Veikko Pelto-Piri
Lars Kjellin1- 1Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
- 2Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
- 3Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet & Stockholm Health Care Services, Stockholm, Sweden
Background: Upholding human rights, including promoting patients’ social inclusion, is essential in forensic psychiatric services to ensure socially sustainable development. Understanding how social inclusion it is perceived by patients is therefore important. Evidence suggests that the Safewards model can enhance social inclusion in inpatient settings. The aim of this study was to explore patients’ perceptions of social inclusion in a forensic psychiatric clinic that implemented the Safewards model. To provide context, a secondary aim was to describe which Safewards interventions were implemented and how patients perceived them.
Methods: Eight male patients from a forensic psychiatric clinic in Sweden were individually interviewed, focusing on Safewards and opportunities for social inclusion. Thematic content analysis was used to deductively code the data under the three core values of a social inclusion model: participation in decision-making, reciprocal relationships, and social justice. Themes for each value were thereafter developed inductively. For the secondary aim, a concise qualitative description was used to create an overview of patients’ perceptions of Safewards.
Results: Patients were aware of the Safewards interventions and were generally positive about them. Nine themes emerged: powerlessness when meeting the doctor; limited experience of involvement in daily decisions; desire to become involved in quality improvement efforts (participation in decision-making); staff members’ availability and positive attitude; fellow patients exhibit care and consideration; withdrawal and avoidance of social interaction (reciprocal relationships); boredom and low mood within the ward; desire for dignified, equal, and safe care; and perception of unjustified confinement (social justice).
Conclusion: The findings suggest that while Safewards may support more compassionate staff–patient relationships, it does not in itself ensure participatory or rights-based care. Achieving higher levels of social inclusion in forensic psychiatric services requires broader cultural and structural reforms beyond the implementation of individual models.
1 Introduction
“Social inclusion is the process by which efforts are made to ensure equal opportunities - that everyone, regardless of their background, can achieve their full potential in life. Such efforts include policies and actions that promote equal access to (public) services as well as enable citizen’s participation in the decision-making processes that affect their lives.” – Social inclusion as defined by Division for Social Policy and Development, United Nations (1).
The United Nations (UN) Convention on the Rights of Persons with Disabilities (CRPD) aims to promote the social inclusion of persons with disabilities (2). Member states that have ratified the convention should take legislative and policy measures to eliminate discrimination against this group. The presence of a disability should not justify deprivation of liberty or the use of coercive measures. Sweden has faced extensive criticism for psychiatric practices that conflict with the principles of the CRPD (3, 4). The UN Committee monitoring the convention has repeatedly criticized Swedish psychiatry for overuse of coercive measures, inadequate documentation and a narrow biomedical perspective, urging the state to improve care and transparency (3, 5). Similar concerns have been raised by Sweden’s national monitoring body under the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT), which has condemned the frequent use of coercive practices in forensic psychiatric services (6). Patients in Swedish forensic psychiatric services often present with multiple and complex needs, including comorbid psychiatric disorders, substance use, cognitive impairments, and various social vulnerabilities (e.g., immigrant or refugee background, low educational attainment) (7–9), which may create barriers to participation and communication. The combination of these factors, together with paternalistic and custodial institution culture, make implementing human rights conventions particularly demanding.
The UN Sustainable Development Goal No. 16 aims to promote the development of effective, accountable and transparent institutions to ensure responsive, inclusive, participatory and representative decision-making at all levels (Target 16:6) (10). Social inclusion is a fundamental foundation for achieving socially sustainable development, as it operationalizes human rights values, such as participation, dignity, equality, and non-discrimination, within institutions (11–13). From this perspective, social inclusion represents both a process and an outcome that enables individuals, particularly the most vulnerable, to exercise their rights and participate fully in society (11, 14). Such efforts provide individuals with opportunities to actively participate and make their voices heard (10, 15, 16). At the beginning of the 21st. century, a policy of social inclusion was introduced in many organizations working with disabled persons, creating a need to measure and evaluate it (12, 13, 17). However, the instruments developed were criticized for their narrow definitions of social inclusion, their tendency to disregard the inherent power imbalance between users and service providers (16, 17) and failure to address social inclusion as a context-dependent set of values rather than a narrowly defined empirical concept (11, 18). In psychiatric services, understanding of social inclusion as a set of core values is appropriate, as the World Psychiatric Association and The World Association of Social Psychiatry have adopted several declarations that align with human rights and incorporated social inclusion in their psychiatric ethical framework (19–21).
In this paper, we define social inclusion in inpatient psychiatric services as consisting of three core values: Participation in decision-making, reciprocal relationships and social justice (Table 1) (21, 22), a definition that aligns with earlier and contemporary literature (17).
Table 1. Core values of social inclusion in institutional psychiatric settings, modified from Pelto-Piri & Kjellin, 2021 (21) and Pelto-Piri & Wetterling 2024 (22).
The first core value in the model (Table 1) concerns patients’ rights to participate in their care and treatment, a principle that emerged in medical ethics after World War II as a reaction to the paternalistic tradition in medicine (20). According to the World Medical Association’s Code of Medical Ethics, physicians are obliged to inform patients at every stage of the care process and to offer care that aligns with the patient’s best interests, to which the patient has the right to consent or refuse (23, 24). These criteria represent the minimum standard for participation. Today, patients may also be offered multiple options for their care and the possibility of seeking a second opinion. Shared decision-making can be considered part of participation (25). However, in this model, it is categorized under the second core value, reciprocal relationships, which is emphasized in person-centered, recovery-oriented, and other strength-based approaches. It highlights that human relationships are essential for survival and health (26) as well as each individual’s right to mutual relationships with others (27, 28). The values underlying these approaches are closely interrelated and can be viewed together, following the WHO’s description of a collaborative model of health and social care in which the individual’s unique goals, strengths, and preferences are central to care planning and decision-making. The core value of reciprocal relationships highlights the creation of trusting and mutual relationships based on respect, empathy, and understanding. It seeks to promote dignity, autonomy, and meaning in life rather than focusing solely on symptom reduction. From this perspective, the individual is recognized not merely as a recipient of care but as an active partner whose experiential knowledge complements professional expertise (25, 29). The third core value, social justice, concerns recognizing patients as citizens and right-holders in relation to the psychiatric services, which are duty-bearers (24, 30). Social justice partly refers to the fair distribution of resources, opportunities and privileges within society (31) and is especially important when working with vulnerable populations, such as forensic psychiatric patients (32). It is also a part of psychiatric ethics, implying that staff should engage in promoting patients’ civil rights (27, 28, 31, 32). According to the European Standard on Patient Involvement in Health Care (24), this responsibility extends beyond individual staff members to the organizational level, requiring healthcare institutions to provide the structural and cultural conditions that enable professionals to practice person-centered and participatory care. Furthermore, social justice also implies that patients and their organizations should be encouraged to participate in the co-creation and co-production of psychiatric services (22). The recovery perspective emerged from the social justice movement. However, it has been suggested that it has since been co-opted and mainstreamed by professionals and policymakers, who have subsequently downplayed the original emphasis on social justice (33, 34).
