Building from the ground up: exploring forensic mental health staff’s relationships with patients

ABSTRACT

Recovery-orientated care is becoming generally accepted as the best practice, and continued development in the ways it is practiced is necessary to ensure improvement of ongoing care. Forensic patients often experience double stigmatization (the dual stigma of mental illness and offending behaviour) and during admission to hospital may lose touch with their community supports. While working through their personal recovery, patients develop therapeutic relationships with their multidisciplinary team members. When positive, these relationships can enhance a patient’s recovery. Clinical staff members participated in 88 in-depth interviews, which were transcribed, reviewed, and analysed using thematic analysis. From analysing the data, main themes and subthemes emerged related to staff’s perceptions of therapeutic relationships. When developing relationships, staff need to overcome receptiveness issues by increasing trust through understanding their preconceptions, reducing stigma, sharing innocuous stories, and giving patients the time they need. The key pillar underpinning all traits ascribed to patients and staff is collaboration and approaching treatment protocols with a social approach is essential to enhancing recovery. Staff shared a holistic view of recovery that incorporated the benefits of positive relationships and the need to create a sense of home within the institution.

KEYWORDS:

• Forensic mental health
• staff–patient relations
• qualitative research

Introduction

When entering forensic programs for treatment, patients have been noted to experience double stigmatization because of their mental illness and criminal offence (Adshead, 2012; Drennan & Wooldridge, 2014). While working through their recovery, forensic patients often lose touch with community and/or family supports because of the long time periods spent in facilities. While in hospital, patients interact with a broad interdisciplinary team on a daily basis, and as previous support networks become scarce, the role of staff in patient support becomes more significant.

Recovery-oriented treatment highlights that a patient’s pathway to recovery involves more than just medication (Anthony, 1993). Its adoption across various mental health disciplines is being welcomed as an approach that empowers patients and provides them with meaningful social activities and relationships (Davidson, O’Connell, Tondora, Lawless, & Evans, 2005; Nijdam-Jones, Livingston, Verdun-Jones, & Brink, 2015). There is no universally agreed upon definition for recovery (Davidson et al., 2005), but it is generally recognized to involve a personal journey undertaken to overcome the negative effects of mental illness and develop a new satisfying purpose and meaning in one’s life (Anthony, 1993). At the core of recovery-focused care is therapeutic relationships. Positive relationships lead to a positive recovery (Horvath, 2000).

Within the forensic setting, supportive relationships with staff can provide patients with positive role models and assist in their recovery (Nijdam-Jones et al., 2015). Forensic staff must achieve a balance between custodial and relational expectations when developing relationships within recovery-orientated settings (Hammer, 2000; Martin & Street, 2003). The dual nature of staff member’s role requires a balance between custodial- and relational-based care (Mason, Lovell, & Coyle, 2008; Peternelj-Taylor, 2000; Rask & Hallberg, 2000; Swinton & Boyd, 2000) and this may impact the ability of staff to develop positive relationships with their patients.

Within the forensic setting, therapeutic relationships have been shown as both influential and predictive in treatment and user satisfaction (Bressington, Stewart, Beer, & MacInnes, 2011; Coffey, 2006; Horvath, 2000), but there is paucity of research on staff’s experiences and understanding of therapeutic relationships (Aston & Coffey, 2012; Barnao, Ward, & Casey, 2015; Coffey, 2006). Gildberg, Elverdam, and Hounsgaard (2010) reviewed the literature in forensic settings and found patients and staff perceive there are two key views on staff–patient relationships: ‘paternalistic and behaviour changing care’ and ‘relational and personal quality depending care’. ‘Paternalistic and behaviour changing care’ focuses on patients from the perspective of control, rule enforcement, and parenting behaviours. Within this category, the literature points to three distinct characteristics: controlling and observing, setting limits and enforcing rules, and supporting patients (Baxter, 2002; Hinsby & Baker, 2004; Moore et al., 2002; Rask & Aberg, 2002). These relationships correspond to the traditional views of forensic staff–patient relationships. ‘Relational and personal quality depending care’ focuses on patients and has relationships listed as an underlying intention (Gildberg et al., 2010). These relationships are characterized by personal qualities, chatting, and social activities (Gildberg et al., 2010; Martin & Street, 2003; Rask & Hallberg, 2000). Throughout a patient’s stay in a forensic setting, there is a progression in the relationships they have with staff (Askola, Nikkonen, Putkonen, Kylmä, & Louheranta, 2017). The progression is influenced by how staff and patients respond to everyday interactions, as these responses can shape their current and future relationship outcomes (Ellis & Day, 2013).

