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Turning towards recovery in forensic psychiatric inpatients – a study based on staff experience

Professor, PhD, Mid Sweden University, Kenneth.Asplund@miun.se

Associate Professor, Mid Sweden University & Sundsvall Forensic Psychiatric Hospital, Susanne.Strand@miun.se

PhD (Health Science), Dalarna University, helen.olsson@miun.se

Senior Lecturer, PhD, RN, Mid Sweden University, Lisbeth.Kristiansen@miun.se

  • Side: 175-188
  • Publisert på Idunn: 2014-10-13
  • Publisert: 2014-10-13

Many individuals sentenced to forensic psychiatric care fail in the rehabilitation process, resulting in long-term inpatient hospital care. The concepts of turning points and treatment readiness in forensic settings should therefore be afforded more attention. Much can be learned from the features that characterize trajectories of recovery and processes related to turning points. The aim of this study was to explore forensic nursing staff’s experiences of forensic psychiatric patients’ turning towards recovery. A qualitative content analysis was used to analyse interviews with 13 forensic psychiatric nursing staff. Analysis of the data revealed two main themes with implications for clinical practice: promoting a turning point and recognizing a turning point. In the first of these, the emphasis was on actions and conditions that must exist to promote a turning. In the second, the main experiences related to recognizing a turning point were stories about visible and perceptible changes in the patient. The experiences that stood out most distinctly were those of being able to wait out the patient, and having patience when there was a lack of progression. The composition of staff and patients contributed to whether or not the environment was perceived as salutary.

Keywords: changing process, forensic psychiatric care, interviews, recovery

A major objective in forensic psychiatric care is to reintegrate people with serious psychiatric disorders into society. The goal is to reduce the risk of violent behaviour as much as possible, and to rehabilitate the patient to the extent that they can return to a socially well-ordered life in society. The transition from hospital patient to preparation for discharge is not a straightforward journey (Coffey, 2012). Forensic psychiatric inpatients with a history of high risk of violence have described the process of recovery as a long and arduous journey, with many pitfalls, where experiences of failure and disease relapse were common (Olsson, Strand & Kristiansen, unpublished paper). This indicates a need for more thorough study into how forensic staff perceive turnings towards recovery. Mezey, Kavuma, Turton, Demetriou & Wright (2010) specified a number of difficulties associated with the potential recovery of forensic psychiatric patients. Prolonged periods of detention in restrictive, high security environments reduce the patient’s potential for independence and autonomy, limit their ability to influence their treatment, and reduce feelings of optimism and confidence.

Treatment readiness in forensic psychiatric settings is a concept that deserves further attention. Day & colleagues (2007) claim that treatment readiness should be considered a condition where there is a positive change regarding motivation, problem awareness, and an interest to engage in a treatment program and integrate with other group members. They also state that «being ready for treatment» depends on the social climate in the institution and the accessibility of intervention measures.

A study of treatment readiness among violent offenders found that improved treatment readiness consisted of changes in their attitudes and motivation, emotional reactions to the offences they had committed, and a change way of viewing the offence (Day, Howells, Casey, Ward, Chambers & Birgden, 2009).

One way to understand trajectories of recovery and processes linked to change and turning points is to examine research related to transition. A transition can be defined as a disruptive life event in which an individual redefines their sense of self and redevelops self-agency through person-environment interactions (van Loon & Kralik, 2005). In terms of the essential properties of transition experiences, Meleis, Sawyer, Im, Messias, and Schumacher (2000) state that all transitions involve change and all transitions are characterized by a flow and a movement over time. Likewise, transitions are associated with an increasing awareness; and the level of awareness affects the level of engagement. Meleis et al. (2000) also state that vulnerability is related to transition experiences, and this vulnerability affects everyday life, health, relationships, and environment.

A common description from individuals who have undergone recovery is a key shift of emphasis and an experience of a defining moment or turning point (Allott, Loganathan & Fulford, 2003; Topor, 2001). According to Topor (2001) the journey from the lowest position to this turning point can vary in duration, and may proceed in small steps. It may involve maturation processes or circumstances that force the individual to make a decision to change. Referring to Fredriksson (2002), turning points appear to take place when facades are broken and suffering no longer has to be suppressed, but this process must be based on a safe communion and a sense of belonging.

