From Toxic Institutions to Therapeutic Environments: Residential Settings in Mental Health Services. Penelope Campling, Steffan Davies & Graeme Farquharson. (eds) London: Gaskell, 2004, £25.00 pb, 286 pp, ISBN: 1-904671-07-1

Based on the concern that the therapeutic community has been neglected as a modus operandi for residential mental health settings (whether high security hospitals, acute wards or longer stay rehabilitation), this edited collection of relatively brief chapters certainly has a worthy commitment. Because despite all the community initiatives and, more recently, the introduction of specialist teams such as assertive outreach, early intervention and crisis resolution, the heart of modern mental healthcare remains the in-patient unit. But the decline of that purpose-built therapeutic institution, the asylum (the historical context of which is nicely summarised in Kathleen Jones’ opening chapter), has left mental health provision under-resourced, in terms of coherence, space for illness, recognition and staffing resources. It is a touch odd to see Anthony Sheehan (architect of the poorly evidenced new ‘ teams’ currently depriving wards of staff) writing a foreword. It is also worrying to see few front-line authors, i.e. acute ward nurses or doctors, or even managers of homeless hostels or high dependency units in the community.

There are some useful chapters of course, for example ‘Delivering psychological therapies in acute inpatient settings’ by Peter Kinderman and ‘Measuring the therapeutic environment’ by Christine Timko and Rudolf Moos. The best and most practical is ‘A carer’s perceptions of the therapeutic value of inpatient settings’ by Peter Ruane, in that at least he mentions the process of ‘sectioning’, in contrast to the strange absence of any mention of the Mental Health Act 1983 throughout the rest of the book. All chapters also suffer from a limited research base, although there are some useful references, mainly to descriptive papers, the various well-known guidelines and to local audits. There is much mention of politically correct terms like ‘social inclusion’ and ‘ recovery’, and every chapter ends with a ‘ Conclusion’. However, many of these are rather bland and idealistic, for example that on ‘Rehabilitation and continuing care’. The final words of this chapter suggest that specialist rehabilitation units ‘used flexibly within a well-managed, integrated network of care… can act as a source of social support and psychological containment that helps to enable the start of the recovery journey’. This is irrefutable, but the heart of the problem, the lack of resources, is not addressed.

Whether or not one considers that the therapeutic community movement needs to be reinstituted - and the original Northfield experiments were not exactly high-class social research - there is sufficient detail in this collection to stimulate those organising and managing in-patient services. Psychiatric institutions are by definition paradoxical, in that they try to ‘ treat’ people who do not have a ‘mental illness’ (i.e. those with personality disorders) and they are also asked to treat people in hospital who do not want to be there, while constantly discharging those who would like to stay. They have always been criticised, historically and in modern times, because by definition they attract stigma within and outside psychiatric communities. How we make them better in the 21st century will need hard-nosed research as well as better-trained staff. This committed book only really tells half the story.