ORIGINAL ARTICLE
Ivana Furimsky,1 Michelle Chen,2 Fiona Wilson,1 Gary Chaimowtiz1,3
1 Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada; 2 Faculty of Health Sciences, McMaster University, Hamilton, Canada; 3 Forensic Psychiatry Program, St. Joseph’s Healthcare Hamilton, Hamilton, Canada
Cite: Furimsky, I., Chen, M., Wilson, F., & Chaimowtiz, G. (2022). Patients’ and family members’ experiences of recovery in a forensic psychiatry program. International Journal of Risk and Recovery, 5(2), 3-13. https://www.forensicpsychiatryinstitute.com/patients-and-family-members-experiences-of-recovery-in-a-forensic-psychiatry-program/
The introduction of a recovery approach to forensic psychiatry services has been embraced in recent years. The recovery approach moves patient care beyond the domains of symptom reduction and aggression management. It places the importance on the patient’s personal experiences and values, and instills hope for a future with meaningful activities and supportive social relationships. As an initial step to integrating a recovery approach, we sought to better understand patients’ and family members’ perspectives and experiences of recovery in a forensic psychiatry program (FPP). This project involved one family member and two patient focus groups. All groups were asked what recovery meant to them and what we could do to support their recovery in the FPP. The focus groups were audio recorded and transcribed. A thematic analysis approach identified themes from the transcripts. Family themes included the patient returning to their original identity, opportunities to address the past, developing positive connections with others, balancing rehabilitation in the forensic environment, and maintaining communication with staff. Patient themes included developing positive connections, developing better communication about the forensic system, balancing rehabilitation in the forensic environment, and progressing with their lives. Patients and family members described their experiences of recovery in our FPP. Some areas for improvements were identified, which can form the groundwork for future improvement initiatives in our FPP.
Key words: recovery, forensic psychiatry, forensic patient, forensic family, focus groups
The introduction of a recovery approach to forensic psychiatry services has been embraced in recent years. The recovery approach works to enhance practices and move patient care beyond the domains of symptom reduction and identification of risk factors for violence. A recovery approach places importance on the patient’s personal experiences, values, and instills hope for a future with meaningful activities and supportive social relationships (Davidson et al., 2005). The goal is on individual development by the patients and a quality of life that works with the illness rather than focusing on being symptom-free (Morgan & Rees, 2018; Shepherd et al., 2016).
While conventional mental health practices and research have focused on clinician perspectives, recent trends have highlighted the importance of the patients’ perspectives regarding care (Livingston et al., 2012; Marklund et al., 2020). Crucial to recovery is a relationship between patients and staff that recognizes and incorporates the perspectives of patients as they begin the process of accepting and overcoming their individual challenges. Similarly, patient perspectives may pinpoint effective interventions that clinicians may not identify (Tapp et al., 2013).
Recovery-oriented guidelines have been developed to help mental health services implement a recovery approach (Mental Health Commission of Canada, 2015). A core idea of recovery is that patients are active participants, rather than passive recipients of care. Trends in health services recognize patient contributions and perspectives as key pieces to maximize the therapeutic value of care (DeBronkart, 2015). Best practices from general mental health services have been used to inform forensic mental health practice and the development of interventions for forensic patients (Simpson & Penney, 2011). However, some of the challenges patients and families experience in the forensic system remain unique compared with other mental health services (Davidson et al., 2006; Mann et al., 2014; Tomlin et al., 2020).
Forensic mental health services differ from general mental health services in a few ways. Forensic services are for patients with mental illnesses who have been found not criminally responsible or unfit to stand trial and touch both legal and health-care systems. Forensic psychiatric facilities have high levels of environmental and procedural security, where visits are regulated and restrictive orders may not allow patients to leave the hospital. Access to personal belongings may be restricted, as is intimacy and contact with the outside world. These restrictions can last many years and can have an effect on social, occupational, and vocational domains, as well as decrease motivation and hope because patients often lack an understanding of their lengthy course in the forensic system (Ghaemi & Pope, 1994; Tomlin et al., 2020).
Creating a supportive and rehabilitative environment for forensic patients can be a challenge. Forensic patients are unwillingly detained in hospital, and this would impose threats to autonomy and choice, especially where feelings of oppression are often unavoidable (Livingston et al., 2012; Mann et al., 2014). Also, the risk for violence in forensic psychiatric services poses another barrier to a recovery approach, where the focus on safety may confine the limits of a patient-centred approach (Hörberg & Dahlberg, 2015; Morrissey et al., 2018). This type of milieu can also lead to authoritarian and restrictive attitudes by staff (Askola et al., 2020).