It has been suggested in the literature that forensic psychiatric services should introduce a value basis with a stronger focus on human rights, as this would provide opportunities to adopt a strength and recovery-oriented practice (35). One way to support such a shift may be through the implementation of the Safewards model to reduce coercion and improve ward climate, an approach that this study sought to explore. The Safewards model was originally developed to prevent conflict and containment in acute psychiatric wards and consists of ten interventions (36) but is now also being used in many forensic psychiatric services (37). Frequently the primary reason for implementing Safewards in forensic psychiatric services is not reduction of coercive measures, which are relatively few compared with acute psychiatry. Instead, Safewards addresses important challenges in forensic psychiatric care, such as creating a sense of community and hope, communication strategies and early support for patients in need of care (Table 2) (36, 38). Safewards could thus facilitate a shift from the traditional paternalistic and custodial culture towards a more inclusive care culture (39). When Safewards was implemented in forensic psychiatric services, a need for adaptations was observed and research has been conducted on developing such adaptations (39, 40).
Table 2. The ten Safewards’ interventions for reducing conflict, from Fletcher et al., p. 3 (38).
To ensure the social sustainability of forensic psychiatric services, there is a growing expectation for the field, internationally and in Sweden, to adopt more person-centered, recovery-oriented and other strength-based approaches (41, 42). This shift can be achieved by promoting an institutional culture that upholds human rights and enhances patients’ social inclusion (43). To advance forensic psychiatric services in this way we need a deeper understanding of how social inclusion is perceived by patients. Although there are some challenges involved in adapting and implementing the Safewards model in forensic psychiatric services, evidence suggests that it can enhance social inclusion, particularly in terms of how patients perceive their situation (37, 44). The aim of this study was to explore patients’ perceptions of social inclusion in a forensic psychiatric clinic that implemented the Safewards model. To provide context, a secondary aim was to describe which Safewards interventions were implemented and how patients perceived them.
2 Materials and methods
2.1 Design
This interview study employed qualitative content analysis and qualitative description to examine data from semi-structured interviews (45–47). These methods were chosen to provide a comprehensive account of patients’ narratives within the framework of social inclusion, focusing on their experiences of living in a forensic psychiatric clinic implementing the Safewards model. To ensure methodological rigor, the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was applied (48).
2.2 Settings and sample
The study was conducted in a clinic that primarily provides care for individuals sentenced within the catchment area of a Swedish county with approximately 300, 000 inhabitants. According to national classifications, it is considered an intermediate region, with an urban center surrounded by smaller municipalities and rural communities. The clinic consisted of four wards that predominantly, but not exclusively, treated male patients. It had 27 beds in three low-security wards and seven in a medium-security ward, which also functioned as an admission ward. One of the low-security wards served as a discharge ward. This arrangement meant that patients were transferred between wards during their care. The clinic started to implement Safewards in 2020. The wards had implemented three to five interventions. While all wards included Talk Down in their training for managing aggression and violence, only two wards had integrated it as part of their work with Safewards. One of the wards worked especially hard on Calm Down Methods. They had furnished a small, doorless room called the calm room in a homely style with two armchairs. This room was appreciated by patients and primarily intended for use in the Calm Down Methods intervention but was also used for conversations. All wards conducted patient meetings. However, only one had implemented the Mutual Help Meeting intervention.
The interviews were conducted at the turn of the year 2022/23. We applied three exclusion criteria: Patients who were (1) unable to provide informed consent, (2) acutely ill or exhibited violent behavior, making an interview inappropriate and (3) unable to participate in an interview due to insufficient proficiency in Swedish. A nurse provided a list of nine patients who met the inclusion criteria. All eligible patients were interviewed, except for one individual who was on leave during the scheduled visits. At the time of recruitment, the clinic had 34 patients, including three women who were excluded based on the agreed criteria. Eight male patients were interviewed, their ages ranging from 21 to 63 years, with a mean age of 40 years.
2.3 Interview guide and procedure
A semi-structured interview guide (see Supplementary File 1) was used, with questions about social inclusion at the ward, the implemented Safewards interventions and Safewards’ contribution to a safe ward environment. The interviewers did not have any relationship established with the patients prior the study commencement. The patients were informed about the study both verbally and in writing by the nurse in charge, who also asked about their interest in participating. The interviewers later repeated the study information, and all participants gave their written consent to participate. Individual interviews were conducted in a room at the ward. Prior to the interviews, participants were informed that the interviews would be conducted by a research assistant (see Acknowledgements) and a researcher (VP, see Authors’ Contributions), both of whom had personal experience as patients in psychiatric inpatient care. The purpose of this disclosure was to be transparent and honest with the participants, possibly influencing their perception of the interviewers as credible and trustworthy and, consequently, what experiences they chose to share (49). The interviews, which lasted from 23 to 50 minutes (mean 35 minutes), were recorded and transcribed verbatim.
2.4 Analysis and interpretation
To address the supplementary aim and provide an overview of patients’ experiences of Safewards, nine Safewards interventions were used as categories to generate a concise qualitative description (46, 47). The Positive Words intervention was excluded, as it relates to staff handovers, during which patients are not present.
To address the main aim, a qualitative content analysis was employed (45). The three theoretical core values of the social inclusion model served as an analysis matrix for deductively categorizing the interview data. Following this initial categorization, an inductive analysis was conducted within each category to identify emerging themes. Initially, the four researchers (VP-P, LiK, LaK, JW) were each assigned one interview to read thoroughly, marking relevant sentences and paragraphs, which were then categorized under the social inclusion core values. Any ambiguities or uncertainties regarding coding were discussed and resolved through consensus. The interviews were then divided among LiK, LaK and JW, who proceeded to code the entire dataset in Excel after which the codes were checked by another of the three researchers in this group. At our second meeting, we addressed problems involving interpretation and overlapping coding within the social inclusion categories and agreed on a consistent approach. At the third meeting, we reviewed the analyzed material, identifying recurring patterns and key insights. We selected significant quotations that exemplified social inclusion and organized them into themes. As the last step, during our concluding meeting and final interpretation, all authors reviewed the potential themes and collectively selected those that best represented the interview content. VP and AB, who were involved in the implementation of Safewards in their respective regions, did not conduct primary analyses, such as coding of interviews, but contributed to the discussions during the entire analysis process.
2.5 Reflexive practice and positionality
The research team, consisting of senior researchers, experts by experience (from acute and forensic psychiatric inpatient services, but not from the included clinic) and a medical master student, engaged in ongoing reflexive practice throughout the study to address their positionality and potential influence on the research process. Three individuals, one interviewer and two authors, had lived experience of mental health issues and psychiatric inpatient care. This diversity enriched the research process but also necessitated critical reflection. Throughout the research process, the team held discussions about their positionalities and preconceptions related to the research topic, ensuring an awareness of the risk of bias as well as enhancing the rigor and trustworthiness of the study (50).
