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

November 2021
The Center For Health Design

Why does this study matter?
In Sweden, a mentally ill person who commits a crime is sentenced to care instead of prison with an average length of stay of five years. The major aim of forensic psychiatric care is to provide rehabilitation and reintegration to prevent new crimes and violence by mentally ill patients. An environment that mirrors “normal life” is seen as more compatible than traditional short-stay hospital settings. It is important to understand these environments from the perspective of patients during their most vulnerable moments.

How was the study done?
This research team used a qualitative methodology to try to understand the patient perspective secure inpatient care settings in Sweden between 2010 and 2016. Staff from three similarly configured, purpose-built forensic psychiatric hospitals identified patients to participate in interviews. Nineteen of 63 patients consented for participation.

The research team used photovoice data collection, a method that empowers marginalized people and disentangles intimately linked concepts like “space and place.” Prior to interviews, each patient was given a camera and a written note that said, “Please, take photographs of 3–4 objects in your room that are important to you in a positive or negative sense.” The photos were used during open-ended interviews to help patients explain what was in the photo and what it meant to them.

First, the research team reviewed 19 interviews in search of meanings, possible patterns, and themes. Second, the researchers agreed on the main content and patient focus of 78 photographs. Next, the researchers identified relevant content and meanings that then were related to one another and coded.  Finally, the research team linked and compared meanings with one another to identify a number of overall themes and implications.

So what do we learn from this study?
Four themes emerged from the analysis:

  1. Having a private place: Patients felt safe in private rooms that allowed them to withdraw, reflect, and be surrounded by personal items. All the patients took photographs of their beds and emphasized how much they meant to them. Windows and niches were used as shelves to store or display objects.
  2. Upholding one’s sense of self: Private rooms with dedicated bathrooms helped patients feel respected as a person and to live on their own terms. Displaying belongings, establishing boundaries, wearing personal clothing, and taking responsibility for their space gave them feelings of having value.
  3. Feelings of comfort and harmony: Normal living conditions, such as a private bathroom, cozy furniture, and other design features that created a functional living space gave patients feelings of comfort and a sense of harmony. Patients felt calmer knowing they had a quiet private space where they could retreat as well as welcoming public spaces to host family and friends.
  4. Remaining connected to one’s life: Being part of a context and connecting with others was facilitated by photographs, visitation, views from the window, activities with other inmates, as well as access to computers, phones and television.
Can we say the results are difinitive?
Forensic psychiatric inpatient populations have numerous human subject ethical study protocol protections put in place due to their vulnerability. The amount of care and commitment demonstrated by the research team to give these patient’s a voice is commendable. Furthermore, the methodology used was right on target for honoring each patient as a partner in person-centered research. This methodology could and should be replicated in other settings to understand the patient perspective.

It is worth noting that the findings in this study contradict previous reported patient experiences in traditional forensic psychiatric care facilities (e.g., a lack of activities, boredom, and a less meaningful everyday life). More research is needed to gain clarity for the outcomes between traditional and purpose-built facilities in this regard.

What's the takeaway?
The design of the newer person-centered forensic psychiatry facilities is reportedly based upon extensive collaboration between the designers, management, and care staff to ensure that design decisions are grounded in science- and experience-based, systematically provided data. While this may be consistent with the tenets of evidence-based design, it does not reflect the person-centered philosophy of acknowledging the person behind the illness/crime as an equal contributor of insight for design... Arguably the most unique, difficult to obtain, and insightful experience-based perspective.

Olausson, S., Wijk, H., Berglund, I. J., Pihlgren, A., Danielson, E. (2021) Patients’ experiences of place and space after a relocation to evidence-based designed forensic psychiatric hospitals. International Journal of Mental Health Nursing, Pages in press

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Learn more about this research paper in our Knowledge Repository