Therapeutic milieu approaches within a high security hospital: a qualitative analysis of patients' experiences of ward-talking-groups
Background: Research has shown that staff-patient relationships within secure forensic services appear to be influenced by an ethos of institutional control, most evident in the tensions of developing meaningful therapeutic relationships while continuing to maintain high levels of security. In an attempt to address the perceived deficits in these relationships, the development of a positive therapeutic milieu was proposed within a high security hospital. Novel therapeutic interventions, known as Ward-Talking-Groups (WTGs), were introduced as a first step towards the development of this milieu. It was also recognised that research exploring the efficacy of psychological interventions for the treatment of psychotic symptoms have exclusively focused on community based settings or general psychiatric hospitals. Although the findings from these reviews have some utility within a forensic psychiatric population, this population also have a number of co-occurring complex needs that inevitably impact on treatment outcomes. Objective: The primary study aimed to explore in detail patients' experiences of being part of their WTGs. A systematic review was also conducted to review the existing literature regarding the efficacy of psychological interventions for the treatment of psychotic symptoms in individuals with forensic needs. Methods: For the primary study, semi-structured interviews were conducted with ten male participants detained within a high security hospital. The data was transcribed and analysed using Interpretative Phenomenological Analysis. For the systematic review, using predefined inclusion and exclusion criteria, eight databases were searched, selected journals were hand searched and two grey literature databases were searched to identify relevant studies. 9 Results: For the primary study, three themes emerged from the data: Coming together as a unit; Liberty Vs. Control, and Facing something new. For the systematic review, eight studies fulfilled the inclusion criteria for review, with relevant information from each study being extracted and tabulated. The identified studies were scored against quality criteria. Discussion: For the primary study, the findings highlight the importance of patients being able relate to other people within their WTG, with the challenges and benefits of this being at the forefront of participants' minds. Participants described an increased sense of liberty within their WTG, while being acutely aware this was within the context of a high security hospital. Participants' feelings towards the introduction of their WTG appeared to be split; some felt ambivalence towards them, while others were open-minded about them. Reflecting on the introduction of their WTGs, participants shared the view that more information about them was necessary. However, they differed in their approach to seeking this out. For the systematic review, overall findings from the review papers tentatively suggest there is some evidence for the efficacy of psychological interventions in the treatment of psychotic symptoms in individuals with forensic needs. Clinical implications, strengths and limitations, and future research possibilities are outlined for both the empirical study and systematic review.