups or unstructured interviews were used to explore the views of people who had been service users (but were currently well) and of nursing staff and consultants working in the new hospital. The participants gave their views on the aspects of the hospital which were beneficial or detrimental to well-being and the reasons for their views. Informants discussed hospital design in terms of: (1) respect and empowerment for people with mental illness; (2) security and surveillance versus freedom and openness; (3) territoriality, privacy, refuge, and social interactions; (4) homeliness and contact with nature; (5) places for expression and reaffirmation of identity, autonomy, and consumer choice; and (6) integration into sustainable communities. Themes emerging from this research were interpreted in light of ideas from geographical research on therapeutic landscapes constituted as physical, social, and symbolic spaces, as well as research from environmental psychology. The findings have practical implications for hospital design and underline the need to consider empowerment of patients in decisions over hospital design. We note the challenges involved in determining therapeutic hospital design given changing models of care in psychiatry, lack of consensus over models of care, and the varying and somewhat conflicting requirements these imply for the physical, social, and symbolic attributes of design of hospital spaces. We also note the implications of our findings for an interpretation of therapeutic landscapes as contested spaces.

Towards a General Explanation for the Survival of the Private Asylum

Taken together, the ascendancy of community care and the dominant role of the state as a funder of services have meant that private sector residential care for people with mental health problems is now a rarity in most countries. Yet private asylums have persisted in some places. The authors propose an analytical framework for understanding such ‘institutional survivals’. This framework problematises the public—private and community—asylum boundaries that have hitherto been taken for granted. The framework is applied to case studies in Canada and New Zealand. Survival of these institutions is found to be centrally associated with accommodations with legislative environments, proactive innovation, and the availability of markets.

Stressed spaces: mental health and architecture

OBJECTIVE

To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users.

BACKGROUND

Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design.

METHODS

Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identified and numerical data that emerged from quantitative studies was tabulated.

RESULTS

Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designing for the adolescent, forensic facilities, interior detail, patients' rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in design process. Of the 165 articles (including conference proceedings, books, and theses), 25 contained numerical data from empirical studies and 7 were review articles.

CONCLUSIONS

Based on the review results, especially the growing evidence of the benefits of therapeutic design on patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process.

KEYWORDS

Evidence-based design, hospital, interdisciplinary, literature review, post-occupancy.

The Israeli Medical Association's discourse on health inequity

The present paper analyses the emergence and characteristics of Israeli Medical Association (IMA) discourse on health inequality in Israel during the years 1977-2010. The IMA addressed the issue of health inequality at a relatively late stage in time (2000), as compared to other OECD countries such as the UK, and did so in a relatively limited way, focusing primarily on professional or economic interests. The dominant discourses on health inequalities within the IMA are biomedical and behavioral, characterized by a focus on medical and/or cultural and behavioral differences, the predominant use of medical terminology, and an individualistic rather than a structural conceptualization of the social characteristics of health differences. Additionally, IMA discourses emphasize certain aspects of health inequality such as the geographical and material inequities, and in doing so overlook the role played by class, nationality and the unequal structure of citizenship. Paradoxically, by disregarding the latter, the IMA's discourse on health inequality has the potential to reinforce the structural causes of these inequities. Our research is based on a textual critical discourse analysis (CDA) of hundreds of documents from the IMA's scientific medical journal, the IMA's members journal and public IMA documents such as press-releases, Knesset protocols, publications, and public surveys. By providing knowledge on the different ways in which the IMA, a key stakeholder in the health field, de-codifies, understands, explains, and attempts to deal with health inequality, the article illuminates possible implications on health policy and seeks to evaluate the direct interventions carried out by the IMA, or by other actors influenced by it, pertaining to health inequality.