In the past decade, there has been an increase in literature looking at understanding patients’ experiences with recovery in forensic psychiatric services. More specifically, qualitative research looking at patients’ perspectives of recovery are beginning to yield some common themes. Systematic reviews of the recovery approach have identified concepts such as connections, hope, identity, meaningful life, and empowerment (Clarke et al. 2016; Leamy et al., 2011). Although the literature suggests that forensic patients endorse the importance of these mainstream concepts of recovery, forensic patients also have unique needs compared with other mental health populations that must be recognized (Aga et al., 2017; Mann et al., 2014; Mezey et al., 2010; Shepherd et al., 2016; Turton et al., 2011).
In recent years, qualitative studies involving forensic patients have identified important themes for recovery in forensic settings. However, some of the themes emerging from qualitative studies may be affected by contextual factors, such as policies, local practices, relationships with staff, and availability of services. As an initial step to integrating a recovery approach into our forensic psychiatry program, we sought to obtain the perspectives of patients and their family members. Our paper describes a qualitative study we conducted to gain a better understanding of patients’ and family members’ perspectives and experiences of recovery in a forensic psychiatry program (FPP).
Methods
Design
We used focus groups with an evaluative, descriptive focus to gain participants’ perspectives about their recovery in an FPP. To promote more open and honest responses from participants, the facilitator was a staff member from outside the FPP. The facilitator was skilled in conducting focus groups and creating an environment where participants were encouraged to share their perspectives of recovery.
Each focus group followed a general interview guide with the following open-ended questions:
- What does recovery mean to you?
- What could we do to support your recovery in the FPP?
Each of the three focus groups were audiotaped. Transcription of the audiotapes was done by a transcriptionist outside the FPP.
Participants and Recruitment
Patients were recruited through community meetings on the forensic in-patient units. As well, outpatients responded to a flyer that was posted in the forensic outpatient waiting room. Patients had to speak English and be willing to talk about their experience of recovery in the FPP to be eligible to participate. Patients contacted the project lead if they were interested in participating in the project.
Family members or a person the patient considered a significant other were invited to participate in this project. Case managers and social workers typically had more established relationships with family members and contacted them by email or phone to provide an explanation of the project. Interested individuals were contacted by the project lead to provide more information about the study.
All participants signed a consent form to participate and be audiotaped. Upon completion of the focus group, each participant was given an honorarium for participating in the focus group.
Ethics
This project was recognized as a quality improvement initiative by the research ethics board. All participants in the focus groups provided written informed consent to participate in the project.
Analysis
A thematic analysis approach was taken following the framework described by Rabiee (2004) in analyzing the focus group transcripts. The framework provides steps to sift through a substantial amount of data while maintaining the integrity of social interaction and addressing lived experiences.
In this study, analysis began with two of the authors (I.F. and M.C.) familiarizing themselves with the focus group audiotapes and transcripts. Memos and notes were taken with the transcripts to help code the data and link different segments in the data. The coded data were then categorized to generate concepts and subthemes. At times, the two authors may have placed quotations from the transcripts under different themes. When a discrepancy was identified, both authors re-read the transcripts to obtain a better understanding of the context of where the quotation originated. Once a context was identified, the authors identified the theme under which the quotation best fit. Each quotation in the manuscript has a coinciding number [in square brackets], which represents the line number in the transcript where the quotation is found.
The themes arising from the focus group transcripts were linked to the purpose of the project, which was to gain a better understanding of patients’ and family members’ perspectives and experiences of recovery within our FPP. Quotations representative of emergent themes were identified. The themes were compared between the patient and family focus groups for similarities and differences.
The results of the thematic analysis along with supporting quotations were presented to a recovery group in the program. The recovery group included both front-line staff and patients from the program. The results were presented to the recovery group to raise awareness of our patients’ current experiences with recovery in the FPP. Many front-line staff confirmed an awareness of these themes from discussions with patients. Patients in the group confirmed the accuracy of the themes either through their own experiences or from speaking with other patients. The results were also presented to the recovery project team and compared with the peer reviewed literature to identify similarities and differences.
Results
Twelve patients, including 11 males, participated in the focus groups. Patient participants’ length of stay ranged from three to 52 months. Two patients were outpatients at the time.
Five family members of patients in the FPP also participated in the focus groups. At the time of the project, they had been connected with the FPP for 14 to 52 months. Participants were three mothers and two fathers of three patients.
Family Focus Group
The family focus group identified five themes and related subthemes as important to recovery (Table 1). Direct quotations from the family focus group transcripts are used to support each main theme.
Table 1
Family focus group themes and subthemes
Family Theme 1: Returning Patients to Their Original Identity
Family members noted that patients became increasingly productive and independent during their time in the hospital. In particular, this change in attitude shifted away from the characteristics that emerged with the onset of mental illness and was viewed as a return to the patient’s regular way of being. Some family members also acknowledged that it took time for the patient to start returning to how they used to be, while other family members were still waiting.
