In a new study published in Frontiers in Psychiatry, a team of researchers has revealed a knot of apprehension among psychiatric clinic staff in Switzerland regarding the prospect of embracing a recovery orientation (RO) approach in forensic clinical settings.
Clinic staff raised concerns ranging from the logistics of security requirements to the fear of a potential dip in power and authority. However, the team believes the execution of an RO approach could still be possible within the walls of these clinical settings. This study sheds light on the staff’s initial wariness:
“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,” the researchers shared. “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 attitudes and ideals and fearful anticipations — such as the loss of authority and power — also played a central role.”
The authors hoped to gauge and analyze the viewpoint of psychiatric staff on implementing RO in a secure clinical environment, the crux of RO being the empowerment of individuals diagnosed with mental illnesses to lead meaningful lives despite their conditions.
The researchers utilized focus groups from two Swiss forensic psychiatric university hospitals, which had undergone RO training sessions. Fifty staff members participated in these groups, contributing to the gathered perspectives.
Two researchers, one interviewer, and one assistant/observer, were present in each focus group. The focus groups were held on hospital premises and lasted between 60 and 75 minutes. Each session began with the researchers asking the following question: “You all participated in the training session, which introduced the concept of RO. When you think about it, what goes through your mind?” The researchers then identified themes present in the transcriptions of the focus groups.
The researchers grouped their findings into three main themes: the challenges associated with RO, expected obstacles, and potential RO interventions. In addition, each category hosted a series of subthemes.
In the challenges linked to RO, the team noted six subthemes. First was the tension between security and therapy. Many participants discussed balancing the dual roles of helping those at their clinics for treatment and safeguarding the larger society. The demand for safety from the community was sometimes perceived as being at odds with positive risk-taking in therapeutic interventions. The clinic staff has to act within the bounds of the legal system that requires certain things of the patients. These requirements can sometimes destroy the working relationships so crucial to recovery.
Social connectedness was another subtheme within the challenges associated with RO. According to the RO perspective, social connection is central to recovery. However, focus group participants report many patients, especially those diagnosed with psychosis/schizophrenia, have little interest in forming relationships with others.
Hope was a third subtheme identified by researchers. Participants associated RO with hope and a brighter future for their patients. However, participants also mentioned how difficult it was to give someone hope, especially patients guilty of a serious crime.
The fourth subtheme within challenges associated with RO was Identity and finding meaning. Participants had difficulty grasping these ideas and found it challenging to bring them to their patients. Participants also expressed concern that some staff may project their own idea of “healthy” identity and meaning onto the patients, thereby detracting from the patient’s individual way of recovery.
Empowerment and participation were the fifth subtheme within RO challenges. While some participants expressed that involving patients in the everyday running of the wards could lead to increased self-efficacy, others were concerned that such strategies could lead patients to overestimate their abilities and slow their path to recovery.
Trust was the last subtheme identified by researchers within RO challenges. While trust can be critical to recovery, participants said some patients hide potentially important information about their mental illness to avoid negative consequences. Participants were also aware that their relationship with patients would always involve a power differential, which makes trust more difficult.
In anticipated obstacles, staff highlighted issues like self-stigmatization, structural obstacles like space limitations, and personal hurdles, such as conflicting staff attitudes towards RO.
The participants observed the self-stigmatization of their patients as well as stigmatization by the judicial system. Structural obstacles observed by participants included limited space, canceling planned activities due to unexpected crises, and a shortage of clinical staff. Personal barriers included conflicts among staff members, attitudes that conflicted with RO, and missing opportunities for reflection.
Possible RO interventions emerged as a third theme.
First, participants expressed that a shift would need to occur from focusing on symptoms to concentrating on resources. Second, the participants discussed getting patients to participate in their recovery, especially in the face of necessary criticism. Third, the participants were concerned with wards for both patients and staff that would allow for the strictness demanded by security concerns and the flexibility needed to operate under the flag of RO. Fourth, many participants agreed that inviting recovered patients to speak to current patients could be a helpful intervention. Fifth, participants discussed how to present group therapy offerings could be tweaked within a RO framework. Sixth, participants debated the role clinical staff should play in transitioning patients from the ward back into their communities.
The researchers acknowledge some limitations to the current work. Participants were self-selected. A random sample could provide more accurate results. This research was limited to 2 psychiatric facilities in German-speaking Switzerland, significantly limiting generalizability outside that particular context.
Past research has found that forensic psychological exams are unreliable and biased, which can lead to wrongful convictions. In addition, life inside a forensic psychiatry unit is difficult and can often lead to trauma. One author wrote about the indignities they faced in a forensic unit, including being treated by people that were likely not mentally sound themselves.
Schoppmann, S., Balensiefen, J., Nienaber, A., Rogge, S., & Hachtel, H. (2023). The perspective of staff members of two forensic psychiatric clinics in German-speaking Switzerland on the introduction of recovery orientation: An explorative study. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.946418 (Link)