Confinement and psychiatric care: a comparison between high-security units for prisoners and for difficult patients in France

This paper examines the uncertain meaning of confinement in psychiatric care practices. Investigating the recent expansion of high-security units in French public psychiatry, for patients with dangerous behavior (units for difficult patients) and for suffering prisoners (specially equipped hospital units), we aim to understand psychiatry's use of confinement as part of its evolving mandate over suffering individuals with violent behavior. Although historically the epicenter of secure psychiatric care for dangerous individuals shifted from the asylum to the prison, a review of public reports and psychiatric literature demonstrates that psychiatrists' attempt to reclaim confinement as part of therapeutic practice underpinned the recent development of new units. Institutional-level analysis emphasizes psychiatry's enduring concern to subordinate social defense motives to a therapeutic rationale. Analyzing local professionals' justifications for these units in two emblematic hospitals, the paradoxical effects of a security-driven policy arise: they allowed the units' existence, yet prevented psychiatrists from defending a genuine therapeutic justification for confinement. Instead, professionals differentiate each unit's respective mission, underlining the concern for access to care and human dignity or defending the need for protection and safety from potentially dangerous patients. This process reveals the difficulty of defining confinement practices as care when autonomy is a core social value.

Relocating from out-of-area treatments: service users' perspective

Asylum closures over recent decades resulted in mental health services being increasingly sited in the community. However, under provision of highly supported accommodation led to service users being placed away from their local area in 'out-of-area treatments' (OATs). OATs have raised major concerns in relation to enabling service users' recovery, owing to limitations in promoting autonomy, social dislocation and costs. In 2004, an OATs project was set up in a London Borough to address these concerns. In the first 4 years, the project succeeded in relocating 22 service users to less restrictive environments locally. This study aims to explore the outcome of relocation from service users' perspective. A qualitative methodology was utilized. Semi-structured interviews were carried out with seven service users who relocated. All seven service users shared a strong aspiration for independent living but there was associated loneliness. Five welcomed increased contact with family and friends, but lacked social confidence, inhibiting social inclusion. Service users with long-term and consistent care managers were more able to address fears. Five out of seven service users concluded that relocation increased their autonomy thus enhanced their quality of life.

Compassionate containment? Balancing technical safety and therapy in the design of psychiatric wards

This paper contributes to the international literature examining design of inpatient settings for mental health care. Theoretically, it elaborates the connections between conceptual frameworks from different strands of literature relating to therapeutic landscapes, social control and the social construction of risk. It does so through a discussion of the substantive example of research to evaluate the design of a purpose built inpatient psychiatric health care facility, opened in 2010 as part of the National Health Service (NHS) in England. Findings are reported from interviews or discussion groups with staff, patients and their family and friends. This paper demonstrates a strong, and often critical awareness among members of staff and other participants about how responsibilities for risk governance of 'persons' are exercised through 'technical safety' measures and the implications for therapeutic settings. Our participants often emphasised how responsibility for technical safety was being invested in the physical infrastructure of certain 'places' within the hospital where risks are seen to be 'located'. This illuminates how the spatial dimensions of social constructions of risk are incorporated into understandings about therapeutic landscapes. There were also more subtle implications, partly relating to 'Panopticist' theories about how the institution uses technical safety to supervise its own mechanisms, through the observation of staff behaviour as well as patients and visitors. Furthermore, staff seemed to feel that in relying on technical safety measures they were, to a degree, divesting themselves of human responsibility for risks they are required to manage. However, their critical assessment showed their concerns about how this might conflict with a more therapeutic approach and they contemplated ways that they might be able to engage more effectively with patients without the imposition of technical safety measures. These findings advance our thinking about the construction of therapeutic landscapes in theory and in practice.

Girly mags and girly jobs: pornography and gendered inequality in forensic practice

This article presents findings from a discourse analytic study into the constructive nature and textual variations of language in a high-security hospital. It explores how mental health nurses, and men convicted of sexual offences who also have a diagnosis of personality disorder, talked about pornography and sexual crime in the context of forensic provision. Access to sexually-explicit media, in relation to treatment environments for people convicted of sexual offences, has become a cause for professional and political concern in the UK. Data collection and analysis, undertaken concurrently, were informed by a discursive design. Semistructured interviews, as co-constructed accounts with nursing staff and detained patients, were audio-taped and transcribed. Data were coded to identify the discursive repertoires, or collective talk, of respondents. In contrast to empirical inquiry into pornography and sexual violence, methodology shifted attention from measurement to meaning, and situated research in a clinical domain. The findings focus on performative language use, where talk about pornography textured the treatment environment, contributed to an overtly masculine discourse, framed the ward as male space, and promoted gendered inequality. The discussion questions the legitimacy of the therapeutic enterprise.