We’re so fortunate to come in here because now he’s changed back to like he was … He went back to like he was … I really think he didn’t know what he was doing, and now it’s amazing how we’ve got our son back. [23–24], [27], [28–29]
Yeah, I have seen a lot of improvement in him, and I’m waiting until he is just actually normal. I wouldn’t say he’s perfect right now, and he’s working on his dressing. [101–103].
Family Theme 2: Addressing the Past
Family members took the opportunity to talk about the experience of having the patient enter the forensic psychiatric system. Although this wasn’t the focus of the group, the supportive environment of having others in similar circumstances encouraged a supportive discussion. These shared experiences decreased feelings of social isolation and anxieties about present circumstances.
The blame was always put on me because I was the one always calling the police. [366]
Family members said they felt that patients acknowledging their past actions promoted self- awareness, responsibility, and remorse. Family members gave examples of conversations where patients showed remorse. Verbalizing remorse helped decrease family members’ feelings of blame and guilt.
He never referred to us as mom and dad. It was [Name-X] and [Name-Y], and now, it’s hard for him to come to terms with the way that he was because I know we mean a lot to him, and he tells us that often. [197–199]
A family member provided another example of a patient acknowledging their past actions and the resulting consequences. The family member described a conversation they overheard between the patient and another family member:
They’re about the same age and he’s telling him all kinds of things that he went through. He even told him about being put in the jail, and he hopes in his life he never sees the inside of that place again. [256–257]
Family Theme 3: Developing Positive Connections
Family members said they found that positive connections with staff fostered feelings of confidence in care. Staff support outside the hospital strengthened independence, encouraging positive feelings about discharge, and hope for the future.
I know that we can still phone, and I can get help. I have a whole list of numbers. They left us very well-equipped that we can get help. [My child] comes and sees case workers. [1304–1305]
Family experiences in the forensic system presented unique circumstances. It was important for family to feel supported, especially when preparing for discharge from the hospital. Family members felt that having positive peer relationships on the unit would decrease loneliness and stigma for the patient.
This may be with the patients and maybe with psychiatrists just to kind of referee the whole thing because everybody thinks when you’re sick, they’re just a little island, but if they see other people with maybe not the same illness but similar, they don’t feel so alone. [789–792]
There is a stigma. Yeah, and I think a lot of people that haven’t actually personally dealt with it like we have, they don’t understand it. [219–220]
Family Theme 4: Balancing Rehabilitation in the Forensic Psychiatric Environment
Family members said they felt that being on a forensic in-patient unit was very different than living in the community. However, they said they felt that the forensic psychiatry system was necessary to limit risks and contributed to a greater understanding of patients’ circumstances. Some family members said they felt the patients were bored and didn’t have many responsibilities on the unit. They suggested that asking patients what they wanted to do and finding activities to keep patients occupied and happy would help with their recovery.
Something he did say is that they should be doing more physical things and jobs. That’s something he wanted to do when he first got in here. He said oh, if I even at least could just even sweep the floor or work in the kitchen doing the dishes. [823–825]
Yeah, I think we should see if it’s their interest. It should be about their interest because, if you offer things that they’re not exactly into, they might not join the group, so we have to find out what their interests are first. But just find things to keep them occupied and happy, and even if they’re happy, they will recover even faster. They can develop those skills at the same time that would enable them to get back into society, find a job, and just go to find a purpose. [495–500]
Family Theme 5: Maintaining Good Communication with Staff
Good communication with the hospital staff increased confidence in care and feelings that the patient was safe. Availability of staff was essential to make the family feel cared for, easing tensions, and increasing feelings of respect and trust toward staff. The staff provided information about available resources that could help with the patient’s recovery. Staff were also instrumental in facilitating visits with patients and provided support during interactions with the patient.
I think that you do a great job in supporting the family, and I always knew when our [child] was in the hospital. We came often, three times a week, to see [them], and we got to know who [they were] seeing, a lot of people, and I found that [staff] were always available if we needed help. If we had a question that we didn’t know the answer to, we would get an answer. [1295–1299]
Patient Focus Groups
The patient focus groups identified four main themes and related subthemes that were important to their recovery (Table 2). Direct quotations from the patient focus group transcripts are used to support each main theme.
Table 2
Patient focus group themes and subthemes
Patient Theme 1: Developing Positive Connections
Patients talked about developing and maintaining positive connections with patient peers, family, and staff. Existing interactions with staff highlighted issues with unequal power distribution on the unit. Patients indicated a power imbalance and the lack of a relationship between staff and patients created a disengaging environment.
An activity that I always enjoy doing is going for a walk with staff around the hospital on (inaudible). I would get to know the staff a lot better, get to know what they do and stuff like that, what they like doing. It’s just an experience which boosts recovery, because when you get to know the staff, the staff like you a lot better. When staff have a general outlook on your behaviour and they can benchmark it and create windows so that they will know that no matter what, that you’re not going to mess up. [441–446]
Patients valued maintaining connections with their family while they were on the unit even through virtual connections.