3 Results
Before presenting the main findings, a brief description is provided of the Safewards interventions implemented in the four wards and participants’ perceptions of them. Our findings suggest that most participants were aware of the Safewards interventions and generally viewed them positively, see Table 3.
Table 3. Participant perceptions of Safewards in the four wards of the clinic.
To address the main aim, we created nine themes in the analysis grounded in the core values of social inclusion: participation in decision-making, reciprocal relationships, and social justice (Table 4).
Table 4. Overview of the thematic framework.
3.1 Participation in decision-making
3.1.1 Powerlessness when meeting the doctor
Participants stated that the doctor has a plan regarding their care that cannot be influenced by the patient’s own thoughts or opinions. The feeling was that the doctor has overwhelming power regarding care content and decision-making and does not take patients’ opinions into account. The participants were frustrated about the lack of participation in their own care process, which increased when they felt that their voices were not heard or taken seriously.
“You know, there’s really nothing you can have a say in. The doctors have a plan, and that’s the plan that sticks: you have to get treatment, find a job, get a flat, then move on to outpatient care—and once you’re through that, you’re discharged.” – Participant 7.
The participants expressed that they had few meetings with the doctor with too much time elapsing between meetings and that their mental health status could change significantly in the meantime. Although they did not have many meetings with the doctor, they described the doctor as having full insight into their situation. A sense of being under constant observation intensified feelings of powerlessness.
Interviewer: Have you ever noticed, if someone doesn’t follow the rules, what happens then?
Participant 3: Yes, they write it down in, um, some book or make a note.
Interviewer: But what do the staff do then? For that patient, besides making a note or something?
Participant 3: They tell the doctor. So, it’s up to the doctor then. I’ve experienced that.
3.1.2 Limited experience of involvement in daily decisions
The participants expressed that their ability to make everyday decisions was limited to a weekly meeting, where they were allowed to choose activities for the weekend, which toppings to have on their sandwiches and what type of bread they want with their coffee. Although these choices were relatively minor, they were nonetheless perceived as meaningful and important aspects of everyday life.
“Yeah, I mean, it’s the little things, really—like choosing what spread you want [for breakfast] or stuff like that. It’s part of feeling involved, you know? You might not get a say in the big, important stuff, but choosing your spread can feel like a big deal when you’re having breakfast. Like, getting your egg instead of nothing.” – Participant 5.
These meetings appeared to be the only occasion when patients had some sort of influence on the ward. Some participants described a feeling of powerlessness when it comes to important aspects of their own care and daily life at the clinic.
3.1.3 Desire to become involved in quality improvement efforts
Participants made suggestions about how to improve everyday life and the atmosphere in the ward to increase the feeling of normality and make it more homely. There were requests and ideas for more meaningful activities, such as cooking together with other patients and staff. They wanted activities that could provide opportunities for socializing with others to promote the feeling of inclusion and belonging. For example, a participant expressed that the design of the Safewards Clear Mutual Expectations intervention was flawed. Although he believed the expectations were positive and contributed to a better atmosphere, it felt frustrating not to have been involved in the process of creating them.
“I mean, sure, it says good things, absolutely, but it’s not something we, the ones actually sitting in here now, have been part of creating together. That’s why it feels so off, you know, when I read ‘The mutual’. We’ve not been a part of it. I do understand that it’s meant to be there, like, it’s got a purpose—to guide how we’re supposed to behave towards each other and the staff and all that. And yeah, I understand that, I do, but still.” – Participant 1.
3.2 Reciprocal relationships
3.2.1 Staff members’ availability and positive attitude
Staff members were generally described as positive and accessible, striving to create a supportive environment for the patients. Most of the staff worked actively to promote participation in activities. Participants appreciated the support and encouragement they received from the staff. They listened to patients with respect, which contributed to an atmosphere of understanding and empathy.
“Yes, but I have to admire the staff because when they notice that someone wants to talk and so on, they usually ask. So, you go aside and sit in the calm room, you know, so yes, they’re good at that.” – Participant 8.
An atmosphere of calm and well-being was created for patients through conversations and interactions, including playing cards and offering massage to reduce anxiety. Staff handled most situations in a calm, professional manner and treated patients in an individual way, creating a feeling of personal care and a stable, safe atmosphere on the ward. Many staff members were described as skilled in using the Talk Down intervention, calmly communicating with distressed or aggressive patients. Despite many positive descriptions of staff, some staff members were described as more stressed and less empathetic than others. Their work was more routine based, and they treated all patients in the same way, leading to a feeling of non-individual care. Participants described that this could reinforce their sense of illness rather than promoting their well-being.
“Yeah, but some are more stressed—only stressed when they’re here—while others stay calm and just take things easy, go about it methodologically. And then you’ve got the ones who are like, ‘What do we do now?’ You know, just running around. Like, go home instead! What are you even doing here? It just makes things stressful. Of course we feel that.” – Participant 1.
Participants described being influenced by each other’s moods. If someone was nervous or stressed, the rest of the patient group was negatively affected. In such situations it was especially crucial for staff to act in a stable and calm manner. If staff members were perceived as stressed or lacking empathy and not maintaining a consistent level of support, it could create anxiety and insecurity within the patient group.
3.2.2 Fellow patients exhibit care and consideration
Participants generally expressed that fellow patients had an empathetic and considerate attitude, for example, they usually buy things for each other when out shopping.
“Yeah, but we share sweets and stuff like that. I went shopping the day before yesterday for a bloke who’s not allowed out—he chucked 60 kronor at me and said, ‘Get as much sweets as possible.’ So, I did. The atmosphere’s good and all that. But then, not everyone’s doing great either. Eh, but I reckon everyone wants the best for each other—no one’s putting anyone down or anything. So that’s a positive.” – Participant 4.
According to participants, there was mutual understanding and concern between patients. They were aware of each other’s needs and feelings and paid attention when other patients were feeling unwell. One participant thought that the presentations of persons in the Know Each Other intervention was good for those with less social skills, enabling them to feel more involved in the ward’s social community. There were also descriptions of patients who had a negative and complaining attitude, from whom participants chose to distance themselves from.
Interviewer: Another way, and yes, but this thing of showing consideration, seeing each other and being able to get comfort and feel hope both from other patients and staff, what is that like?
Participant 7: It depends on how you talk to them. You know, I only talk to my friends and so, my friends or those I hang out with. And they are very supportive. They say, ‘Come, you’ll be out soon, come to the flat, you will be fine,’ and so on. But there’s a whole lot of other rubbish with other patients where they sit and complain every day and make you think about being really locked up. They are the ones who need comfort the most, I think.
3.2.3 Withdrawal and avoidance of social interaction
Participants reported that many fellow patients withdrew and avoided interaction with both staff and fellow patients. Although staff encouraged activities and social engagement, some patients preferred to remain in their rooms.