Relationships are important for recovery and within the forensic setting they are particularly complicated because of the dual role staff members have. Understanding how staff navigate these relationships is important to understand how we can support and enhance recovery-oriented practices. This study aims to understand therapeutic relationships within a recovery-oriented forensic setting. This research explores and begins to fill the gap on forensic mental health frontline workers’ perceptions and experiences with therapeutic relationships.

Methods

This study aimed to explore how forensic mental health staff experience staff–patient relationships; a constructivist qualitative approach was chosen based on Braun and Clarke (2006). As part of a larger study, semi-structured interviews were conducted between September 2015 and October 2016 within a forensic program of a tertiary mental health facility in Ontario, Canada. The facility endorses a recovery-orientated model of care with staff trained to provide treatment that aligns with recovery principles. Recovery principles take a more holistic patient-centred approach to treatment and place value on collaboration, empowerment, and hope. The facility contains three minimum and three medium security inpatient units. These units are staffed with registered nursing professionals, along with a broad interdisciplinary team consisting of: psychology, psychiatry, social work, pharmacy, occupational therapy, recreational therapy, and behaviour therapy.

Participants

Participant recruitment initially used convenience sampling; however, while on the units a snowballing strategy was employed. A total of 88 forensic staff members participated in the study, 65 females and 23 males. 64 of the interviews were with nursing professionals and the remaining 24 were with individuals in the pharmacy, psychiatry, and allied health professions. 53 participants worked on a minimum security unit, 33 on a medium security unit, and 2 whom worked on both minimum and medium security units. 13 participants declined to answer the remaining demographic information. Participants ranged in age from 22 to 63 and the average age was 40.1 (SD = 10.9). Participants had an average of 9.1 years of experience in this setting (range = 0.3–31; SD = 7.2). The average number of years qualified was 13.2 (range = 0.3–36; SD = 9.8).

Ethics

Ethics approval was granted by the relevant facility research ethics committee. At all times, the privacy and confidentiality of the participants was held at the highest regard. All participants provided informed consent and were advised that participation was completely voluntary. No identifiable information remained in the quotes and pseudonyms were used to illustrate the various participant experiences and maintain confidentiality.

Procedure

A standardized semi-structured interview guide was used for all the interviews. There were three major questions forming the basis of the interview guide: 1) Can you explain how you initially develop your relationships with patients? 2) What traits do you believe are important for patients and staff to possess when thinking about your relationships? 3) How can the long-term impact of your relationship with patients be enhanced? All interviews were conducted by non-clinical researchers to avoid any perception of coercion or breach in anonymity. The interviews were held in a private room on-site. Any of the unit staff who were interested in participating were given the chance to partake in an interview. The interviews took on average 30 minutes and were audio recorded with the participant’s consent. These audio recordings were later transcribed verbatim and all identifiable information was removed.

Data analysis

A thematic analysis based on Braun and Clarke (2006) approach was used for data analysis. Analysis began when the transcripts were reviewed for accuracy against the original audio files, and the researchers familiarized themselves with the data. Notes were taken of potential codes and questions that the analysis could aim to address. Initial coding was completed using NVivo 11 Pro software and involved reviewing every transcript and creating various codes and tags. Following this initial coding, all the data were collated and sorted into potential themes based on relationships between, within, and across codes and themes. From this search, themes were reviewed by both researchers and a theme list was created. The data were then reorganized and reviewed to ensure no additional data were missed in prior coding stages. Finally, the themes were further defined and subdivided and a logical transition between the overarching themes was identified. This resulted in three key themes and their corresponding subthemes being created. All data coded within the subthemes were reviewed and primary decisions about compelling extracts and presentation were made. Key quotes were selected based on their illustrative capacity. In addition, word clouds were produced using NVivo to depict the qualities ascribed to staff and patients for a holistic picture.

Rigor

The co-authors provided a multidisciplinary approach to the research project, both in terms of discipline and clinical experience. Non-clinical researchers, who had no professional or personal connection to the participants, conducted the interviews to prevent any perceived undue pressure and reduce the chance of biased responses. Accurate, verbatim, and thorough transcriptions were obtained by having two researchers review each transcript against their original audio file. The views expressed in the interviews were compared and contrasted to ensure saturation had been reached. The experiences presented in this paper represent a comprehensive and collective view of staff experiences with staff–patient relationships. The themes were determined based on reflections of both researchers as to the underlying patterns and ideas. The researchers jointly determined the quotes best suited for each theme and then selected the most representative and compelling extracts.