Resistance and challenge: competing accounts in aftercare monitoring

This article explores a candidate example of competing accounts of aftercare under supervision of a discharged forensic patient and worker in one part of the UK. It is taken from a study involving 59 in-depth interviews with patients and their workers to investigate community return after detention in forensic psychiatric facilities. Fear of mental illness and associated dangerousness are embodied in discourses surrounding the forensic patient. In living with deviant labels and seeking to establish independence from the psychiatric system patients' talk demonstrates nascent identity work in an attempt to resist alternative dominant discourses. Workers however deploy occupational knowledge of risk and associated monitoring as the basis for claims of safe aftercare. Both patient and worker accounts are reflexively aware of competing versions and seek to portray the provision of aftercare monitoring in self-interested ways. Aftercare monitoring and supervision may ostensibly be about integration and rehabilitation but as this study shows risk is an ever-present concern forming an important backdrop to the attempts of patients to forge new identities and the normalising ideologies of those working with them.

"Screen and intervene": governing risky brains

This article argues that a new diagram is emerging in the criminal justice system as it encounters developments in the neurosciences. This does not take the form that concerns many "neuroethicists" -- it does not entail a challenge to doctrines of free will and the notion of the autonomous legal subject -- but is developing around the themes of susceptibility, risk, pre-emption and precaution. I term this diagram "screen and intervene" and in this article I attempt to trace out this new configuration and consider some of the consequences.

New spaces of inpatient care for people with mental illness: a complex 'rebirth' of the clinic?

This paper examines the implications for design of inpatient settings of community-based models of care and treatment of mental illness. The study draws on ideas from relational geographies and expands interpretations based on Foucault's writing. We analyse material from a case study which explored the views of patients, consultants, and other staff from a new Psychiatric Inpatient Unit in a deprived area of East London, UK. We discuss in particular: the tension between providing a caring and supportive institutional environment and ensuring that patients are returned to the community when they are ready; the links between an acute inpatient facility and its local community; the potential significance of the psychiatric hospital as a relatively stable feature in the otherwise insecure and unpredictable geographical experience of people with long-term mental illnesses. We discuss the relevance of these issues for design of new psychiatric inpatient facilities.

Dangerousness and mental health policy

Mental health policy development in the UK has become increasingly dominated by the assumed need to prevent violence and alleviate public concerns about the dangers of the mentally ill living in the community. Risk management has become the expected focus of contemporary mental health services, and responsibility has increasingly been devolved to individual service professionals when systems fail to prevent violence. This paper analyses the development of mental health legislation and its impact on services users and mental health professionals at the micro level of service delivery. Historical precedence, media influence and public opinion are explored, and the reification of risk is questioned in practical and ethical terms. The government's newest proposals for compulsory treatment in the community are discussed in terms of practical efficacy and therapeutic impact. Dangerousness is far from being an objectively observable phenomenon arising from clinical pathology, but is a formulation of what is partially knowable through social analysis and unknowable by virtue of its situation in individual psychic motivation. Risk assessment can therefore never be completely accurate, and the solution of a 'better safe than sorry' approach to mental health policy is ethically and pragmatically flawed.

The geography of mental health: an established field?

PURPOSE OF REVIEW

The purpose of this review is to offer an outline introduction to a field of inquiry known as the geography of mental health (or mental health geographies). Since this is the first time the field has been reviewed in this journal, attention will be paid to the history of the field, not just recent findings.

RECENT FINDINGS

Research has chiefly, but not exclusively, tackled (i) the spatial epidemiology of mental ill-health and (ii) the changing locational associations of mental health care.

SUMMARY

This review has concentrated chiefly on contributions to this field of inquiry made by researchers with a background in the academic discipline of geography. While there are 'geographical' contributions made by workers from other disciplinary backgrounds, there is arguably something distinctive, particularly in the most recent scholarship, arising from a theorized sensitivity to the entangled relations of mental health, society, space and environment.