“No, I don’t know. They stay in their rooms. I’m more out in the day room during the day. Most people stay in their rooms.” – Participant 6.
They also described a lack of interesting activities and a generally low mood on the ward. At the same time, some participants actively sought social interaction and wished to engage with both staff and fellow patients. Furthermore, the extent to which participants felt safe with staff and other patients influenced their decision to either stay in their rooms or socialize with others.
Interviewer: Does it appear that staff members have a common view on how to work and how to treat patients, or does it differ between different staff members?
Participant 2: It differs. The ones I have the best contact with, um, are a bit more open with me. I talk more with them, we play cards, and then there are staff members I have maybe no contact with at all. I don’t even talk to them.
Interviewer: Do you act differently when those staff members are on duty.
Participant 2: Um, it depends. Some days, it’s only those staff members who are working and then I keep to myself. I’m in my room, mostly.
Interviewer: Okay.
Participant 2: And then I think that if something were to happen that day, I probably wouldn’t go to them.
3.3 Social justice
3.3.1 Boredom and low mood within the ward
Participants described that the four wards were characterized by a general feeling of boredom, vulnerability and lack of activity. There were participants who expressed that most days were monotonous and uneventful, with only occasional days perceived as meaningful. Another participant described a boring daily routine where the days merged together without any variation.
“Yeah, not much happens. Just drink coffee all day, that’s probably the only thing you do. Coffee, smoke, take medicine, that’s probably all you do and go out sometimes.” – Participant 6
Participants also noted that their fellow patients tended to keep to themselves in their rooms, which added to the general feeling of boredom and isolation. The food was perceived as poor and the possibility of creating homely and comfortable environment was limited, as personal items such as rugs and blankets were not allowed. The staff said that it was not possible to have such items in the room due to the risk of fire. Participants were reminded by staff that hospital rules apply. For example, there was a rule in one of the wards that forbade patients from putting their feet on the coffee table, which one participant mentioned as being something you would normally do in a home environment. The participants suggested that more activities should be offered, such as eating or cooking food with more variety and from other cultures or having coffee outside the ward to break the monotony of everyday life.
“Sometimes we go to the clinic’s small cottage. I’ve never been there before, but I know they do it when it’s not as cold as it is now. And then … yes, sometimes you might be allowed to help in the kitchen and cook or something.” – Participant 3
3.3.2 Desire for dignified, equal and safe care
The participants expressed that the feeling of safety in the ward was important, and they mostly experienced it as a safe place. Some participants perceived their stay at the ward as safer compared to their life outside the institution. The Clear Mutual Expectations contributed to this feeling of safety. Without a clear structure for what is allowed and what is prohibited, it could be difficult for patients to navigate and feel safe.
“Yes, but it’s that rules are followed and, and that everyone has the same value and so on. So, everyone is equal. No one should have more rights than anyone else, the same rule should apply to everyone.” – Participant 4
A participant described the uncertainty that arose when rules were not clearly defined. There were also experiences of uncertainty and anxiety, especially when faced with new incidents and patients. For example, a participant expressed being “on guard” all the time. The importance of being treated with dignity and respect was highlighted. At the same time there were experiences of exclusionary and non-empathetic meetings with certain staff members and fellow patients. For example, staff could choose not to engage in conversation with a patient who, according to one participant, they perceived as intimidating. Participants also emphasized the importance of everyone being treated equally, which was generally the case in the ward, although occasional incidents of favoritism or special treatment by staff were also reported.
“I think there are certain rules that only apply to certain people. Let’s say there’s a patient who has rings. Now, we’re not allowed to have rings here, but because this patient has outbursts, she can keep her rings. But me, who does nothing, I’m not allowed to have rings precisely because I do nothing. Eh, they don’t dare to take her rings precisely because she has outbursts like that.” – Participant 2.
3.3.3 Perception of unjustified confinement
Participants expressed the unfairness of being locked up for many years, for example, for harassment or theft. They were aware of that a forensic psychiatric sentence in Sweden is not time-limited and typically results in a significantly longer period of care compared to a prison sentence.
Interviewer: Would you like to have more of a say?
Participant 6: No, I don’t know. I don’t think there’s any point. You just have to stay off drugs and keep calm in here, and eventually, I’ll be discharged. But I think it’s cramped in here. I’ve got … [a conviction for] harassment—even though I didn’t do it, for example. So I shouldn’t be here. … Sitting here, wrongly convicted, judged based on old records. Too many times.
Interviewer: But when you say that there’s no point in participation, how do you mean? Can you explain a bit more?
Participant 6: No, it’s just hopeless. I see this as a punishment and nothing else. Whether I’m guilty or not doesn’t matter, you get punished anyway. It’s like a punishment.
Several patients at the clinic were not allowed to be discharged from inpatient care, even though both they and the doctor considered that they were ready to leave. The reason for this was the lack of available housing and support.
“And the other patients, they liked me and all. And no, I don’t know, but it was a good time for me anyway. It was when I had come out of the psychosis and started to feel really good, you know. So, everything was going smoothly and I felt that soon I would probably be discharged. And I was. But now, now even though you feel healthy and well, it’s this thing about the flat, isn’t it? The doctors have said it themselves that only if I have a flat will I start outpatient care and be given leave so that it’s already sorted (sighs).” – Participant 8.
This situation was described as frustrating and a limitation for the patients. They felt that their opportunity to reintegrate into society is delayed by having to wait for suitable accommodation, leading to the risk of becoming institutionalized as well as limiting their opportunities to regain independent living and participation in society.
4 Discussion
This study highlights a tension between the ideals of human rights and the lived realities of patients in a forensic psychiatric clinic implementing Safewards. While Safewards aims to promote a more recovery-oriented and inclusive environment (51), our findings show that patients’ experiences of social inclusion remained limited. Safewards appears to have potential for fostering social inclusion, as its implementation in the clinic was generally well-received by the participants in our study. Participants described predominantly positive reciprocal relationships with staff members and fellow patients but the organization as such had not become more inclusive. Participants’ knowledge and experiences were seldom actively sought, and they reported limited opportunities to participate in decision-making in their care and daily lives. Regarding social justice, the ward environment was often considered dull, with limited activities and few forums for meaningful social interaction. Participants could feel that their time on the clinic resembled punishment rather than treatment, expressing frustration about prolonged care durations. This was especially true for those who could not be discharged due to the municipality’s inability to provide housing and support after their treatment had ended.