I’d say having more access to our family on the unit. A big thing for me is me and my family text, and we Facebook a lot … I just don’t have access to my family when I think it would beneficial over time. [358–359, 360–361]
Patients also identified that some of the policies and rules prevent patients from showing compassion and interacting in meaningful ways.
Right now, the hospital trains us not to help anyone, because we can get in trouble for it, when that’s not [being] a human being …. We’re all in the same boat, and sometimes it’s sinking, and we’ve got to bail it out. We can’t because we’re not allowed to hand things or donate things [to each other]. [566–567, 569-570]
Patient Theme 2: Developing Better Communication About the Forensic System
Lack of information about the patient’s course of treatment in the hospital served as a barrier to motivation and hope. As a result, frustration increased about wasting time in the system and not knowing what to do to progress through the system.
They have the team meeting about you behind closed doors, and you’re not there to hear what the nurse, or the psychiatrist, or anyone has to say about you. So, you’re in the dark, and they don’t tell you how you can improve. They simply give you a green sheet eventually, and you wait for it, and say, this is what your privileges are. They don’t say how you can improve and what they’ve noticed from you being in the in-patient unit. [399–404]
At times, the difference in opinion between the staff and patients of where the patients were in their recovery created a reluctance to engage with the system.
And my disposition has been direct community. And I would like to go to school, to [college], in September. But I’m not going to be at that stage of my choice with my privileges. But I feel like I’m ready. So, I don’t have the choice to go to [college] yet. I have to wait until another full year is wasted, so I can go to [college]. So, I don’t have the choice to go myself. I have to wait until the doctors and the nurses say that I’m ready and I’m a low risk and stuff like that. [655–660]
Psychoeducation allowed patients to understand their illnesses, creating a sense of acceptance and responsibility. This promoted self-management and increased feelings of independence.
I think what would help me recover was a psychoeducation. Psychoeducation based on what would help me homogenate and control my symptoms, what I’m experiencing, right, so that I can tackle day-to-day living. When you can tackle day-to-day living, that’s the first step towards recovery. [346–349]
Patient Theme 3: Balancing Rehabilitation in the Forensic Environment
The restrictions placed on a forensic in-patient unit made for an inflexible structure, which resulted in the temporary suspension of responsibilities, risk management priorities, and lack of personal autonomy. Patients recognized that increased security and rules were necessary for some patients, however, at the same time, limited choices and activities for others. As patients progressed closer to moving into the community, they said they found the unit did not simulate living in the community.
If it’s worth doing well, it’s worth focusing [on] all things together. So, trust me when I say, I need this, or I don’t need that. Because when I say, I don’t need this, or I don’t need that, that’s my honest [opinion]. And if you’re going to say you have no choice, you have to do it, well then you’re making me do something that I think is pointless, and you’re wasting my energy. [593–597]
Well, that’s a pretty strict rule that we don’t follow in general society. If I can’t share, what can we do? I’m supposed to be selfish or do it underhanded behind your back? [730–732]
Conversely, security and risk assessment were regarded as necessary, suggesting the importance of balancing structure and autonomy.
Maybe not so much open the doors, because there are some patients, and we are criminals. Let’s get down to the facts. There are some patients that would escape and probably would do something terrible. So, we can’t just leave the doors open, I mean. But we can get certain passes for the security, and they could open them for us. [337–340]
The emphasis on security impeded on autonomy, which resulted in limited choices for activities. Rather than wasting time, participation in therapeutic activities was preferred to build self-confidence and acquire new skills for re-integration into the community.
I’d say more hobbies. People want to get good at something that builds their confidence up. So, if I could learn guitar or to play it better, maybe professionals come in and help guide us or teach us more often. We do rec therapy, which is once a day, an hour, we get volleyball every Wednesday or something, but that’s not enough. You start feeling good about yourself and get better at something. Once you get better at something, that builds the self-confidence. [542–547]
Patient Theme 4: Moving Ahead with Their Lives
Patients said that refocusing and goal setting were important to build self-confidence. Patients recognized their circumstances and their past actions, but they said they did not want their past circumstances to define who they are. Regaining motivation allowed patients to move forward with their lives, make changes, and want to help others. Regaining motivation and building self-confidence were seen as significant aspects of rehabilitation.
being healthy, going back to my old life without the old routines, without the drugs, without the drinking, without the smoking, without all of the stuff, the bad friends that I used to hang out with, you know. A new life, a second chance. [714–717]
We might be criminals or done something stupid because we were sick, but it doesn’t make us bad people. Like, we want to help each other. [567–568]
Patients indicated that there is encouragement from staff to participate in treatment, education, and skill building offered by the program. However, the programs offered may not necessarily have been in areas in which the patient had an interest or felt would help create hope and recovery. The patients said they knew what would create hope and help them recover, hence their time could be better spent on personal goals they valued and enjoyed.