In this article, we consider turning points to be part of a changing cycle or life cycle, and therefore note that they should not be seen as a single point. The focus is on the experiences of turning points and recovery as perceived by forensic staff. In this study, the criteria indicating recovery were being able to obtain short term release in the forensic care, having some form of regular recreational activity, and avoiding violent behaviour.

To the best of our knowledge, there are no studies available on staff perceptions of the features that characterize a turn towards recovery. According to Viljoen, Nicholls, Greaves, de Ruiter and Brink (2011), little is known about how the process of recovery and resiliency begins. De Ruiter & Nicholls (2011) state that there is a continuing need to increase our knowledge about what works in risk prevention and which factors contribute to successful integration into society.

The aim of this study was to describe forensic nursing staff’s perceptions and experiences of forensic psychiatric patients’ turning towards recovery.

Method

This study used an inductive descriptive design with a qualitative approach (Patton, 2002). Knowledge is constructed in the interaction between the interviewer and the interviewee; and the findings, understandings, and insights that emerge from the subsequent analysis are the fruit of the qualitative inquiry (Patton, 2002). A researcher conducting a qualitative research interview attempts to understand the world from the point of view of the informants, and to develop a sense for and an understanding of their experiences (Kvale & Brinkmann, 2009).

Research context

The research sample was drawn from staff at a maximum security forensic psychiatric clinic in a region of Sweden. The clinic is a resource for individuals nationwide, and admits patients from psychiatric and correctional units all over the country. It is one of the largest forensic clinics in Sweden, with approximately one hundred inpatients divided into eight care units.

Work in the clinic is characterized by an interdisciplinary cooperation, and the staff members have different professional backgrounds. Prior to the study, the researchers had no connection with or attachment to the clinic or the staff.

Swedish forensic psychiatric care includes the use of key care persons, with recruitment performed among staff members in the clinic. The task of the key person is to get the patient involved in planning and treatment, and to provide encouragement and mental support. These key persons can also be supportive in maintaining contact with other caregivers in the community.

Study participants

A purposive sample of study participants was used. Selecting information-rich cases – in this case, individuals with experiences of turning points – allows attention to be focused on the significant issues (Patton, 2002). Forensic staff were recruited on the basis of their assignments as key persons for forensic patients. They worked in five of the eight care units.

The interviews were carried out from June to August 2012. Thirteen staff members met the criteria and were asked to participate. All thirteen agreed to take part, and they then received further information about the purpose of the study.

The group of thirteen participants had an average age of forty years (range 30–60). Six of them were female. They had been in the profession for an average of 7 years (range 2–35). Three of them were registered mental nurses, one was a registered nurse, and the other ten were assistant nurses.

Data collection

The interviews were tape recorded and transcribed verbatim by the first author (HO). The participants were free to choose a location that felt comfortable to them, and the interviews varied in length from 43 to 65 minutes (median 52 minutes). Each interview started with a conversation about the concepts of recovery processes, treatment readiness, and turning points. The main interview question was: «Can you please describe the notable changes you have observed in your patients over time?» To address the research question, a number of follow-up questions were asked in order to get as full and as rich a story as possible. All interviews were conducted by the first author (HO).

Data analysis

A qualitative interpretative content analysis (Patton, 2002) was used to explore experiences of patients’ recovery and turning points as perceived by the forensic nursing staff. The overall analytical procedure comprised a stepwise reading of the text, and was characterized in five steps. A main feature of the analysis was a recurring feedback to the research questions.

First, the transcribed interviews were read through several times to get a sense of the whole. The next step was to divide the text into meaning units (texts discussing the same topic) as expressed by the informants. In the third step, the meanings units were condensed; this entailed concentrating the interview notes while preserving the essence of the text. In the fourth step, the condensed meaning units with similar content were grouped, sorted, and abstracted into sub-themes and themes through a back-and-forth analytical process.

Sub-themes were defined as a set of recurring statements expressed by several participants correlating to the research question (Sandelowski & Barraso, 2002). The final step produced five sub-themes and two themes (Table 1). At an interpretative level, the themes run like a thread through the condensed meaning units and the sub-themes, and include the main content of the analysis.

Table 1. Examples of meanings units, condensed meaning units, sub-themes, and themes

Meaning units

Condensed meaning units

Sub-themes

Themes

When you feel that something is changing, that someone is changing… whether it is due to medicine, nursing, or time. No matter what, it feels incredible. Now you can breathe a sigh of relief. Now we can really get down to work... (Interview 6)

When the change came about, it was a great relief, and the real work could begin.