4.1 Participation in decision-making
The paternalistic tradition in health care generally, and especially in psychiatric services, makes it challenging to achieve participation in decision-making (20), especially within forensic psychiatric services due to their dual mission (52, 53). On the one hand, there is a caregiving role guided by the ethics of care, while on the other, there is a custodial role aimed at protecting the public from potentially dangerous behaviors. Staff members describe the balance between care and security as delicate in these settings (52, 54). Consistent with previous research (54, 55), participants in this study expressed a desire to participate in meetings about their care and to have greater influence over their treatment. However, they had limited opportunities to express their opinions, be taken seriously and influence their care and daily lives. It could be argued that listening to patients and providing greater opportunities for participation could be achieved without compromising safety (52, 54). Some researchers have highlighted the benefits of implementing shared decision-making within forensic psychiatric services (56), while others have emphasized the importance of building a strong therapeutic relationship and promoting a “realistic” level of patient participation (52). These perspectives reflect complementary aspects of the broader effort to enhance patient involvement in forensic psychiatric services. However, despite the ambitions expressed by staff, there still appears to be a lack of structural support enabling patients to participate in a meaningful way (21, 55, 57). The Safewards model was viewed by staff at the clinic as a tool to enhance patient participation, but it was not adopted by doctors or other professionals at the organizational level which limited its potential impact (58).
4.2 Reciprocal relationships
Creating an atmosphere of openness and support in forensic psychiatric services enables patients to feel safe and respected, which in turn can promote their well-being and rehabilitation as persons (59). Therefore, it is not surprising that patients have described connectedness to others as important (60). In our study, staff members were mostly described as available, positive and caring. However, some were perceived as stressed and unempathetic, hence when they were on duty, patients often remained in their rooms, the only space in which they felt safe. The participants were impressed by the ability of certain staff members to communicate with distressed patients. If staff members treat patients as persons worthy of respect and de-escalate conflicts, it increases the likelihood that patients will be open to learning how to control their emotions and actions. This in turn can provide opportunities for the patient to develop into a co-creator of a positive psychological climate on the ward (61). The study participants did not describe any co-creation processes or experiences of having their knowledge and personal insights valued or actively sought by staff. While meetings with staff were generally described as humane and compassionate, the organizational delivery of treatment and care was not perceived as person-centered or participatory. It was instead experienced as routine-driven and unresponsive to patients’ needs and wishes, thereby limiting opportunities for genuine social inclusion within the care environment (11).
4.3 Social justice
When it comes to social justice, it seems that staff in the present study were communicative. Furthermore, the participants did not report serious incidents of poor staff behavior, such as abuse of patients, harsh words or negative views of psychiatric patients, which frequently emerged in our earlier studies (21, 62). This may reflect the staff’s increased awareness and deliberate use of language promoted through the Safewards model (58). However, participants reported the same lack of activities and forums for meetings as in previous studies. Activities could serve as a means to promote citizenship and recovery, thereby enhancing social justice (31). The National Preventive Mechanism, which monitors Sweden’s compliance with the CAT, has also noted this problem and criticized a forensic psychiatric clinic for failing to adequately provide patients with opportunities for occupational therapy, daily outdoor access and other meaningful activities (No. O-4-2023) (6). A recurring issue in our study was the participants’ perception of unjustified confinement. This is linked to Sweden’s abolition of the insanity defense in criminal law (4). Historically, individuals who committed serious crimes could be discharged after a short forensic psychiatric care duration when no longer deemed to be suffering from a severe mental illness, a practice widely viewed as unjust by the general public. In response, legal amendments introduced mandatory special discharge reviews, effectively extending the duration of care for individuals convicted of serious offenses. However, at the same time, no equivalent measures were taken to prevent disproportionately long confinement for individuals convicted of minor offenses (4). Many patients remain in forensic psychiatric services after completing treatment, as the court deems the risk of recidivism to be high in cases where the municipality has not arranged appropriate housing and support for the individual, leading to considerable frustration. The National Preventive Mechanism has also criticized this practice (No. O-1-2021) (6), highlighting it as a violation of patients’ human rights, as it deprives them of their liberty without a justified need for psychiatric treatment. These social justice issues cannot be solely addressed through the implementation of Safewards. There is a need for Swedish forensic psychiatric services to be more accountable, transparent and place greater emphasis on patients’ human rights, in the same way as the Comprehensive Framework to Advance Equity, Diversity, and Inclusion in a Forensic Service in Ontario, Canada (63).
4.4 The safewards model and social inclusion
Safewards’ potential for enhancing patients’ social inclusion has yet to be fully achieved in the clinic in which the study was conducted. In another study conducted at the same clinic, staff at the clinic reported actively working to become more care-oriented (58), something that our participants had noted. However, there was also resistance to the implementation of Safewards on the part of some staff members, which is supported by other studies (64, 65). The clinic environment was perceived as dull, and participants were disappointed at not being involved in the development of Clear Mutual Expectations. A key area for improvement lies in incorporating greater co-creation into the implementation process. Mutual Help Meetings could be used to promote patient engagement, but none of the participants reported positive experiences of these meetings. To achieve more meaningful outcomes, it may be necessary to implement Mutual Help Meetings in a way that aligns more closely with the core principles of the intervention. These meetings, together with Everydayness, an intervention proposed in Safewards Secure (40), could serve as a platform for reshaping daily life on the ward, fostering a sense of community and collaboration. Involving patients in the co-creation of Safewards interventions and social activities would also be in line with human rights values, like social justice and non-discrimination (14).
4.5 Is social inclusion possible in forensic psychiatric services?
A literature review on recovery in forensic psychiatric services suggests that social inclusion and normality are primarily linked to integration into society as a citizen (66), whereas other perspectives emphasize that institutional settings themselves can be adapted to support social inclusion (67). Given our definition, forensic psychiatric patients are also citizens with rights, making social inclusion a relevant goal within institutions. However, as this study and existing literature indicate, inclusion remains insufficient. The main reason is that the shift toward a more compassionate approach by staff does not appear to have been accompanied by organizational changes supporting participation and person-centeredness. Instead, existing structures tend to reinforce a routine-based model of care. Organizational barriers to person-centered care have been described as deeply rooted in a long-standing biomedical and positivist paradigm. This paradigm emphasizes professional rather than personal goals, relies on objective measures and evaluations, and positions patients as passive recipients of care. Successful efforts to overcome these barriers have included sustained leadership commitment and multidisciplinary teamwork aimed at changing routinized practices and communication strategies (68).
4.6 Strengths and limitations
This study offers new perspectives on Safewards, due to employing a value-based analysis, which has not previously been used. One of the study’s strengths is the interviewers were experts by experience. Another is that the analysis was carried out by researchers with diverse research backgrounds and varying experiences of forensic psychiatry as staff, patients, researchers and students. Combined with reflective practice, this contributed to a robust interpretation of the interview data.