I think it should be individual goal setting. I mean, there’s not a lot of that. As much as the system will say, well, what do you want to do, what do you want to do, it doesn’t really say goals. The first goal is [to] get out of here, etcetera, but I mean more profound goals. [144–147]
So, that’s something for me was don’t doubt or limit my self-confidence because I do that enough. And that would give me hope in myself. You don’t have to supply hope for me. I’d like to supply my own hope. [589–592]
Discussion
This project attempted to gain an understanding of the perspectives and experiences of recovery from patients and family members receiving services in an FPP. It sought to understand what recovery meant to patients and family, as well as how an FPP could support their recovery.
Recovery is not done alone, and most patients will be discharged into the community and continue their recovery there. Both family and patients identified the importance of having positive relationships with others throughout their recovery. The importance of connecting with others who can provide support and encouragement, and be positive role models were identified in the literature (Davidson et al., 2006; Leamy et al., 2011; Marshall et al., 2018; Tomlin et al., 2020). Fundamentally, the recovery process focuses on the individual through the support of the family and staff (Topor et al., 2018).
Developing Positive Connections
Developing positive relationships among patients was identified in helping with recovery. This theme emerged in both patient and family focus groups. Family members indicated that relationships with other patients on the unit was important in preventing social isolation and idleness. Patients viewed other patients as potential support systems on the unit who provided avenues to share experiences, practice compassion, help each other, and develop meaningful relationships. However, patients indicated that peer relationships were difficult to develop on the unit because some of the policies precluded patients from developing meaningful relationships with others. The theme that policies in the forensic mental health system precluded the development of meaningful relationships was also reported in other studies (Aga et al., 201; Livingston et al., 2013; Marklund et al., 2020; Tomlin et al., 2020).
Developing positive relationships with staff was also identified as helping with recovery. Family members indicated that having a positive relationship and good communication with staff increased confidence, encouraged independence, and decreased anxiety as patients approached discharge. The literature indicates that a trusting relationship with staff considerably influences recovery, and family members may feel overwhelmed and not equipped to support the patient without this support (Gómez-de-Regil et al., 2014; Priebe et al., 2018).
Patients also indicated that positive relationships with staff was important to their recovery. However, patients in this study reported there was a lack of collaboration and communication between the staff and patients. This led to a lack of understanding of processes and protocols in the forensic system, which increased feelings of uncertainty and feeling like they were wasting their time. Patients identified procedural aspects that precluded them from participating in meetings where decisions were being made about their trajectory in the forensic system. The literature suggests that good care involves positive staff interactions that allow patient perspectives to be understood, and patients are invited and heard rather than act solely as recipients of information (Askola et al., 2018, Hörberg et al., 2012; Livingston et al., 2013; Olsson et al., 2015; Selvin et al., 2016).
Providing Family Support
The dynamics of the family focus group highlighted the idea that family members require support and education throughout the patient’s stay in the forensic system. At times, the discussion kept circling back to what the family had to do to get the patient help. Frequently, family members asked questions about how others handled particular situations. Family members of forensic psychiatric patients hold a crucial role in rehabilitation and are an essential resource, yet they are often under considerable stress themselves (Absalom-Hornby et al., 2011; Laithwaite & Gumley, 2007).
Initial feelings of disbelief, devastation, anger, fear, and guilt over time may establish heavy emotional burdening if left unaddressed (MacInnes & Watson, 2002). Having a forum to share experiences can be used to form social alliances, which can alleviate feelings of social isolation and stigma that are frequently reported in psychiatric patients’ family members (Absalom-Hornby et al., 2011; Chang & Horrocks, 2006; Tsang et al., 2002).
Where possible, patient experiences are fundamentally intertwined with family involvement. Family perspectives and experiences are critical when assessing repeated crime because family members usually hold knowledge of occurrences outside of the hospital (Askola et al., 2017).
Family members play an important role in the recovery of forensic patients. Patients described wanting to maintain contact with family, and family members described needing information and access to resources on how to help the patient and themselves. Forensic programs need to focus on developing services aimed at keeping families engaged in the recovery of forensic patients, while providing families with the necessary support.
Facing Stigma
Patients and family members in the forensic psychiatry system face stigma. Triple stigma has been identified when patients have a mental illness, addiction, and offending history (Livingston et al., 2011). Family members recognized the impact of stigma toward themselves and the patient, which can lead to being ostracized by the community and causing social isolation.
Interestingly, stigma was not a concern raised in the patient focus groups. It is not clear whether patients were unwilling to discuss it because it was a sensitive issue or if forensic patients, who have been in hospital for long periods and not engaged in the community, have yet to experience the full impact of stigma. However, qualitative studies have indicated that stigma is experienced by forensic patients and can hold back recovery (Aga et al., 2019; Livingston et al., 2011; Mezey et al., 2010; Tomlin et al., 2020).