Experiencing the start of a transformation

 

Little things can become big things, and you should not set the bar too high ... you have to figure out where the threshold is for each patient and you have to find the right tempo for each of them… (Interview 13)

The staff must be responsive and adaptable depending on where in the process the patient is.

Being responsive and adaptable

Promoting a turning point

The composition of the group of patients is of utmost importance. Patients can have a very good influence on each other. They lighten up the mood and stick together. If any of them are transferred out of the ward, it may be completely destroyed… (Interview 13)

The composition of the individuals in the department affected the health care environment.

Working together for a salutary health care environment

 

You can see the change… when the patient begins to take care of themself… they start to come back. They develop a healthy glow in their cheeks, and perhaps you have a smile ... (Interview 9)

The patient starts to take care of themself and looks healthier and happier.

Experiencing a visible change in the patient

 

They start keeping track of their hygiene… they begin to clean their room… they spend more time in the department… they venture out and walk about. They are also beginning to make more demands about exemption from restrictions and a desire to take part in activities… (Interview 11)

A higher level of activity could be detected in the patient. They also began to make demands and have opinions on the care.

Observing a shift in the patient’s attitudes and actions

Recognizing a turning point

Ethical considerations

The study was approved by the Research Ethics Committee of Umeå University (Dnr. 07/164M). Written permission to conduct the study was provided by the director of the forensic clinic. Participation was voluntary, and could be terminated at any time with no questions asked. Before the study began, the first author (HO) provided the participants with written information, and written informed consent was obtained.

Findings

While the participants said that they were unaccustomed to describing the processes around turning points, this was not an entirely foreign experience for them. They described turning points and positive changes in a vivid manner. The interpretive analysis of the data revealed two main themes with implications for clinical practice: promoting a turning point and recognizing a turning point.

The theme promoting a turning point placed emphasis on the actions and conditions that must exist among the staff to promote a turning: having patience, being able to adapt, and being highly responsive and reflexive in their work. The composition of staff and patients contributed to whether or not the environment was perceived as salutary. The theme recognizing a turning point focused on providing a description of how turning points and treatment readiness could be expressed in care. This theme dealt with apparent positive changes in the patient where a higher level of activity and presence could be detected. A turning could also be perceived by means of more vibrant facial expressions and posture in the patient, with the staff getting a general sense of being invited to communicate.

Promoting a turning point

In this theme, the emphasis was on actions and conditions that need to exist to promote a turning point. The participants’ experiences of what promoted a turning point in the patients can be illustrated by three sub-themes: experiencing the start of a transformation, being responsive and adaptable, and working together for a salutary health care environment.

Experiencing the start of a transformation

It was clear that the nursing staff experienced the long length of stay as a positive factor, because this made it possible to follow the patient’s recovery over time. This time span was regarded as a mutual journey with the patient. Some of the participants expressed a concern that the patient had a long and arduous journey in front of them: «It is important to convince the patient that I understand that they are going through a difficult process. They have thoughts about what people think about them as a patient; they are extremely vulnerable at this point…» (Interview 5). The participants described how a longer detention gave them a chance to build a long lasting relationship with the patient in which they themselves often took a parental role. A large part of the relationship was built on trust and earned trust. This developed and changed in pace with a deepened relationship between the staff and the patient.

According to the participants, it was not uncommon for a newly admitted patient to have had experiences at several psychiatric clinics around the country. This lack of continuity often created feelings of disillusionment and alienation in the patient, which initially could be stressful to work with. The participants said that in some cases long periods of time would elapse without them successfully achieving any alliance with the patient, which they described as worrisome and frustrating.

Often, they felt that life for newly enrolled patients was marked by shock and crisis processing. According to the participants, this was derived from a combination of acute mental illness and post-traumatic stress from a committed offence. As one participant described,»… for most of them the first six months are mainly all about survival, you know, staying alive…» (Interview 1). Even if progress was slow, each step was experienced as a reward that generated satisfaction and encouragement for the staff. One participant described how when a patient took a step towards a positive change, the relationship suddenly began to feel relaxed, and then the real work could begin.