Findings

From the transcripts, three major themes were identified: developing a therapeutic relationship, traits in a recovery-focused relationship, and the future for relationships. All of these themes were further subdivided based on the analysis.

Developing a therapeutic relationship

Staff members explained that developing a therapeutic relationship with a patient involves three steps: increasing receptiveness, recognizing the role of preconceptions and stigma, and providing patients with time and stories.

Receptiveness

Staff perceived when forming a therapeutic relationship, part of their role was to help their patients develop a sense of their own recovery. Staff members explained there were different ways to increase a patient’s receptivity. Appearing approachable, changing their behaviour to match a patient’s, and learning more about a patient were some ways staff formed relationships. One theme apparent in many of the staff’s experiences was that staff should be the ones making this first gesture. Frank, a nurse on a medium unit, explained:

I think a lot of it comes back to us. We’re here, we’re here to do – to develop relationships, to teach them, to make them feel secure. Cause whatever difficulty they have, interpersonal communications is up to us to address in helping them. And the onus should not be on them.

Within discussions around developing therapeutic relationships, one experience common to staff was that patients may feel negatively about being on a forensic unit, due to the custodial component of the setting. Staff felt negativity could shape a patient’s receptiveness towards relationships. Anne, a nurse on a medium unit, shared her experience:

You know a lot of the times they have no family and it’s debilitating for them and they’ve lost everything. It’s like when they come here it’s sometimes the worst day of their life. So yeah, you feel like, I feel like if I was here and I ended up here as a patient I would really want somebody to genuinely want to talk to me, want to listen to me and I try to do that.

Preconceptions and stigma

Staff members explained that they themselves have preconceptions and beliefs when forming strong working relationships with patients. Staff noted that these ideas shape initial and ongoing interactions with patients. Both nurses and other staff members explained that they had to be open when they met new patients. There was a general belief that it was unfair of staff to focus on the patient’s index offence because doing so made it difficult to see them as a person. Seeing patients as a person first and their illness and crime second was discussed throughout the interviews as a way to negate stigma. Tina, a nurse on a minimum unit, shared her belief:

I think knowing that they are a person as well, and not judging them and stigmatizing them for what brings them into the hospital and what they’re trying to recover from. So treating them as an individual and as a person.

Overall when developing a therapeutic relationship, staff members believed they needed to be open, non-stigmatic, and empathetic.

Time and stories

Staff shared an understanding that at first both themselves and the patients may feel uncomfortable, but as time progressed these feelings dissipated. Chantelle, an allied health professional on a medium unit, explained:

…Just as maybe I’m a little uncertain and feeling unsafe because I’m not quite sure who this person is, they’re probably feeling the exact same way because they don’t know me. So I think they… You know – as you start to spend a little bit more time and get them more involved in things, the more [activities] they come out to and the safer it becomes.

Staff had many examples of experiences where they opened up to patients. Sharing an innocuous detail about oneself and creating an environment with a fun and safe undertone were common actions across experiences. Brie, a nurse on a minimum unit, shared a story where she used something simple to show that she could be approachable and open:

You have to show a little bit of personal stuff because you know…One day. Ok, I’ll tell you a funny story. We’re watching a video, and there was an old video and I said, “Oh my” and I walked by and said “Oh my god that was like me in the 70s dancing at the disco.” Well, they thought it was so funny and they were laughing and I’m like “What’s so funny?” and I started dancing. They go “You are dancing.” I go “Yeah!” I said I used to dance at the discos and so they thought that was so funny. But I showed a human side, like I showed a human side of myself.

This experience of sharing something small that lightened the mood in the unit’s environment was common to many experiences shared by staff. Staff noted that using humour or genuine friendliness was a great way to break through the initial barrier between patients and staff.

Traits in a recovery-focused relationship

In discussions around maintaining relationships, staff identified two ideas which greatly impacted the ability for therapeutic relationships to grow. Firstly, staff experienced that there are specific qualities which are important for staff and patients to possess, when developing therapeutic relationships, namely being honest, open, and respectful. Secondly, the social approach used when communicating, impacted how relationships developed between staff and patients. These qualities help mitigate the impact of the dual role responsibilities (custodian and clinician) inherent in a forensic setting.