Addressing the Offending Behaviour
Family members and patients saw addressing the past offending behaviour and what led up to it as important for patients. Family members noticed that patients who acknowledged their past actions expressed remorse and recognized the consequences of their actions. Patients said they felt that talking about what happened and how to avoid it in the future gave them hope and confidence. These feelings align with what is found in the literature, where accepting the social and personal consequences of their actions may lead to guilt, remorse, or even shame. The literature indicates that accepting the offender identity is a crucial component in preventing future crime and developing insight (Askola et al., 2017; Askola et al., 2020).
Balancing the Forensic and Recovery Environment
Both the family and patient focus groups indicated that there should be more opportunities for patients to participate in activities to promote daily living skills. Patients indicated that being on the unit caused boredom and did not prepare them for living in the community. They viewed the lack of activity as restrictive and impeding their recovery. The restrictions of the unit created a disconnect between security and therapy, limiting their motivation to live independently. The literature suggests that care based on protocol has been reported to risk patient–staff relationships, hinder recovery, and destroy individuality (Aga et al., 2019; Askola et al., 2020; Higgins et al., 2016; Looi et al., 2014; Marklund et al, 2020; Morrissey et al., 2018; Slemon et al., 2017; Tomlin et al., 2020).
The literature suggests balancing agency and rehabilitative practices to incorporate a broader set of practices that enact life on the unit (Tucker et al., 2019). This aligns with themes from our study in which family members spoke of the need to allow patients control over domestic activities on the unit to increase feelings of responsibility and mitigate the potentially negative impact of idleness and boredom. Additionally, family members valued experiences of success in patient progress, which increased confidence, proactivity, and motivation, and encouraged patients to look toward the future (Pearson & Tsang, 2004).
Conclusion
The aim of this project was to obtain patient and family perspectives of recovery as experienced in our FPP. Since patients’ and family members’ perspectives are influenced by many context-specific variables, the results found in our project can not necessarily be generalized to other FPPs. However, the perspectives and experiences identified by our patients and family members provide a valuable foundation for future quality improvement initiatives in our program.
The small sample sizes of both the patient and participants can be a limitation. However, the information gained from the participants has provided valuable insights into the recovery of patients in our program. This information can be confirmed through further study with a larger group of patients and family members from the program to gain a broader perspective.
With a growing body of literature about forensic patient and family members’ experiences in forensic psychiatric services, there appear to be themes emerging that are unique to the forensic environment. Further exploration of this body of literature may develop a more solid evidence base to identify the unique needs of patients who are recovering in a forensic psychiatry environment.
Conflict of interest: none
References
Absalom-Hornby, V., Gooding, P., & Tarrier, N. (2011). Coping with schizophrenia in forensic services: The needs of relatives. Journal of Nervous and Mental Disease, 199(6), 398–402. https://doi.org/10.1097/nmd.0b013e31821cd394
Aga, N., Laenen, F. V., Vandevelde, S., Vermeersch, E., & Vanderplasschen, W. (2019). Recovery of offenders formerly labeled as not criminally responsible: Uncovering the ambiguity from first-person narratives. International Journal of Offender Therapy and Comparative Criminology, 63(6), 919–939. https://doi.org/10.1177/0306624X17730617
Askola, R., Louheranta, O., Soininen, P., Putkonen, H., Åstedt-Kurki, P., & Paavilainen, E. (2017). The offense as perceived by the parents of forensic psychiatric patients. Issues in Mental Health Nursing, 38(9), 705–711. https://doi.org/10.1080/01612840.2017.1326993
Askola, R., Nikkonen, M., Paavilainen, E., Soininen, P., Putkonen, H., & Louheranta, O. (2018). Forensic psychiatric patients’ perspective on their care: A narrative view. Perspectives in Psychiatric Care, 54, 64–73. https://doi.org/10.1111/ppc.12201
Askola, R., Soininen, P., & Seppänen, A. (2020). Offense-related issues in forensic psychiatric treatment: A thematic analysis. Frontiers In Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00925
