Patients' Views With Regard to Personal Recovery in Forensic Psychiatry in German-Speaking Switzerland—An Explorative Study

Abstract

Recovery orientation (RO) is a modality of supporting patients to improve self-determination, leading a meaningful life and well-being in general. This approach is widely studied in general psychiatry, but evidence is lacking for forensic inpatient settings in Switzerland. While secure forensic clinics tend to be regarded as total institutions, which are an anathema to RO, a project to implement RO interventions in this setting was financed by the Swiss Federal Office of Justice. This explorative study investigates baseline expectations and views of patients in forensic wards in German-speaking Switzerland in the context of a recovery-oriented intervention. As such wards are non-existent in Latin-speaking Switzerland, the investigation could only be carried out in this language region. Six focus groups with 37 forensic inpatients were conducted. Thematic analysis revealed two major and several subthemes. The major theme “heteronomy” includes the subthemes “stigmatization and shame,” “coercion,” “lack of support,” “mistrust,” “waiting,” and “structural impediments.” The subthemes “learning to live with the disorder and working on oneself,” “participation,” “connectedness,” “confidence,” and “joie de vivre” belong to the major theme “regaining self-determination.” In this way, results of prior research are extended to forensic peculiarities. Furthermore, the personal views of patients are discussed in detail regarding their possible influence on therapeutic outcomes and personal recovery. These findings should be of help to therapeutic staff in the respective setting to be better informed about, and to counter the effects of, heteronomy and long-term hospitalization. Important in this regard is the concept of procedural justice and the subjective client's perception thereof.

The Totalising Nature of Secure and Forensic Mental Health Services in England and Wales

“…This is consistent with the broader literature that indicates mental health staff generally tend to attribute patient aggression to internal factors, such as patient psychopathology, more readily than environmental or situational factors including communication between the patient, staff member, and other patients ( 92 ). A study found that staff reframe restrictive practise as acts of compassion and necessary means of managing risk, thereby reducing feelings of unease derived from constantly acting against the will and wishes of their patients ( 93 ).…”

“…It's defined what we have to do and not talked about what makes it troublesome to achieve it. If goals are not met, there is no support, there is more pressure” ( 93 ).…”

“…Specific focus on secure mental health services is warranted as restrictive practises are often viewed as an integral part of forensic psychiatry but have received limited research attention relative to other areas of psychiatric practise ( 106 , 108 ). Patients have reported that coercion is applied in a disproportionate way not only in terms of individual measures but to the system as a whole ( 93 ). A correlation has been found between disruptive behaviour, violence, and seclusion use in relation to sense of community and ward climate ( 109 ).…”

“…Research has indicated that staff's emotional world can affect the deployment of restrictive measures with higher levels of anger likely to lead to the endorsement of management techniques such as the use of restraint, whereas those who experienced higher levels of guilt were less likely to sanction the use of seclusion ( 112 ). A study found that staff reframe restrictive practise by describing interventions as acts of compassion and as necessary means of managing risk, thereby reducing feelings of unease derived from constantly acting against the will and wishes of their patients ( 93 ). The manner in which staff process and understand their actions has an impact on their emotional reactions to the ways in which they interact with patients.…”

“…Patients have expressed the need for an ethical authority that monitors forensic psychiatrists and secure and forensic mental health services ( 93 ). This demonstrates the existence of a perceived need for protection from arbitrariness.…”