Violence, Aggression and Therapeutic Relationships: Understanding the Lived Experiences of Females within Low and Medium Secure Forensic Mental Health Units.

Aims: To explore female secure forensic mental health (FMH) patients’ therapeutic relationship (TR) quality; the impact of witnessed, or perpetrated, violence upon psychological wellbeing and TRs; and perceived beneficial support following exposure to violence within the units. Background: Female FMH patients possess unique vulnerabilities, psychological and offending profiles; have commonly experienced early childhood trauma, attracted Borderline Personality Disorder diagnoses, and by definition appear highly likely to witness or perpetrate violence. In other settings, strong TRs are consistently associated with positive outcomes, their significance is highlighted within FMH literature yet it is unknown how female FMH patients experience TRs with their clinical teams, or how witnessing or perpetrating violence affects these relationships. Methodology: Qualitative methodology was employed within an interpretivist paradigm. 8 females were recruited through purposive homogenous sampling, across low and medium secure units. In-depth semi-structured interviews were conducted. Data was analysed by means of thematic analysis. Results: Twenty themes, and accompanying subthemes, were extracted from participants' data. TRs are experienced as challenging, complex, multi-faceted; and impact upon wellbeing and recovery. Violence is perceived as ‘normal’, however incidents have a profoundly negative psychological impact, and affect journeys of recovery. Managing exposure to violence involves the need for patients to take care of themselves. Staff were perceived as trying their best but often getting it wrong, participants expressed the need for pro-active staff involvement. Participants perceived the damage caused to TRs by incidents, as predominantly due to negative changes in staff behaviours. Conclusions: TRs serve a variety of important functions for female secure FMH patients. Witnessing or perpetrating violence negatively impacts upon TRs, wellbeing and recovery. Findings are discussed in relation to previous research, psychodynamic and systemic theories. Implications are discussed regarding: the development and maintenance of TRs, improving psychological containment, FMH workforce development, and the broader management of violence.