Honest, open, and respectful

In discussions about staff’s role within therapeutic relationships, staff explained from their experiences certain qualities were important to possess for ensuring relationship formation. Figure 1 illustrates a word cloud depicting the important attributes and qualities ascribed to staff. The size of the word is indicative of the frequency at which the word was listed. Honesty, listening, respect, empathy, and consistency were all qualities staff perceived as important for therapeutic relationship maintenance.

Figure 1. Qualities staff perceived as important for staff in terms of their relationships with patients.

In addition, staff explained there were various attributes important for a patient to possess to enhance the relationship building process. Figure 2 illustrates a word cloud depicting the qualities staff deemed to be important for patients to possess. The word cloud was created from all of the important attributes and qualities staff ascribed to patients. Being willing, open, communicative, and respectful were commonly ascribed characteristics to patients in terms of helping to develop relationships.

Figure 2. Qualities staff perceived as important for patients to possess in reference to having good relationships.

Social approach

How staff approached communication emerged as an important element for maintaining a therapeutic relationship. Staff perceived being transparent, non-threatening, engaging, accepting, supportive, and sincere throughout interactions led to more positive experiences with patients. The experience of approaching treatment or recovery related interactions from a social perspective was discussed by many staff members as an effective way to get the information they needed without any negativity or hostility. Staff explained that patients could tell the difference between staff who were doing a job and those who actually cared. Zoё, an allied health professional on a medium unit, shared her experience:

Nursing staff have certain questions that they have to ask. They are asking the same questions and patients know, they recognize sincerity and they recognize when somebody’s just trying to get their job done. And eventually they just tell you what you want to hear or they get annoyed and say ‘I’ve already answered these questions like 5 days in a row, I don’t want to answer them again.’ So, I don’t know finding creative ways to talk to patients, like maybe if you know that somebody likes cards, maybe sitting down and playing a game of cards with them. [Saying,] ‘So how are you feeling today, did you sleep well last night?’ So, it doesn’t seem so scripted.

Finding ways to change routine questioning into everyday social interactions led to experiences of more honest responses from patients and better relationships.

Future for relationships

When discussing the long-term impact that individual staff–patient relationships have, staff identified that these relationships influence recovery and identified perceived areas for improvement through increased activities and a sense of homeliness on the unit.

Recovery

Staff observed that having strong relationships can enhance a patient’s recovery. Recognizing that patients can be on forensic units for long periods of time, staff shared the importance of being cognoscente of this when looking at relationships. Sarah, a nurse on a medium unit, explained: ‘They’re here for years, so you better figure out how you can all work together and get along because they’re not going anywhere’. Staff shared experiences of working through the ups and downs because they cannot give up on these relationships as patients are mandated to remain in hospital. Additionally, staff discussed how the time frame makes them invested in helping patients achieve their future goals. Christopher, a nurse on minimum unit, shared his belief of:

Talking to them, trying to find out what they need. Or what they might need. Not just for the day, but the near future. Like, what plans do they have? That way I can see if there is something I can help them with. You know, perhaps they want to go back to school, they want to get a job, get training, you know.

Staff perceived their relationships with patients as more permanent and lasting. A desire to help patients accomplish their personal recovery goals, beyond mental wellness, was common among forensic staff.

Perceived areas for improvement

Despite staff sharing positive experiences with relationships, they made two suggestions for ways things could improve.

Activities

Many staff shared experiences of past working environments where there were more activities on the unit. Staff perceived activities as important for maintaining patient engagement, but also as a platform for social interactions between staff and patients. Victoria, a nurse on a minimum unit, shared her perception of how activities could enhance relationships:

I come back to doing more activities, engaging in more activities on the unit. We’re often seen as just being the people that hold the keys and give out medication. So it’s you know, to be able to sit and do other things or go off the unit more often with them or like engaging you know others. Well I mean more off unit activities I think would be a big thing.

This experience of activities allowing staff to be seen as more than their prescribed roles was shared as an important mechanism for addressing the power differentials between staff and patients inherent in the forensic mental health system.

Homeliness

The notion that patients start to see the unit as their home was something that was shared in many staff experiences. Staff discussed one way to improve therapeutic relationships would be to make the unit feel more homely. Laura, a nurse in a medium security unit, shared how she felt a homely unit could impact relationships:

Being able to sit out there and have supper with them or breakfast or whatever you want to do. Sit and have a cup of coffee with them, I guess it needs to be homey that way. And I think if you can do that your relationship is going to get better with a lot of the patients.

Making small homely touches to the unit milieu whether in the form of actions, gestures, or physical changes was something discussed by many staff as a way to improve relationships.