Chang, K. H., & Horrocks, S. (2006). Lived experiences of family caregivers of mentally ill relatives. Journal of Advanced Nursing, 53(4), 435–443. https://doi.org/10.1111/j.1365-2648.2006.03732.x
Clarke, C., Lumbard, D., Sambrook, S., & Kerr, K. (2016). What does recovery mean to a forensic mental health patient? A systematic review and narrative synthesis of the qualitative literature. Journal of Forensic Psychiatry & Psychology, 27(1), 38-54. https://doi.org/10.1080/14789949.2015.1102311
Davidson, L., O’Connell, M. J., Tondora, J., Lawless, M., & Evans, A. C. (2005). Recovery in serious mental illness: A new wine or just a new bottle? Professional Psychology: Research and Practice, 36(5), 480–487. https://doi.org/10.1037/0735-7028.36.5.480
Davidson, L., O’Connell, M. J., Tondora, J., Styron, T., & Kangas, K. (2006). The top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services, 57(5), 640–645. https://doi.org/10.1176/ps.2006.57.5.640
DeBronkart, D. (2015). From patient centred to people powered: Autonomy on the rise. BMJ, 350, Article h148. https://doi.org/10.1136/bmj.h148
Ghaemi, N. S., & Pope, H. G. (1994). Lack of insight in psychotic and affective disorders: A review of empirical studies. Harvard Review of Psychiatry, 2(1), 22–33. https://doi.org/10.3109/10673229409017110
Gómez-de-Regil, L., Kwapil, T. R., & Barrantes-Vidal, N. (2014). Predictors of expressed emotion, burden and quality of life in relatives of Mexican patients with psychosis. Journal of Psychiatric and Mental Health Nursing, 21(2), 170–179. https://doi.org/10.1111/jpm.12071
Higgins, A., Doyle, L., Downes, C., Morrissey, J., Costello, P., Brennan, M., & Nash, M. (2016). There is more to risk and safety planning than dramatic risks: Mental health nurses’ risk assessment and safety‐management practice. International Journal of Mental Health Nursing, 25(2), 159–170. https://doi.org/10.1111/inm.12180
Hörberg, U., & Dahlberg, K. (2015). Caring potentials in the shadows of power, correction, and discipline—Forensic psychiatric care in the light of the work of Michel Foucault. International Journal of Qualitative Studies on Health and Well-Being, 10(1), 28703. https://doi.org/10.3402/qhw.v10.28703
Hörberg, U., Sjögren, R., & Dahlberg, K. (2012). To be strategically struggling against resignation: The lived experience of being cared for in forensic psychiatric care. Issues in Mental Health Nursing, 33, 743–751. https://doi.org/10.3109/01612840.2012.704623
Laithwaite, H., & Gumley, A. (2007). Sense of self, adaptation and recovery in patients with psychosis in a forensic NHS setting. Clinical Psychology & Psychotherapy, 14(4), 302–316. https://doi.org/10.1002/cpp.538
Leamy, M., Bird, V., Le Boutiliier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry, 199(6), 445–452. https://doi.org/10.1192/bjp.bp.110.083733
Livingston, J. D., Nijdam-Jones, A., & Brink, J. (2012). A tale of two cultures: Examining patient-centered care in a forensic mental health hospital. Journal of Forensic Psychiatry & Psychology, 23(3), 345–360. https://doi.org/10.1080/14789949.2012.668214
Livingston, J. D., Nijdam‐Jones, A. & Team P. E. E. R. (2013). Perceptions of treatment planning in a forensic mental health hospital: A qualitative, participatory action research study. International Journal of Forensic Mental Health, 12(1), 42–52. https://doi.org/10.1080/14999013.2013.763390
Livingston, J. D., Rossiter, K. R., & Verdun-Jones, S. N. (2011). ‘Forensic’ labelling: An empirical assessment of its effects on self-stigma for people with severe mental illness. Psychiatry Research, 188(1), 115–122. https://doi.org/10.1016/j.psychres.2011.01.018
Looi, G. M. E., Gabrielsson, S., Sävenstedt, S., & Zingmark, K. (2014). Solving the staff’s problem or meeting the patients’ needs: Staff members’ reasoning about choice of action in challenging situations in psychiatric inpatient care. Issues in Mental Health Nursing, 35(6), 470–479. https://doi.org/10.3109/01612840.2013.879629
Mann, B., Matias, E., & Allen, J. (2014). Recovery in forensic services: Facing the challenge. Advances in Psychiatric Treatment, 20(2), 125–131. https://doi.org/10.1192/apt.bp.113.011403
MacInnes, D. L., & Watson, J. P. (2002). The differences in perceived burdens between forensic and non-forensic caregivers of individuals suffering from schizophrenia. Journal of Mental Health, 11(4), 375–388. https://doi.org/10.1080/09638230020023741
Marklund, L., Wahlroos, T., Looi, G.-M. E., & Gabrielsson, S. (2020). ‘I know what I need to recover’: Patients’ experiences and perceptions of forensic psychiatric inpatient care. International Journal of Mental Health Nursing, 29(2), 235–243. https://doi.org/10.1111/inm.12667