Being responsive and adaptable

Achieving an alliance with the patient was described by the participants as being largely about patience, being able to adapt, and being highly responsive and reflexive. Many participants described the importance of being attentive to the patient's current emotional state and mood, and slowing down the pace if the patient began to feel ill or uncomfortable. Trying to speed up or trying to rush the patient to reach a goal could lead to resistance or avoidance. One participant described how frustrated he was that his patient was not progressing:

We weren´t getting anywhere and I was trying and trying…..in the end I thought; what´s normal for me and what´s normal for the patient? Perhaps my ambition was a bit too strong for him, so I lowered the bar quite considerably and after that things went really well … (Interview 13)

One participant described how the patient must be given the opportunity to form an opinion about the context of the environment around them, and pointed out that this could take time: «New patients feel that it´s really nice to have their own room, a kind of private place to go to. They must have a chance to get the feeling of the place before they take the plunge out into…» (Interview 7).

Having a high level of awareness at work was important for many of the participants. This was partly regarding the patient's health, where it was important to be aware of warning signs of impending illness, and partly through an awareness of their own position within the process. It appeared that the participants were experiencing several processes at the same time, but with different patients; and this required a particularly high level of responsiveness and adaptability from them. One participant expressed it as follows: «… some of the team can have two or three patients all at different stages in the process, and that isn´t easy …» (Interview 2).

At first it was difficult to know how the patient felt and what their needs were. In cases where the patient rejected relationships, the staff had to rely on each other in order to form an opinion about the patient. The work was described as involving detection, a bit like piecing together a jigsaw puzzle in order to reach an alliance and establish communication with the patient.

In order to achieve a good caring communication, it was important to be sensitive to the manner in which the patient wanted the conversation to proceed. As one participant stated: «You can try talking in the car, or go and get a coffee, or try switching to a different environment. You have to try things out in different ways…» (Interview 2).

Most of the participants agreed that processes regarding turning points were all about time, and that a turning point was not experienced over a day. The turning point was regarded as an ongoing process which entailed helping the patient to build a sustainable network around themself and making sure to maintain a suitable pace.

Working together for a salutary health care environment

All the narratives emphasized the importance of the health care environment in enabling the patient to take the step to change. A good climate in the ward was influenced both by a good interaction between the staff and by the composition of the patient group. Most of the participants felt that an important element of this work was feeling safe in their working group and knowing that they could rely on the support and assistance of their colleagues. Many participants described how moods and attitudes in the ward could spread, with both the staff and the patients being affected by this. As one participant expressed it, anxiety could be transmitted: «…if you’ve got several patients who are really sensitive to stress and anxiety and if there’s an atmosphere in the place that makes someone anxious, then that feeling can spread very easily…» (Interview 13). On the other hand, the participants also spoke about how a good composite patient group generated strength and optimism among everyone in the ward. Patients could, for example, encourage each other to say no to drugs, or prevent threats and violence in the ward. One participant described such a situation: «The patients say; we don’t do drugs here. You can’t take drugs in here. We forbid you to bring in anything that can ruin the atmosphere in our ward …» (Interview 7).

A friendly and tolerant atmosphere between the patients was described as important in bringing about positive changes and turning points. One participant said that the climate in her department was currently characterized by convivial forbearance: «… most of the inmates are really nice to each other. They notice when someone isn’t doing so well and they try to relate to them…» (Interview 12).

When the patient group was congenial, the participants found that their work became easier. In these cases, patients being transferred out could be a setback, as the group was splintered and the atmosphere could deteriorate in an instant.

Recognizing a turning point

This theme contained descriptions of how the participants recognized a turning in the patient, and what determined the turning point. Two descriptive sub-themes were constructed in accordance with how the participants perceived the process of the turning point: experiencing a visible change in the patient, and observing a shift in the patient’s attitudes and actions.

Experiencing a visible change in the patient

One common feature that characterized turning points and treatment readiness was the way in which the participants first noticed visible changes in the behaviour of the patients. This could be a small thing, such as when a patient began to have a better rhythm for their daily activities and sleep. Another sign could be when a patient began to venture out in the department more often, and began to make contact and communicate with other patients in a freer and more relaxed manner than before.

Most of the participants described how patients who may have previously stayed away and refused contact now interacted in a different way and perhaps even smiled. It was possible to perceive different, more vibrant facial expressions and posture in the patients. The most frequent description of a visible turning point in a patient was the experience of being able to make eye contact with them and get a sense of being invited in. One participant stated «He could look me in the eye, and yet it wasn’t quiet in the room even if I didn’t talk. I felt that he was trying to take part in the conversation. We could have a laugh and it wasn’t always about serious stuff …» (Interview 2).

