Agents and spectres: Life-space on a medium secure forensic psychiatric unit

Using a trauma-informed care framework to explore social climate and borderline personality disorder in forensic inpatient settings

Tensions between therapeutic and security needs on forensic wards can create a social climate which is challenging for both mental health nurses and patients. Social climate refers to the physical, social and emotional conditions of a forensic ward which influence how these environments are experienced. For patients with borderline personality disorder (BPD), previous trauma means that the social climate of forensic settings may be experienced as retraumatising, negatively impacting the outcomes and wellbeing of both patients and mental health nurses. Trauma-informed care (TIC) has been offered as a contemporary framework for mental health nursing in inpatient units which aims to create a therapeutic social climate. In this critical review, we drew widely on literatures examining the social climate in forensic settings, the relationships between patients with BPD and staff (including mental health nurses), and the experiences of patients with BPD in forensic and inpatient settings to draw out the implications of scrutinising these literatures through the lens of TIC. Attending to the physical, social and emotional conditions of social climate in secure settings highlights how forensic wards can mirror trauma experiences for patients with BPD. Implementing TIC in these contexts has the potential to evoke positive shifts in the social climate, thus reducing the risk of retraumatisation and leading to improved outcomes for patients and staff.

The Role of the Built Environment as a Therapeutic Intervention in Mental Health Facilities: A Systematic Literature Review

OBJECTIVES

This systematic literature review synthesizes and assesses empirical research concerning the use of the built environment as a therapeutic intervention in adult mental health inpatient facilities. The review explores the impact of facility design on patient outcomes.

BACKGROUND

There is a growing recognition that the built environment in mental health facilities must strike a balance between ensuring safety and providing a therapeutic atmosphere. A review addressing how facility design contributes to this therapeutic environment is warranted.

METHODS

Database searches were conducted in CINAHL, Embase, PsychInfo, PubMed, and Web of Science from inception up to March 10, 2022. The Scottish Intercollegiate Guidelines Network (SIGN50) critical appraisal checklists were used to assess the quality of included studies.

RESULTS

Of the 44 peer-reviewed studies identified from nine countries, several factors emerged as vital for the therapeutic environment in mental health inpatient facilities. These included personal spaces prioritizing privacy and control of the environment, daylight-optimized spaces, versatile communal areas promoting activities and interaction, designated areas for visits and spiritual/contemplative reflection, homelike environments, the inclusion of artwork in units, open nursing stations, and dedicated female-only areas. Yet, there is a need for research yielding stronger evidence-based designs harmonizing with therapeutic needs.

CONCLUSION

This review offers initial guidance on designing mental health facilities that foster a therapeutic environment, while highlighting that the influence of facility design on mental health inpatients is considerably under-researched.

Forensic Psychiatric Patients' Experiences of Personal Recovery: A Wilsonian Concept Analysis

ABSTRACT

Psychiatric patients' recovery processes have been studied rather extensively, and a relatively clear consensus on what recovery is already exists. We examined whether the personal recovery of forensic psychiatric patients varies from this definition. We conducted a concept analysis to assess the personal recovery of patients in forensic psychiatric hospitals based on 21 articles and then evaluated how our results compared with existing definitions on psychiatric and forensic recovery. On the basis of this comparison, we concluded that the personal recovery of forensic psychiatric patients does differ from that of other psychiatric patients. The recovery process of forensic psychiatric patients can be described through five themes: personal development and autonomy, social inclusion and normality, redemption and overcoming, future orientation and hope, and advancing process. The burden of a psychiatric disorder causes similar challenges, yet a criminal history and long hospitalization periods are distinctive issues for forensic patients, both of which can lead to severe alienation from society and deterioration of skills needed in life outside an institution. The results suggest that processing the criminal offense should be part of the care; furthermore, institutions should support forensic psychiatric patients in their reintegration into society and personal development. Identifying special recovery challenges can be useful when designing effective care and promoting the recovery of forensic patients. Thus, our results suggest that certain features of forensic psychiatric patients' recovery should be considered when planning their psychiatric care.

Vitality and nature in psychiatric spaces: Challenges and prospects for 'healing architecture' in the design of inpatient mental health environments

Historically, nature has been considered central to healing and recovery in institutional mental health settings, with inpatient spaces designed to mirror the restorative forces nature may afford. Within contemporary healthcare architecture, the discourse surrounding nature's role has once again become prominent, especially in the concept of 'healing architecture'. While the literature on 'healing architecture' primarily considers how to connect recovery to nature through interventions in the built environment, less interest has been directed towards how nature is configured in design processes and what implications that has for the everyday experiences of patients and staff. In this paper we consider the design and implementation of one particular psychiatric hospital in Denmark to show that the 'nature' brought into this healthcare space can be experienced as anything but 'natural' and may reduce rather than enhance a felt sense of 'vitality' amongst patients. Based on our analysis, we end the paper by suggesting four principles for future healthcare design.

