Journal of Community & Applied Social Psychology

J. Community Appl. Soc. Psychol., 14: 29–30 (2004)

Commentary

Review of ‘A Safe Place? Service Users’Experiences of an Acute Mental Health Ward’by Daniel Wood and Nancy Pistrang

Mental health inpatient wards are often the places where people with a first experience of

psychosis finds themselves, alone and scared. Yet there is an absence of published research

on the patient’s experience of safety in these settings.

In at least one inner-London mental health facility, neither the staff nor patients enjoy

feelings of safety. Rather, the ward is a place where fear and violence rule a vulnerable

group of individuals, many of whom are held against their will, and who are supposedly in

a ‘place of safety’. Troublingly, this view was shared by staff: ‘Psychiatric wards are sup-

posed to be safe places . . .where you’re supposed to be able to get better . . . you’re not

supposed to be assaulted’ (Steve).

The article’s findings cause us to wonder how people ever get well when they are treated

in an atmosphere where their physical and emotional welfare may be subjected to worse

constraints than those from which they have come away. It is particularly disturbing that

the staff seem to share the view about the threats of the ward environment whilst doing

nothing to change them because they feel powerless too.

Happily the 28-bedded wards used by the participants in the study are rarer these days.

There has been a movement towards smaller units with an upper limit of 16 beds, and there

is an aspiration for single-room accommodation with women-only facilities, in keeping

with the various developments in UK Government policy. It is not yet clear whether lower

numbers and better ward design will improve the patient experience. The closure of the

old institutions too often lost the good with the bad, for instance the extensive grounds and

quiet surroundings of the old asylums was a feature which many patients valued highly.

One of the problems in inner-city wards is that there is nowhere to get away from people.

Antagonistically, the general reduction in bed numbers has tended to lead to the admis-

sion of those patients who are most seriously ill, and many of them under the provisions of

the Mental Health Act 1983. This may mean that these are smaller, very much more dis-

turbed settings where the behaviour elucidated in the article is more extreme and more fre-

quent. The level of control and medication (forced or otherwise) increases and this enhances

the atmosphere of fear and powerlessness and also instils a culture of treatment/control

which relies on yet heavier medication. This further enforces the ‘us and them’ divide of

patients and staff and would seem to be counter to a therapeutic relationship.

The research echoes the cries of service users over the years ‘nobody ever talks to me’

whilst tempering it with the views of some patients that they would neither want nor feel

able to indulge in therapeutic conversation with staff. The inevitable question is: ‘what are

Copyright # 2004 John Wiley & Sons, Ltd.

we doing for the patient’? Whilst the present study is not concerned with examining the

general benefits of inpatient treatment, some interesting inferences may be drawn.

There is some evidence that the views of the Ward Manager significantly influence the

culture of a ward, as do the staff numbers, and whether staff are permanent or temporary.

Additional information of this type may have helped to judge whether the responses in

these interviews were idiosyncratic or significant. Nonetheless, the bulk of the evidence

obtained bears out the experience of the wider group of service users who find themselves

inpatients. The experience of admission is a daunting one, being thrown into a milieu in

which there are a number of people whose very illnesses cause fear.

Women are often subjected to experiences which would certainly come into the realms

of the criminal law outside hospital, and the authorities, whilst sympathetic, seem unable

to provide the safety which is a right for female patients and staff. Whether this is more

appropriately done by having single-sexed wards is one of the current debates. However,

the pressure on beds these days militates against this option.

The authors’ views on seclusion are clear from the use of the expression ‘seclusion cell’.

This is not a term which would meet with NHS approval. Seclusion is not a form of treat-

ment nor does any serious person claim that it is. Recent case law may lead to it being used

much more rarely. Sadly, in a dangerous world with too few staff to manage units effec-

tively, it is sometimes the counsel of desperation. It may be that the frequency of the use of

seclusion is one measure of how therapeutic that environment is. Similar arguments apply

to control and restraint and forcible medication. It is unlikely that anyone so dealt with

would believe in the benevolence of the system which is treating them.

This article is an important narrative about the experiences of staff and patients and

leads to the conclusion that inpatient facilities do not provide the basic requirements of

safety and support which we should be affording to patients who have to be there. It is

clear too that the staff do not spend enough time considering and discussing what is going

on with the patients, and within their own staff groups. This is particularly surprising when

one of the most common comments is that ‘the staff are always in the office and spend

hours in handover’. Such systems are clearly failing to deliver a safe or positive experience

for patients or staff. There is room for more detailed work and this article provides an

interesting beginning.

SCOTT STEVENS

Camden Mental Health Consortium

Hampstead Town Hall

213 Haverstock Hill, London NW3 4QP, UK

Scott Stevens is Chair of the Camden Mental Health Consortium. This is a user-owned

mental health charity which is concerned to develop user perspectives in the development,

monitoring, evaluation and review of mental health services, and is dedicated to seeing

that service users have the maximum opportunity to fulfil their own lives. We are anti-

stigma and a lot of other things. The website has more details www.cmhc.org.uk

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/casp.759

30 S. Stevens

Copyright # 2004 John Wiley & Sons, Ltd. J. Community Appl. Soc. Psychol., 14: 29–30 (2004)