THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY

2018, VOL. 29, NO. 5, 744–761

https://doi.org/10.1080/14789949.2018.1508486

Building from the ground up: exploring forensic

mental health staff’s relationships with patients
Lisa A. Marshalla,b and E. A. Adamsa
a
Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada; bDepartment
of Psychiatry, University of Toronto, Ontario, Canada

ABSTRACT
Recovery-orientated care is becoming generally accepted as the best prac-
tice, 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 recov-
ery. 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.

ARTICLE HISTORY Received 19 March 2018; Accepted 19 July 2018

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 work-
ing through their recovery, forensic patients often lose touch with commu-
nity and/or family supports because of the long time periods spent in
facilities. While in hospital, patients interact with a broad interdisciplinary

CONTACT Lisa A. Marshall marshalll@ontarioshores.ca

© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use,
distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered,
transformed, or built upon in any way.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 745

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 recov-
ery 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 relation-
ships 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 under-
standing 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: ‘paterna-
listic 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
746 L. A. MARSHALL AND E. A. ADAMS

(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 treat-
ment 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
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 747

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 commit-
tee. 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 infor-
mation 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 inter-
views. 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 ques-
tions 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
748 L. A. MARSHALL AND E. A. ADAMS

subdivided and a logical transition between the overarching themes was

identified. This resulted in three key themes and their corresponding sub-
themes 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 com-
prehensive 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
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 749

a patient’s, and learning more about a patient were some ways staff
formed relationships. One theme apparent in many of the staff’s experi-
ences 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 experi-

ence 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
750 L. A. MARSHALL AND E. A. ADAMS

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 impor-
tant 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 pos-
sess 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.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 751

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 impor-
tant 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.

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:
752 L. A. MARSHALL AND E. A. ADAMS

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

having good relationships.

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 interac-

tions 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 relation-
ships 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.
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 753

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
754 L. A. MARSHALL AND E. A. ADAMS

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 initia-
tives within forensic mental health systems by focusing on concepts com-
mon 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
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 755

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 parti-
cular 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 impor-
tance 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 moti-
vated to ensure these relationships are positive. Within this study, relation-
ships 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
756 L. A. MARSHALL AND E. A. ADAMS

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 listen-
ing. 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 psychol-
ogy as ‘chatting’ (Gildberg et al., 2010; Martin & Street, 2003). ‘Chatting’ has
been seen as an informal communication strategy because of the conversa-
tion 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 com-
pleted 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 diffi-
culties. Our findings highlighted similar experiences of staff working
through relationship challenges with patients. Staff explained they had a
 THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 757

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 engage-
ment 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 foren-
sic 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 parti-
cipate. 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 rela-
tionships 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’ percep-
tions of relationships in a recovery-orientated forensic setting. Therapeutic
758 L. A. MARSHALL AND E. A. ADAMS

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.

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

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