Discussion

This study addressed the literature gap on staff perceptions of staff–patient relationships in the forensic mental health system and showed that they consider relationships in terms of their initial development, overarching traits, and future potential. A recovery-orientated treatment approach empowers patients and encourages meaningful staff–patient relationships and interactions (Davidson et al., 2005; Nijdam-Jones et al., 2015). However, therapeutic relationships in forensic settings are commonly poor and this impedes recovery (Serran & Marshall, 2010). This study contrastingly found staff shared fairly positive experiences with their therapeutic relationships. The findings of this study can help shape relationship improvement initiatives within forensic mental health systems by focusing on concepts common to positive relationships.

On a broader level, staff felt their relationships with patients involved growth and development. The various themes all link together and illustrate the larger picture that forensic staff believe their relationships with patients are interactive and reciprocative in nature. Decisions staff make within their dual role (custodian and clinician) are not autonomous from their patients. In fact, our discussions highlight that staff commonly consider how their relationships and interactions affect their patients. Discussions suggest that there is no one specific way to ensure a therapeutic relationship forms, but rather there are various factors that influence relationships. In addition to this broad overview of the experiences, staff discussed their therapeutic relationships in terms of developing, traits, and moving forward.

Developing

Staff explained that when patients first enter the forensic setting they may feel unreceptive and focus on the involuntary nature of their detention and the power differentials between staff and patients. Within this theme, staff identified the onus was on them and they needed to be empathic towards patients’ feelings. The importance of creating a stabilizing and calming environment for patients, when they first arrive has been previously noted (Askola et al., 2017). Patients can appear defensive when they first arrive at a forensic setting (Crisford, Dare, & Evangeli, 2008). Laithwaite et al. (2009) rationalize this occurs because a patient’s background can lead them to automatically feel threated in new situations. When staff discuss receptivity and trying to increase receptivity, they are discussing how they overcame that initial defensive wall. The literature points to trust as the pillar for ensuring relationships can develop within forensic settings (Askola et al., 2017; Gildberg, Bradley, Fristed, & Hounsgaard, 2012).

Staff shared stories about how their relationships with patients have developed. Stigma interferes with all aspects of mental health and in particular a patient’s recovery and care (Corrigan, 2004; Newton-Howes, Weaver, & Tyrer, 2008; Sartorius, 2002). Staff explained they should see patients as an individual and not their crime or illness, which aligns with findings from Volstad (2008) and Thorpe, Moorhouse, and Antonello (2009). Literature references this behaviour as the underpinning to a ‘non-judgemental’ approach to treatment in the forensic setting (Gildberg et al., 2012). This approach was echoed in our discussions, when staff expressed the importance of entering therapeutic relationships with an open, non-stigmatizing approach.

Staff recognized that at first building a therapeutic alliance could be difficult; however, by sharing personal stories and giving a patient time, these difficulties could be overcome. Both of these strategies link back to the idea of creating trust between patients and forensic staff. Trust requires openness, takes time, and is collaborative (Askola et al., 2017; Rose, Peter, Gallop, Angus, & Liaschenko, 2011). Through sharing innocuous personal stories, staff present themselves as open to their patients and this fosters trust. In a forensic setting where patients are prone to extended stays, recognizing that these relationships will grow with time makes staff motivated to ensure these relationships are positive. Within this study, relationships were viewed as developmental and progressive. Askola et al. (2017) found that therapeutic relationships in the forensic setting take shape in a phased approach. Relationships do not form overnight, but rather require a gradual transition throughout a patient’s treatment.

Traits

Of the traits ascribed to staff and patients there were similarities between the two groups. Being open, respectful, and willing to listen were all identified as important traits to both groups. Openness can impact the receptiveness to potential and future interactions, and links to being non-judgemental and available for discussions (Brunt & Rask, 2005; Gildberg et al., 2012; Schafer & Peternelj-Taylor, 2003). Being respectful has been found as a co-requisite to trust (Rose et al., 2011). Literature suggests listening involves being heard, respected, and treated as a human being (Schafer & Peternelj-Taylor, 2003). The commonalities between the traits suggest that trust and non-judgemental attitude are key qualities for both patients and staff in forensic settings. Many of the traits ascribed to patients focused on communication: communicate, open, talk, conversation, engage, listen. In contrast, the only communication trait ascribed to staff was listening. The nature of these communicative traits highlights staff’s belief that their relationships are collaborations with patients despite the involuntary detention and treatment component of forensic mental health settings.