Towards a social psychology of precarity

This article introduces the special issue 'Towards a Social Psychology of Precarity' that develops an orienting lens for social psychologists' engagement with the concept. As guest editors of the special issue, we provide a thematic overview of how 'precarity' is being conceptualized throughout the social sciences, before distilling the nine contributions to the special issue. In so doing, we trace the ways in which social psychologists are (dis)engaging with the concept of precarity, yet too, explore how precarity constitutes, and is embedded within, the discipline itself. Resisting disciplinary decadence, we collectively explore what a social psychology of precarity could be, and view working with/in precarity as fundamental to addressing broader calls for the social responsiveness of the discipline. The contributing papers, which are methodologically pluralistic and provide rich conceptualisations of precarity, challenge reductionist individualist understandings of suffering and coping and extend social science theorizations on precarity. They also highlight the ways in which social psychology remains complicit in perpetuating different forms of precarity, for both communities and academics. We propose future directions for the social psychological study of precarity through four reflexive questions that we encourage scholars to engage with so that we may both work with/in, and intervene against, 'the precarious'.

Choreographies of sexual safety and liminality: Forensic mental health and the limits of recovery

Medium secure forensic psychiatric units are unique environments within the broader "post asylum" landscape of mental health services. Length of stay is much greater and restrictions on behavior, including sexual behavior, are legally and institutionally legitimated, due to concerns regarding risk. As a result, sexuality is rarely explored experientially with service users and no official policies on sexual conduct and sexual safety have yet been developed.

The perspective of staff members of two forensic psychiatric clinics in German-speaking Switzerland on the introduction of recovery orientation: An explorative study

Recovery orientation (RO) is directed at living a worthwhile life despite being impaired by the constraints of mental illness. Although being quite common in general psychiatry in Switzerland, the dual mission of forensic psychiatry-safeguarding and therapy-challenges the idea of establishing RO as a work philosophy in this context. This explorative study qualitatively investigates baseline expectations and professional perspectives of forensic staff members concerning the idea of establishing RO in Swiss forensic psychiatric wards. Thereby, three central themes were worked out, namely "challenges associated with recovery," "expected barriers," and "possible recovery-oriented interventions." From a general point of view, the staff members were uncertain whether RO interventions could be introduced at all, and if so, to what extent. This, on the one hand, had to do with structural obstacles such as security requirements; however, personal obstacles in the form of different, sometimes contradictory attitudesand ideals and fearful anticipations-such as the loss of authority and power-also played a central role. As forensic psychiatric wards are non-existent in Latin-speaking Switzerland, the study does only refer to the German-speaking language region.

Patients' experiences of place and space after a relocation to evidence-based designed forensic psychiatric hospitals

Forensic hospitals provide care for incarcerated patients who have committed a crime under the influence of serious mental illness. The care and (re)habilitation of the target group require highly competent staff and treatment strategies as well as purpose-built facilities that promote successful recovery. The aim of this study was to examine patients' experiences of place and space in new, purpose-built, evidence-based designed forensic psychiatric facilities in terms of supporting everydayness. A qualitative methodology was chosen. In total, 19 patients agreed to participate. Data were collected through photovoice (a combination of photographs and interviews) at three forensic hospitals, according to an evidence-based design and the concept of person-centred care in Sweden. The data were analysed through thematic content analysis. Four themes emerged from the data, revealing the patients' experiences of the new buildings: (i) having a private place, (ii) upholding one's sense of self, (iii) feelings of comfort and harmony, and (iv) remaining connected to one's life. The findings reveal that purpose-built environments can support everyday living and well-being and can create comfort. This is considered highly therapeutic by the patients. In conclusion, the findings of this study are of imperative importance in the design of health-promoting forensic hospitals.

Stuck in separation: Liminality, graffiti arts and the forensic institution as a failed rite of passage

Forensic psychiatric institutions are tasked with both containment and transformation, with securely policing the border between institution and society and readying patients for return to the community. Forensic institutions can thus be theorised as a form of 'rite of passage', engaged in a process of transformation which both navigates and demarcates social limits. This article contributes to literature on risk and control in clinical institutions by offering a novel theoretical synthesis of features of rites of passage and liminality, as facilitated by an art project in a forensic setting. Through the prism of the Graffiti and Wellbeing Project (GWP), an arts initiative, we explore the ways in which forensic institutions thus offer or impede opportunities for transformation. The project engendered a space for the transformation of difficult emotions and histories through the medium of art creating a liminal space of transformation within the confines of a secure institution. Drawing on Douglas, Kristeva and Bahktin, we argue that forensic institutions largely attempt to manage their own transgressive, marginal status, and the abject experiences of patients, through a recourse to order, suppression and sublimation. We argue for a wider range of responses to the transgressive and marginal experiences and behaviours prevalent in forensic settings, drawing on examples from the GWP.