However, the study has certain limitations. At the time of data collection, each ward had adopted a different subset of Safewards interventions, and several patients had been transferred between wards, resulting in overlapping experiences. Given this mobility and the small sample size, stratifying the analysis by ward was not feasible. Therefore, the analysis was conducted at the clinic level. The sample consisted of eight male patients from a single clinic which is a relatively small number and makes the findings context specific. It is also a limitation that we have no experiences from female patients, since none of the three female patients at the clinic met our inclusion criteria. A common challenge in conducting interviews within forensic psychiatric services is the limited control over participant selection. For this reason, we chose from the outset to invite all patients who were eligible and available to participate. Another problem was that we would have preferred a richer dataset, as some patients occasionally had difficulty expressing themselves. We aimed to obtain longer, coherent narratives, but this was often impossible. Therefore, we also include quotations that illustrate the communication between the participants and the interviewers to provide insight into the nature of their interactions. A further limitation concerns the exclusion of non-Swedish-speaking patients and others with limited language proficiency. This decision was made for practical reasons and because of the abstract nature of the interview questions. Communication and language barriers remain a significant human-rights and equity concern (9). Future research should explore multilingual or observational approaches to better include these patient groups. Nevertheless, we believe that these patient voices can contribute to a deeper understanding of what social inclusion may mean for patients in forensic psychiatric care. However, there is also a need for research exploring the processes of discharge and community reintegration, and how it may influence the possibility for social inclusion of former patients in society.
5 Conclusions
This study demonstrates that the social inclusion model has managed to capture several important aspects of human rights. The implementation of Safewards seems to have the potential to enhance human rights and, consequently, promote socially sustainable forensic psychiatric services. Above all, it appeared that Safewards promoted reciprocal relationships and a more compassionate approach by staff but failed to change the organization in terms of more participatory and person-centered care. However, certain essential aspects of social justice—such as prolonged care duration and the right to a meaningful everyday life—cannot be fully achieved without legislative and policy reforms. Ensuring social sustainability in forensic psychiatric services requires a fundamental cultural shift, with an explicit emphasis on human rights alongside the implementation of Safewards. This study focuses on social inclusion in the institutional environment.
Data availability statement
Data are not available since this could compromise the individual privacy of participants. The data are stored at the University Health Care Research Center, Region Örebro County, and may be available on request by other researchers, without undue reservations. Further enquires can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by The Swedish Ethical Review Authority, Uppsala, Sweden, No. 2020-03881. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
VP-P: Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Project administration, Supervision, Validation, Writing – original draft. LaK: Conceptualization, Formal analysis, Funding acquisition, Methodology, Supervision, Validation, Writing – review & editing. LiK: Formal analysis, Writing – review & editing. JW: Formal analysis, Methodology, Writing – review & editing. AB: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Validation, Writing – review & editing.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. This work was supported by AFA Insurance (AFA Försäkring) and FORTE (Vetenskapsrådet om arbete och välfärd). The funding from AFA Insurance made it possible to collect the data, while the support from FORTE enabled the preparation and writing of the manuscript. The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article, or the decision to submit it for publication.
Acknowledgments
The authors extend their gratitude to all the patients who participated in this study, to the ward managers who made it possible to conduct the study, to Susanne Tell, (Master of Public Health and expert by experience) who interviewed patients and to Gullvi Nilsson who edited the language and proofread the manuscript.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that Generative AI was used in the creation of this manuscript. During the writing process, AI language models (ChatGPT and Claude.ai) were used under the authors’ supervision for language editing and proofreading. The authors remain responsible for the content and interpretation of the manuscript.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2025.1688564/full#supplementary-material
Abbreviations
CAT, Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment; COREQ, Consolidated Criteria for Reporting Qualitative Research; CRPD, Convention on the Rights of Persons with Disabilities; UN, United Nations; WPA, World Psychiatric Association; WASP, World Association of Social Psychiatry.
References
1. UN. E-dialogue “Creating an inclusive society: practical strategies to promote social integration”. In: Working Definition of Social Inclusion. New York, US: Division for Social Policy and Development, United Nations. (2027). Available online at: https://www.un.org/esa/socdev/sib/inclusive_society/social%20inclusion.html (accessed October 25, 2025).
2. WHO. Convention on the Rights of Persons with Disabilities (2006). Available online at: http://www.un.org/disabilities/documents/convention/convoptprot-e.pdf (accessed October 25, 2025).
3. Nilsson A. Unlocking the impact of the CRPD on Swedish mental health law. Int J Law Psychiatry. (2024) 93:101966. doi: 10.1016/j.ijlp.2024.101966
4. Gooding P and Bennet T. The abolition of the insanity defense in Sweden and the United Nations convention on the rights of persons with disabilities: human rights brinksmanship or evidence it won’t work? New Criminal Law Rev. (2018) 21:141–69. doi: 10.1525/nclr.2018.21.1.141
5. Committee C. Crpd/C/Swe/Co/2-3: Concluding Observations on the Combined Second and Third Periodic Reports of Sweden (2024). Available online at: https://www.ohchr.org/en/documents/concluding-observations/crpdcsweco2-3-concluding-observations-combined-second-and-third (accessed October 25, 2025).
6. JO. The Parliamentary Ombudsmen Opcat-Protokoll . Available online at: https://www.jo.se/opcat/#:~:text=Opcat%20%C3%A4r%20det%20fakultativa%20protokollet,bes%C3%B6ksorgan%2C%20f%C3%B6r%20att%20%C3%B6vervaka%20fr%C3%A5gan (accessed October 25, 2025).
7. Rättspsy K. Årsrapport 2024 (2025). Available online at: https://registercentrum.blob.core.windows.net/rattspsyk/r/RattspsyK-Arsrapport-2024-9LQGouL9Y.pdf (accessed October 25, 2025).
8. Edberg H. Intellectual Disability in a Forensic Psychiatric Setting. Stockholm, Sweden: Karolinska Institutet (2024).
9. Rahman OA, Alexiou E, Degl’Innocenti A, Holmberg C, and Olaya-Contreras P. Forensic psychiatric care professionals’ Experiences of communicating with foreign patients and their relatives: the importance of language and culture. Front Psychiatry. (2025) 16:1643806. doi: 10.3389/fpsyt.2025.1643806
10. UN. Transformining Our World: The 2030 Agenda for Sustainable Development (2015). United Nations. Available online at: https://sustainabledevelopment.un.org/content/documents/21252030%20Agenda%20for%20Sustainable%20Development%20web.pdf (accessed October 25, 2025).
11. Silver H. The Contexts of Social Inclusion: Department of Economic & Social Affairs (2015). United Nations. Available online at: https://desapublications.un.org/file/237/download (accessed October 25, 2025).
12. Coombs T, Nicholas A, and Pirkis J. A review of social inclusion measures. Aust New Z J Psychiatry. (2013) 47:906–19. doi: 10.1177/0004867413491161
13. O’Donnell P, O’Donovan D, and Elmusharaf K. Measuring social exclusion in healthcare settings: A scoping review. Int J Equity Health. (2018) 17:15. doi: 10.1186/s12939-018-0732-1
14. Dugarova E. Social Inclusion, Poverty Eradication and the 2030 Agenda for Sustainable Development (2015). Geneva: United Nations Research Institute for Social Development (Unrisd. Available online at: https://www.econstor.eu/bitstream/10419/148736/1/861278364.pdf. Unrisd Working Paper, No. 2015-15 (accessed October 25, 2025).