Most of the participants felt that adjusting medications was time consuming, but several also described how changing medicinal doses could suddenly lead to a speedy and positive change in the patients: «It could take anything from six months to a year before you could see any change. They might have been taking the wrong dose of medicine which just stopped them from moving on. You make a small adjustment and there you are…» (Interview 7).

Observing a shift in the patients’ attitudes and actions

Most of the participants stated that a clear turning point was when a patient approached them and invited them in for a talk. These talks tended to be more intimate, and could involve sensitive areas of the patient's life. Opening up and confiding in the staff also meant an opportunity to progress, which in turn led to an opportunity to advance and to leave the arduous matters behind: «Eventually he started to talk to us in a completely different way and he even shared stuff with us. What we noticed when things changed was that he stopped worrying about all the ‘must dos’…he let it go and said ‘I don´t care about that’ …» (Interview 12).

The turning point included a recurring need to reflect and to look back. The patient needed to make a comparison between what life was like before and how it was now: «… so the patient says it used to be like that before, but it´s better now. He feels safe now. He analyses and thinks back and he can see how positive things are now…» (Interview 9).

Getting a chance to look back could also bring about experiences of post-traumatic stress syndrome from offenses they had committed in the past, or experiences and memories from a psychosis. One participant expressed it as follows: «Then the patient begins to think about the past. He could say ‘I remember this or that….can you tell me about this? Did I really do that? It sounds really bad…’ This makes me feel that things are taking a healthy turn here…» (Interview 6).

According to most of the participants, a turning point could result in the patient having an increased need to occupy his or herself and keep busy. Other changes that could be discerned in relation to a turning point included the patient starting to keep track of their hygiene and begin to clean their room, spending more time in the department, and showing an increased desire to go out for a walk.

There were also descriptions of how the change resulted in the patients being able to articulate themselves in a more advanced way regarding their needs or their thoughts about what a positive future would look like. Two participants described experiences of a patient’s opinions and demands of care increasing when they reached a turning point.

Discussion

This study provides knowledge about nursing staff’s experiences of forensic psychiatric patients’ turning towards recovery. Two main themes were identified in association with turning points: promoting a turning point, where the emphasis was on actions and conditions that need to exist in order to promote a turning, and recognizing a turning point, which covered accounts of visible and perceptible changes in the patients. Together, the themes constitute a guide for how staff can manage and monitor signs of turning points.

According to the participants, the initial phase of care was particularly problematic for the patients. The combination of a lack of continuity of care and diverse reactions to crises and other kinds of mental illness might have aggravated the situation for the patient and reinforced their feelings of vulnerability.

As in other published findings (Wijnveld & Crowe, 2010), the participants in this study described the importance of being able to handle their own frustrations, not expecting rapid change, and not trying to move forward too fast, at least not initially. Opportunities to approach a turning point (Fredriksson, 2002) included cases where the nursing staff were invited in by the patient, and the patient may have even talked about their sufferings.

The narratives in this study show that the turning towards recovery includes a recurring need to reflect and to look back. The patient needs to make a comparison between what their life was like before and how it is today. Berglund (2011) has described how long term-illness (including alcoholism) is associated with «learning turning points». These learning turning points are particularly important when a patient has reached an insight into the need for change, but it requires both courage and willingness to take responsibility for the change. According to Berglund, this health process needs to be supported by the staff as conversation partners, since reflection plays a crucial role in learning to live with long-term illness.

Research has shown that continuity of care, particularly regarding the mental health services, generates a better environment for recovery. One study with a patient perspective revealed that experiencing continuity in psychiatric care was linked to positive experiences of care and also produced a sustained sense of security (Schröder, Ahlström, & Larsson, 2006). It is reasonable to assume that, as indicated in the present study, a lack of continuity of care is a risk factor which could affect the continued recovery process for forensic patients.

A set of features characterized the turning towards recovery. Signs of a turning point could be recognized in the patients who were more prone to interactions with the staff, in particular those who initiated conversations with the staff. Therefore, providing time and opportunity without preconditions, and with the staff being sensitive to invitations and signs from patients who try to reach out, could just be the helping hand the patient needs to initiate a change. In line with this study, Fredriksson (2002) pointed out the importance of investing time and resources to promote a turning point in psychiatric patients. He states that patients who are taken seriously and given the opportunity to remodel their lifestyle open themselves up to relationships in a completely new way. Fredriksson also highlights the fact that patients who are not taken seriously only have one option available: to protect themselves behind a facade in order to avoid suffering, and in doing so compromise the possibility of reaching a turning point.