A qualitative study exploring the patients' perspective from the 'Reserved Therapeutic Space' nursing intervention in acute mental health units

This study aimed to explore the perspective of people who had experienced treatment as patients at acute mental health units, regarding an intervention model to improve therapeutic relationships in the units, which had been previously designed by the nurses. The study participants were people linked to collectives for social activism in mental health. Six focus groups were held. The results were classified into three themes: (a) the meaning of a space to enable the establishment of a therapeutic relationship, (b) the procedures to implement the space, and (c) the difficulties to overcome to establish the space. For the participants, the Reserved Therapeutic Space intervention was perceived as a space where they could share expectations and needs with the nurses, considering it as both valid and useful to improve the therapeutic relationship in acute units. For the participants, the intervention should be structured in three stages: orientation, follow-up, and discharge. The content of the intervention should be proposed by the patients based on their needs and concerns. The barriers identified for carrying out the intervention were the lack of relational competence, the violation of rights, and the lack of accessibility of nurses. The facilitating elements were the availability of nurses, active listening, and empathy. The resulting intervention model includes realities of both groups, providing insights for nurses to initiate a space with patients and improve their therapeutic relationship. This intervention model could be used by managers to test its effectiveness.

An integrative review exploring the experiences of service users carrying a diagnosis of personality disorder and student mental health nurses and the time they share together

OBJECTIVES

This integrative review provides a collective understanding of the experiences of student mental health nurses and service users carrying a diagnosis of personality disorder and the time they share together.

DESIGN

Published studies about the time service users and students share together were systematically selected in order to integrate their findings in a thematic analysis.

DATA SOURCES

Various databases were searched from 1984 until 2020. Specific search terms were used.

REVIEW METHODS

37 studies were included in the integrative review. The studies were from peer reviewed nursing, student, psychology and health related journals. A quality appraisal was completed using Walsh and Downe (2006) framework.

FINDINGS

Four themes emerged from a thematic analysis of the integrative review. These were; With 'Impact of time' as an overarching theme.

CONCLUSION

A positive environment which considers time and focuses on seeing the person, as an individual can lead to the development of therapeutic relationships; a core element of the Nursing and Midwifery Council standards for nursing registration in the UK (Nursing and Midwifery Council, 2018). Students attempting to build such relationships need to be mindful of service users' and their own attachment experiences and the impact these can have on experiences of transference and countertransference, particularly for service users carrying a personality disorder diagnosis. It is important for students to be aware of the supportive impact of positive environments and how doing 'everyday stuff' can make a person feel human despite residing in potentially dehumanizing places.

Healing architecture and psychiatric practice: (re)ordering work and space in an in-patient ward in Denmark

Healing architecture is a defining feature of contemporary hospital design in many parts of the world, with psychiatric in-patient facilities in Denmark at the forefront of this innovation. The approach rests on the contention that designed clinical spaces and the particular dispositions they express may promote patient recovery. Although the idea that health may be spatially mediated is well-established, the means of this mediation are far from settled. This article contributes to this debate by analysing medical encounters in the context of a new purpose-built psychiatric hospital opened in Slagelse, Denmark in late 2015 as an example of healing architecture for the region. Grounded in qualitative research conducted in two wards between 2016 and 2017, we explore the key material and social effects of the hospital's healing architecture, and the spaces and practices it enacts. Following the work of Michael Lynch, we consider both the designed 'spatial order' of the in-patient wards and the 'spatial orderings' unfolding therein with a particular interest in how order is accomplished in psychiatric work. With much of the existing discussion of healing architectures focusing on their impacts on patient wellbeing, we consider how healing architectures may also be transforming psychiatric work.

Vital spaces and mental health

The impact of social and material conditions on mental health is well established but lacking in a coherent approach. We offer the concept of 'vitality' as means of describing how environments facilitate 'feelings of being alive' that cut across existing diagnostic categories. Drawing on the work of Stern, Fuchs, Worms and Duff, we argue that vitality is not solely a quality of an individual body, but rather emerges from attunements and resonances between bodies and materials. We use vitality as a lens to explore how movements within and between assembled sets of relations can facilitate or disable feelings and expressions of being alive. Building on extended discussions of both inpatient and community-based mental healthcare, we sketch out a research agenda for analysing 'vital spaces'.