15. UN. Leaving No One Behind: The Imperative of Inclusive Development (2016). New York: Department of Economic & Social Affairs, United Nations. Available online at: https://www.un.org/esa/socdev/rwss/2016/full-report.pdf (accessed October 25, 2025).
16. Cobigo V, Ouellette K, Lysaght R, and Martin L. Shifting our conceptualization of social inclusion. Stigma Res Action. (2012) 2:75–84. doi: 10.5463/sra.v1i3.45
17. Cordier R, Milbourn B, Martin R, Buchanan A, Chung D, and Speyer R. A systematic review evaluating the psychometric properties of measures of social inclusion. PloS One. (2017) 12:e0179109. doi: 10.1371/journal.pone.0179109
18. van der Weele S and Bredewold F. What’s good about inclusion? An ethical analysis of the ideal of social inclusion for people with profound intellectual and multiple disabilities. Health Care Anal. (2024) 32:106–23. doi: 10.1007/s10728-023-00470-y
19. Pelto-Piri V. Ethical considerations in psychiatric inpatient care. In: The Ethical Landscape in Everyday Practice as Described by Staff. Örebro universitet, Örebro (2015).
20. Pelto-Piri V, Engström K, and Engström I. Paternalism, autonomy and reciprocity: ethical perspectives in encounters with patients in psychiatric in-patient care. BMC Med Ethics. (2013) 14:49. doi: 10.1186/1472-6939-14-49
21. Pelto-Piri V and Kjellin L. Social inclusion and violence prevention in psychiatric inpatient care. A qualitative interview study with service users, staff members and ward managers. BMC Health Serv Res. (2021) 21:1255. doi: 10.1186/s12913-021-07178-6
22. Pelto-Piri V and Wetterling J. From paternalism to social inclusion? User organizations’ Narratives of psychiatric services in Sweden. In: Punzi E, Wächter C, and Singer C, editors. Narrating the Heritage of Psychiatry, vol. 1. Leiden, Netherlands: Leiden Brill (2024). p. 79–97.
23. WMA. Code of Medical Ethics (2022). The World Medical Association. Available online at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ (accessed October 25, 2025).
24. Standardization ECf. Patient Involvement in Health Care - Minimum Requirements for Person-Centred Care. Brussels, Belgium: CEN-CENELEC Management Centre (2020).
25. Sandman L and Munthe C. Shared decision making, paternalism and patient choice. Health Care Anal. (2010) 18:60–84. doi: 10.1007/s10728-008-0108-6
26. Holt-Lunstad J. Social connection as a critical factor for mental and physical health: evidence, trends, challenges, and future implications. World Psychiatry. (2024) 23:312–32. doi: 10.1002/wps.21224
27. WPA. Madrid Declaration on Ethical Standards for Psychiatric Practice (1996). World Psychiatric Association. Available online at: https://www.psi.uba.ar/academica/carrerasdegrado/psicologia/sitios_catedras/obligatorias/723_etica2/material/normativas/declaracion_madrid_etica_psiquiatria.pdf (accessed October 25, 2025).
28. WASP. Bucharest Declaration on Social Well-Being and Mental Health Evidence Informed Policies (2019). The World Association of Social Psychiatry. Available online at: https://waspsocialpsychiatry.org/declarations/ (accessed October 25, 2025).
29. WHO. Guidance on community mental health services: promoting person-centred and rights-based approaches(2021). Available online at: https://iris.who.int/server/api/core/bitstreams/184ff4ef-9c4c-4aad-b1c5-437b08bc0184/content (accessed October 25, 2025).
30. Broberg E, Persson A, Jacobson A, and Engqvist AK. A human rights-based approach to psychiatry: is it possible? Health Hum Rights. (2020) 22:121–31.
31. Carr ER and Ponce AN. Supporting mental health recovery, citizenship, and social justice. Community Ment Health J. (2022) 58:11–9. doi: 10.1007/s10597-021-00900-y
32. Cerny-Suelzer CA, Michaelsen K, Wasser T, Kushner D, and Friedman SH. Forensic psychiatry as a key part of residency training in social justice and mental health inequities. Acad Psychiatry. (2024) 48:471–5. doi: 10.1007/s40596-024-01989-5
33. Hunt MG and Resnick SG. Two birds, one stone: unintended consequences and a potential solution for problems with recovery in mental health. Psychiatr Serv. (2015) 66:1235–7. doi: 10.1176/appi.ps.201400518
34. McWade B. Recovery-as-policy as a form of neoliberal state making. Intersectionalities: A Global J Soc Work Analysis Research Polity Pract. (2016) 5:61–82. doi: 10.48336/IJXSRN4104
35. Tomlin J and Jordan M. Strength- and recovery-based approaches in forensic mental health in late modernity: increasingly incorporating a human rights angle? Soc Theory Health. (2022) 20:398–415. doi: 10.1057/s41285-021-00169-x
36. Bowers L. Safewards: A new model of conflict and containment on psychiatric wards. J Psychiatr Ment Health Nurs. (2014) 21:499–508. doi: 10.1111/jpm.12129
37. Mullen A, Browne G, Hamilton B, Skinner S, and Happell B. Safewards: an integrative review of the literature within inpatient and forensic mental health units. Int J Ment Health Nurs. (2022) 31:1090–108. doi: 10.1111/inm.13001
38. Fletcher J, Buchanan-Hagen S, Brophy L, Kinner SA, and Hamilton B. Consumer perspectives of safewards impact in acute inpatient mental health wards in victoria, Australia. Front Psychiatry. (2019) 10:461. doi: 10.3389/fpsyt.2019.00461
39. Maguire T, Ryan J, Fullam R, and McKenna B. Safewards secure: A Delphi study to develop an addition to the safewards model for forensic mental health services. J Psychiatr Ment Health Nurs. (2022) 29:418–29. doi: 10.1111/jpm.12827
40. Maguire T, Harrison M, Ryan J, Lang R, and McKenna B. A nominal group technique to finalise safewards secure model and interventions for forensic mental health services. J Psychiatr Ment Health Nurs. (2024) 31:543–59. doi: 10.1111/jpm.13006
41. WHO. The Who Qualityrights Tool Kit . Available online at: https://iris.who.int/server/api/core/bitstreams/204df45f-b453-4e86-8954-ca8e6f99fc45/content (accessed October 25, 2025).
42. Personcentrering Vid Psykisk Funktionsnedsättning Och Stora Behov: The National Board of Social Affairs and Health . Available online at: https://www.socialstyrelsen.se/kunskapsstod-och-regler/omraden/psykisk-ohalsa/personcentrering-vid-psykisk-funktionsnedsattning-och-stora-behov/ (accessed October 25, 2025).