Caring for incarcerated patients involves major challenges for staff. Boredom, mental illness, and strained relations between patients, as well as between patients and staff, are all features of everyday life in a forensic psychiatric department (Meehan, McIntosh & Bergen, 2006). As this study and others have shown, (Mezey et al., 2010; Schröder et al., 2006; Ward, Day, Howells & Birgden, 2004), the atmosphere in the ward has an impact on the treatment readiness and recovery processes of the patients. Forensic patients who have managed to reduce their assessed risk for violence have described how the environment and the psychological climate affected everyone at the unit. The patients rated the physical environment as being subordinate to the psychological environment, because security and respect were vital issues for them in their recovery process (Olsson, Audulv, Strand & Kristiansen, unpublished manuscript). Without question, these aspects should be considered in detail by senior policy makers when financing and planning future forensic psychiatric care.

There is a need for more knowledge on how turning points and recovery processes develop in order to create deeper understanding and to develop preventive work in forensic psychiatric care. When working as a caregiver, it is important to support opportunities and strengths and to identify obstacles and critical points in patients’ transitions. Further studies will be needed, preferably from a patient perspective, since capturing the experiences of the patients will undoubtedly provide better understanding of how to promote a turning towards recovery. Such knowledge will create opportunities to reduce the suffering for these patients, and ultimately shorten the length of stay.

Rigor of the study findings

Trustworthiness is one dimension of rigor. With qualitative methods, trustworthiness depends on the methodological skill, competence, and quality of the researcher doing the fieldwork (Patton, 2002). The first author (HO) has a long experience in social work. Prolonged engagements including interviews lead to a deeper understanding of culture and language and facilitate better contact with the participants, making it more likely that valuable and accurate information will be obtained (Creswell & Miller, 2000). To enhance the trustworthiness of the study, all three authors were involved in the analytical process and the work was regularly confirmed through discussion until consensus was reached (Patton, 2002).

Credibility was affirmed in a verbal presentation of the data analysis during an education day which involved the participation of, among others, five informants from the current interview study. To review the findings, the participants were posed questions and the participants responded with questions back to the researcher (HO). This form of method triangulation, including participant feedback (Patton, 2002), strengthened the authenticity of the interpretations and influenced the way the analysis was performed.

The purpose of qualitative research is not to generalize the findings; instead it is the reader who should decide if transferability is possible considering other similar contexts. This can be facilitated by providing thick, rich descriptions including as many details as possible (Creswell & Miller, 2000), which was one of our ambitions in the present study.

Our aim was to get an overall picture of how forensic staff experience the processes related to turning points in forensic psychiatric patients. With reference to the complex nature of recovery, there are major differences in how patients undergo a turning point. Therefore, the presentations of the findings in terms of themes may be perceived as basic and one-dimensional. Another limitation is that we did not examine whether staff perceptions of patients' turning points differed between the various professional backgrounds represented in this study.

Implications for forensic psychiatric nursing practice

The process of change and turning points in forensic psychiatric care require attention and encouragement, as well as sensitivity and responsiveness from staff to assist and respond to the patient in their arduous journey. Regular analyses of the patients' recovery processes ought to be a key factor in forensic psychiatric settings, since care and treatments need to be continually adjusted depending on the patient’s position in the process. In order to support the recovery process, staff must be alert to signs and changes in the behaviour of the patient, for example an improved daily rhythm or the patient becoming more communicative.

This study shows that turning points must be supported by forensic psychiatric staff in terms of giving the patient opportunities for reflection on the past and future, and taking advantage of meetings initiated by the patient. Staff must try to deal with frustrations arising from lack of treatment success. To avoid rejection, staff must be prepared to wait out the patient, and not try to speed up the process or rush the patient along. At the same time, staff must be creative and sensitive and actively work to find ways to reach the patient.

A harmonious atmosphere in the unit where patients supported each other was described as clearly favourable for turning towards recovery.

Acknowledgements

The authors wish to thank the participants in this study, for their willingness to share their experiences, and Lars-Henrik Larsson and other staff at the research and development department at the Sundsvall Forensic Psychiatric Hospital, for all their help and support with this study.

Conflicts of interests

None declared.

Funding

This study was supported by grants from the Swedish Research Council, the National Postgraduate School of Healthcare Science, Karolinska Institutet, and Mid Sweden University

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