The findings from this study suggest staff need to approach their jobs with more of a social perspective. Taking a more informal approach to interactions with patients has been previously discussed in forensic psychology as ‘chatting’ (Gildberg et al., 2010; Martin & Street, 2003). ‘Chatting’ has been seen as an informal communication strategy because of the conversation content and location (Martin & Street, 2003). Our study suggests that an informal communication strategy could be used irrespective of the content. A social approach can be used to obtain content, which can then be relayed into formal measurement guidelines. One such guideline is the mental status assessment, which may become repetitive if required to be completed in a standardized manner multiple times each day. Our findings suggest that employing a social approach creates a pleasant and engaging conversation while still obtaining the relevant information. Staff within the forensic setting have been reported to experience tension between their role as a ‘custodian’ and ‘therapeutic’ agent (Mason et al., 2008; Peternelj-Taylor, 2000; Rask & Hallberg, 2000; Swinton & Boyd, 2000). Literature suggests this tension can strain basic staff–patient relationship formation and broader therapeutic relationships (Hillis & McClelland, 1998; Volstad, 2008). A less prescribed approach to obtaining clinical information may improve the quality of the information obtained and assist in relationship formation.

Moving forward

Staff discussed recovery in terms of length stay and the opportunity to build relationships over long periods of time in forensic services. Inpatients spend on average 2.84 years in the forensic setting while undergoing review (Charette et al., 2015). Kurtz and Jeffcote (2011) reported that a prolonged length of stay encouraged staff to overcome relationship difficulties. Our findings highlighted similar experiences of staff working through relationship challenges with patients. Staff explained they had a role in supporting patients on their personal recovery journey. This role included motivating patients to achieve their personal recovery goals. Askola et al. (2017) found staff acted as supporters, motivators, and hope providers in their relationships with patients. The desire shared by staff to help patients achieve their personal recovery goals suggests they want to act as motivators for their patients.

Both activities and homeliness positively influence the psychosocial atmosphere on units. Psychosocial atmosphere has been found to influence the recovery process of patients (Moos, 1989). As patients are often on the forensic units for extended durations, these units can be seen as their home environment (Brunt & Rask, 2005). Staff recognized patients’ perceptions regarding the homeliness of their environment influences the potential for relationships to develop. Brunt and Rask (2005) argue that patient engagement and involvement directly impacts the energy they will invest in their recovery. Staff explained activities provide a platform for social interactions and a way for patients to view staff as more than members of a multi-disciplinary team.

Staff in forensic mental health services need to approach recovery with a broader definition for the positive effect of therapeutic relationships to be seen. Finally, the suggestions by staff to increase activities and the sense of homeliness on units can be applied as initiatives to enhance therapeutic relationships.

Limitations

A limitation of this study is that it was conducted in one forensic setting; therefore, the experiences described may not be representative of all forensic settings. Participation was voluntary and this raises limitations related to the representativeness of the broader forensic staff demographic, as people with a positive outlook towards therapeutic relationships would likely participate. This acts as a strength because it provides feedback for potential tools and information that will help ensure strong relationships occur. The findings of this study are limited in their exploration of staff–patient relationships as they focus solely on the staff’s perceptions. Additional research on therapeutic relationships incorporating patient’s perceptions is needed.

Conclusion and recommendations

Recovery-orientated care is becoming generally accepted as the best practice. Recovery is a broad concept, and many forensic staff want to assist patients with their broader recovery goals. The findings from this study begin to address the lack of research on front-line workers’ perceptions of relationships in a recovery-orientated forensic setting. Therapeutic relationships occur as a collaborative process between patients and staff. Successful relationships require strong development, and this can be achieved when staff take onus for their role and remain non-stigmatic, empathetic, and open to their patients’ recognizing that they are not defined by their index offence. This study emphasized that collaboration is a key trait and clinical information should be obtained using a social approach. Finally, our findings suggest that the extended length of stay experienced by many forensic patients provides opportunities for long-term involvement in a patient’s recovery journey and encourages staff to work through relationship difficulties. Staff discussed the need for more social activities and a sense of homeliness on the unit to foster a positive relationship building environment. Research exploring these ideas could prove fruitful for future interventions aimed at creating better therapeutic relationships in recovery-focused care.

Acknowledgments

This work was supported by the Ontario Ministry of Labour under Grant #15-R-018, which had no bearing on the interpretation or analysis of the results. The views and opinions expressed in this article are that of the authors and are not reflective of any affiliations. The authors would like to thank the research assistants who assisted with interviews and the staff who participated in this research.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the Ontario Ministry of Labour [#15-R-018].