43. Perlin ML. International human rights and institutional forensic psychiatry: the core issues. In: Völlm B and Nedopil N, editors. The Use of Coercive Measures in Forensic Psychiatric Care: Legal, Ethical and Practical Challenges. Springer International Publishing, Cham (2016). p. 9–29.
44. Maguire T, Ryan J, Fullam R, and McKenna B. Evaluating the introduction of the safewards model to a medium- to long-term forensic mental health ward. J Forensic Nurs. (2018) 14:214–22. doi: 10.1097/jfn.0000000000000215
45. Elo S and Kyngäs H. The qualitative content analysis process. J Advanced Nurs. (2007) 62:107–15. doi: 10.1111/j.1365-2648.2007.04569.x
46. Sandelowski M. What’s in a name? Qualitative description revisited. Res Nurs Health. (2010) 33:77–84. doi: 10.1002/nur.20362
47. Sandelowski M. Whatever happened to qualitative description? Res Nurs Health. (2000) 23:334–40. doi: 10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G
48. Tong A, Sainsbury P, and Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care. (2007) 19:349–57. doi: 10.1093/intqhc/mzm042
49. Mehrabadi A, Austin N, Keyes KM, and De Vera MA. It’s personal: navigating research questions that stem from our lived experiences. Int J Epidemiol. (2024) 53:1–5. doi: 10.1093/ije/dyae132
50. Berger R. Now I see it, now I don’t: researcher’s position and reflexivity in qualitative research. Qual Res. (2015) 15:219–34. doi: 10.1177/1468794112468475
51. Melillo A, Sansone N, Allan J, Gill N, Herrman H, Cano GM, et al. Recovery-oriented and trauma-informed care for people with mental disorders to promote human rights and quality of mental health care: A scoping review. BMC Psychiatry. (2025) 25:125. doi: 10.1186/s12888-025-06473-4
52. Söderberg A, Wallinius M, and Hörberg U. An interview study of professional carers’ Experiences of supporting patient participation in a maximum security forensic psychiatric setting. Issues Ment Health Nurs. (2020) 41:201–10. doi: 10.1080/01612840.2019.1658833
53. Pedersen SH, Radovic S, Nilsson T, and Eriksson L. Dual-roles and beyond: values, ethics, and practices in forensic mental health decision-making. Medicine Health Care Philosophy. (2025) 28:199–211. doi: 10.1007/s11019-024-10247-2
54. Selvin M, Almqvist K, Kjellin L, and Schröder A. Patient participation in forensic psychiatric care: mental health professionals’ Perspective. Int J Ment Health Nurs. (2021) 30:461–8. doi: 10.1111/inm.12806
55. Selvin M, Almqvist K, Kjellin L, and Schröder A. The concept of patient participation in forensic psychiatric care: the patient perspective. J Forensic Nurs. (2016) 12:57–63. doi: 10.1097/jfn.0000000000000107
56. Horst PT, Spreen M, de Vries E, and Bogaerts S. Facilitating shared decision making in forensic psychiatry: the HKT-R spider app. J Forensic Psychol Res Pract. (2023) 23:328–43. doi: 10.1080/24732850.2022.2028394
57. Söderberg A, Wallinius M, Munthe C, Rask M, and Hörberg U. Patients’ Experiences of participation in high-security, forensic psychiatric care. Issues Ment Health Nurs. (2022) 43:683–92. doi: 10.1080/01612840.2022.2033894
58. Karlsson J, Anttonen S, Kjellin L, Pelto-Piri V, and Björkdahl A. Who is navigating this ship? A qualitative interview study of nursing staff’s experiences of implementing safewards in a forensic mental health clinic. Int J Forensic Ment Health. (2025) 24:181–91. doi: 10.1177/14999013251332954
59. Olsson H, Strand S, and Kristiansen L. Reaching a turning point–how patients in forensic care describe trajectories of recovery. Scand J Caring Sci. (2014) 28:505–14. doi: 10.1111/scs.12075
60. Senneseth M, Pollak C, Urheim R, Logan C, and Palmstierna T. Personal recovery and its challenges in forensic mental health: systematic review and thematic synthesis of the qualitative literature. BJPsych Open. (2022) 8:e17. doi: 10.1192/bjo.2021.1068
61. Olsson H, Audulv Å, Strand S, and Kristiansen L. Reducing or increasing violence in forensic care: A qualitative study of inpatient experiences. Arch Psychiatr Nurs. (2015) 29:393–400. doi: 10.1016/j.apnu.2015.06.009
62. Pelto-Piri V, Wallsten T, Hylen U, Nikban I, and Kjellin L. Feeling safe or unsafe in psychiatric inpatient care, a hospital-based qualitative interview study with inpatients in Sweden. Int J Ment Health Syst. (2019) 13:23. doi: 10.1186/s13033-019-0282-y
63. Chatterjee S, Simpson AIF, and Wilkie T. A comprehensive framework to advance equity, diversity, and inclusion in a forensic service. J Am Acad Psychiatry Law. (2023) 51:486–93. doi: 10.29158/jaapl.230027-23
64. Price O, Burbery P, Leonard S-J, and Doyle M. Evaluation of safewards in forensic mental health. Ment Health Pract. (2016) 19:23–29. doi: 10.7748/mhp.19.8.14.s17
65. Cabral A and Carthy J. Can safewards improve patient care and safety in forensic wards? A pilot study. Br J Ment Health Nurs. (2017) 6:165–71. doi: 10.12968/bjmh.2017.6.4.165
66. Lumén K, Louheranta O, and Kuosmanen L. Forensic psychiatric patients’ Experiences of personal recovery: A Wilsonian concept analysis. J Forensic Nurs. (2024) 20:103–12. doi: 10.1097/jfn.0000000000000477
67. Bredewold F and van der Weele S. Social inclusion revisited: sheltered living institutions for people with intellectual disabilities as communities of difference. Medicine Health Care Philosophy. (2023) 26:201–13. doi: 10.1007/s11019-022-10135-7
Keywords: safewards, forensic psychiatry, social inclusion, human rights, vulnerable populations, coercive measures, violence prevention, implementation
Citation: Pelto-Piri V, Kjellin L, Kronman L, Wetterling J and Björkdahl A (2025) Between rights and reality: patient perceptions of social inclusion in a forensic psychiatric clinic implementing safewards. Front. Psychiatry 16:1688564. doi: 10.3389/fpsyt.2025.1688564
Received: 19 August 2025; Accepted: 21 October 2025;
Published: 19 November 2025.
Edited by:
Katarina Howner, Karolinska Institutet (KI), SwedenReviewed by:
Christopher Holmberg, University of Gothenburg & Sahlgrenska University Hospital, SwedenValentina Vidaurrazaga Aras, University of Gothenburg, Sweden
Henriette Riley, UiT The Arctic University of Norway, Norway
Copyright © 2025 Pelto-Piri, Kjellin, Kronman, Wetterling and Björkdahl. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Veikko Pelto-Piri, dmVpa2tvLnBlbHRvLXBpcmlAb3J1LnNl