Mental health nurses, promoters of inclusion or perpetuators of exclusion?

The literature identifies that mental health services and those individuals working within them have the potential to facilitate inclusion for their client group, because of their power to initiate potential inclusive opportunities. However, evidence suggests that service users themselves perceive many aspects of mental health services as contributing to the problem of exclusion. This has been attributed to an accumulation of messages, attitudes and disempowering practices that have emanated from mental health care providers over a long period. This study employs focus group methodology in a residential rehabilitation unit in an industrial city in the UK. Discussion of the findings highlight how, in spite of alleged inclusive practices, the attitudes held by members of the unit team could impede the clients' opportunities to become socially included, as a result of defensive practice, paternalistic attitudes, expectations of the local community upon the team and the stagnant views that are embedded in the culture of mental health services. While mental health nurses may see themselves as promoting inclusion, the reality may be quite different.

The development of psychiatric care after the mental health care reform in Sweden. A case register study

A process of deinstitutionalization and a series of mental health care reforms targeting severely mentally ill persons have taken place worldwide. The objective of this study was to follow-up the volume of psychiatric care after the 1995 Swedish reform and to study if the intended efforts of the reform were fulfilled. In a municipality, during the time-period 1994-2003, the development of number of days of inpatient care, inpatient care episodes, visits to outpatient facilities and the number of unique patients were studied using case registers. The number of persons staying in group homes and nursery homes was also studied. The number of days of inpatient care for persons given a diagnosis of schizophrenia was drastically reduced, but this reduction was quantitatively substituted by the persons staying in different kind of group homes. The implementation of new psychiatric field teams directed towards persons with psychosis and new social service field teams targeting this same group were reflected in the registers. Data supported that the intended efforts of the mental health care reform were in fact carried out, but the prioritizing of the target group of the reform may have influenced the care of persons with other kinds of psychiatric problems negatively.

From retreat to health centre: legislation, commercial opportunity and the repositioning of a Victorian private asylum

This paper examines the interplay of commercial imperatives and health care legislation in the survival of a privately owned psychiatric hospital in Guelph, Ontario, Canada. Using documentary and archival evidence, we show how the Homewood Retreat (later Sanitarium, and eventually Health Centre) was able to respond to and anticipate legislative developments through the agency of successive medical superintendents and the structural positioning of the institution as an inextricably integrated element in local and provincial mental health provision. Our case study is used to draw out wider lessons concerning agency, legislative context and treatment modality in the determination of organizational histories. We conclude by noting the important role of the private sector in ensuring the continued provision of an asylum form of mental health care.

The 'three waves' of research in mental health geography: a review and critical commentary

OBJECTIVE

To consider research conducted in the sub-field of mental health geography, concentrating on work published in English.

METHODS

The paper offers an comprehensive, in-depth and critical reading of the relevant literature on mental health geography since the inception of this subfield of inquiry in the early-1970s.

RESULTS

The paper identifies three 'waves' of research within work on mental health geography. It describes these 'waves' in detail, interprets certain strengths and weaknesses of the first two 'waves', which are well-established, and provides suggestions about important questions to be addressed in a future third 'wave'.

CONCLUSION

Much excellent research has so far been undertaken within mental health geography, but there is scope to increase the relevance of this research through widening the focus of research and by being prepared to connect research more directly to mental health policy and politics.

Making space for the 'intellectual' in geographies of disability

There is a growing body of work on geographies of deinstitutionalisation and its consequences, but the weight of this scholarship has focussed on people with mental health problems and physically disabled people. With only few exceptions, the 'post asylum geographies' of intellectually disabled people remain neglected by geographers. We advocate a redressing of this imbalance. First, we assess reasons for the relative absence of 'intellectual' considerations in geographies of disability. We then consider ways in which the full spectrum of those with mental differences might be included in geographical research. We conclude that Wolpert's call 25 years ago to 'open closed spaces' is just as applicable to our efforts to conceptually link health, place, and disability, as it is to the material welfare of vulnerable groups in society.