Marshall, L. A., & Adams, E. A. (2018). Building from the ground up: Exploring forensic mental health staff’s relationships with patients. Journal of Forensic Psychiatry and Psychology, 29(5), 744–761. https://doi.org/10.1080/14789949.2018.1508486
Mental Health Commission of Canada. (2015). Guidelines for recovery-oriented practice: Hope. Dignity. Inclusion. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/MHCC_RecoveryGuidelines_ENG_0.pdf
Mezey, G. C., Kavuma, M., Turton, P., Demetriou, A., & Wright, C. (2010). Perceptions, experiences and meanings of recovery in forensic psychiatric patients. Journal of Forensic Psychiatry and Psychology, 21(5), 683–696. https://doi.org/10.1080/14789949.2010.489953
Morgan, S., & Rees, S. (2018). An evaluation of recovery in a forensic mental health service. Mental Health Practice, 21(10). https://doi.org/10.7748/mhp.2018.e1316
Morrissey, J., Doyle, L., & Higgins, A. (2018). Self-harm: From risk management to relational and recovery-oriented care. Journal of Mental Health Training, Education and Practice, 13(1), 34-43. https://doi.org/10.1108/jmhtep-03-2017-0017
Olsson, H., Audulv, Å., Strand, S., & Kristiansen, L. (2015). Reducing or increasing violence in forensic care: A qualitative study of inpatient experiences. Archives of Psychiatric Nursing, 29(6), 393–400. https://doi.org/10.1016/j.apnu.2015.06.009
Pearson, V., & Tsang, H. W. (2004). Duty, burden, and ambivalence: Families of forensic psychiatric patients in Hong Kong. International Journal of Law and Psychiatry, 27(4), 361–374. https://doi.org/10.1016/j.ijlp.2003.08.001
Priebe, Å., Wiklund‐Gustin, L., & Fredriksson, L. (2018). A sanctuary of safety: A study of how patients with dual diagnosis experience caring conversations. International Journal of Mental Health Nursing, 27(2), 856–865. https://doi.org/10.1111/inm.12374
Rabiee, F. (2004). Focus-group interview and data analysis. Proceedings of the Nutrition Society, 63(4), 655–660. https://doi.org./10.1079/pns2004399
Selvin, M., Almqvist, K., Kjellin, L., & Schröder, A. (2016). The concept of patient participation in forensic psychiatric care: The patient perspective. Journal of Forensic Nursing, 12(2), 57–63. https://doi.org/10.1097/JFN.0000000000000107
Shepherd, A., Doyle, M., Sanders, C., & Shaw, J. (2016). Personal recovery within forensic settings – Systematic review and meta-synthesis of qualitative methods studies. Criminal Behaviour in Mental Health, 26(1), 59–75. https://doi.org/10.1002/cbm.1966
Simpson, A. I. F., & Penney, S. R. (2011). The recovery paradigm in forensic mental health services. Criminal Behaviour Mental Health, 21(5), 299–306. https://doi.org/10.1002/cbm.823
Slemon, A., Jenkins, E., & Bungay, V. (2017). Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry, 24(4), Article e12199. https://doi.org/10.1111/nin.12199
Tapp, J., Warren, F., Fife-Schaw, C., Perkins, D., & Moore, E. (2013). What do the experts by experience tell us about ‘what works’ in high secure forensic inpatient hospital services? Journal of Forensic Psychiatry & Psychology, 24(2), 160–178. https://doi.org/10.1080/14789949.2012.760642
Tomlin, J., Egan, V., Bartlett, P., & Vollm, B. (2020). What do patients find restrictive about forensic mental health services? A qualitative study. International Journal of Forensic Mental Health, 19, 44–56. https://doi.org/10.1080/14999013.2019.1623955
Topor, A., Skogens, L., & von Greiff, N. (2018). Building trust and recovery capital: The professionals’ helpful practice. Advances in Dual Diagnosis, 11(2), 76–87. https://doi.org/10.1108/ADD-11-2017-0022
Tsang, H. W. H., Pearson, V., & Yuen, C. H. (2002). Family needs and burdens of mentally ill offenders. International Journal of Rehabilitation Research, 25(1), 25–32. https://doi.org/10.1097/00004356-200203000-00004
Tucker, I. M., Brown, S. D., Kanyeredzi, A., McGrath, L., & Reavey, P. (2019). Living ‘in between’ outside and inside: The forensic psychiatric unit as an impermanent assemblage. Health & Place, 55, 29–36. https://doi.org/10.1016/j.healthplace.2018.10.009
Turton, P., Demetrious, A., Boland, W., Gillard, S., Kavuma, M., Mezey, G., … Wright, C. (2011). One size fits all: Or horses for courses? Recovery-based care in specialist mental health services. Social Psychiatry Psychiatric Epidemiology, 46, 127–136. https://doi.org/10.1007/s00127-009-0174-6
Corresponding author
Ivana Furimsky, Manager, Quality Assurance, Population Health Research Institute, A Joint Institute of HHS and McMaster University, David Braley Research Institute, 237 Barton Street East, Hamilton, ON L8L 2X2; 905-521-2100 ext. 40383; Ivana.Furimsky@phri.ca