Connectedness: staying connected and being part of a ward community for a long time

Most of the findings were related to the key recovery process of connectedness, which was represented in all the reviewed papers. A major part of the findings regarding connectedness was concerned with service users being a part of the ward community and their relationships with staff. The quality of relationships with staff and the ward environment played an important role in forensic service users’ recovery.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference Barnao, Ward and Casey22,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25–Reference Glorney, Raymont, Lawson and Allen27,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Olsson, Strand and Kristiansen33,Reference Sustere and Tarpey35} The quality of relationships with staff were viewed as essential.^{Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} One service user stated:

Another service user expressed: ‘I have applied to get leave and the staff have supported that. It's important to know that my clinical team are all behind me’^{Reference Di Lorito, Dening and Vollm26} (p. 943). Features that characterised good-quality relationships with staff were showing respect toward service users, having a genuine interest in them and their well-being, being empathic and being flexible in their interaction with them.^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Di Lorito, Dening and Vollm26,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Møllerhøj and Stølan31} One service user stated: ‘(…) A good personal nurse can always be bothered with you, whenever I was depressed he was there to support me’^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} (p. 5). Furthermore, service users valued staff who spent time with them, were helpful and worked collaboratively with them to support change.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Barnao, Ward and Casey22,Reference Marklund, Wahlroos, Looi and Gabrielsson29}

Service users emphasised the importance of having trust in staff, feeling encouraged and supported by them, and not feeling looked down on by them.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Di Lorito, Dening and Vollm26,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} In fact, it was essential to forensic service users on their recovery journeys simply to be treated as individuals and human beings.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Barnao, Ward and Casey22,Reference Møllerhøj and Stølan31} One patient stated: ‘… although we are people with mental problems, we are still human beings with emotions and feelings’^{Reference Møllerhøj and Stølan31} (p. 595). Furthermore, many service users accepted and hoped for long-term support from professionals as part of their enduring recovery journey.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Møllerhøj and Stølan31,Reference Olsson, Strand and Kristiansen33}

Environments that were recovery-promoting were characterised by being calm, supportive and safe, and a place to socialise and to be supported within despite drawbacks.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Di Lorito, Dening and Vollm26,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Olsson, Strand and Kristiansen33} Some felt that their recovery was positively supported by structures, routines and the daily activities on the ward.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Olsson, Strand and Kristiansen33}

Forensic service users described relationships with family, friends, peers and staff as essential for their recovery.^{Reference Shepherd, Doyle, Sanders and Shaw12,Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Livingston28,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} However, some needed help from professionals in re-establishing and repairing existing relationships,^{Reference Cherner, Aubry, Ecker, Kerman and Nandlal24,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Møllerhøj and Stølan31} which may be specific for the forensic service users and relevant to their history of offending behaviour. Two papers also highlighted forensic service users’ desire to help and be supportive of others.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Glorney, Raymont, Lawson and Allen27}

Hope and optimism about the future: looking back and looking forward

Developing hope for a good life in the future and the belief in the possibility of recovery was viewed as an essential recovery process in all 21 papers. FMH service users found that supportive relationships with family, friends and staff fostered hope,^{Reference Shepherd, Doyle, Sanders and Shaw12,Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Sustere and Tarpey35} as did clear goals for their treatment,^{Reference Skinner, Heasley, Stennett and Braham34} and the experience of interventions and procedures that supported personal autonomy.^{Reference Shepherd, Doyle, Sanders and Shaw12}

Many service users described hope for an ordinary life,^{Reference Livingston28,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Møllerhøj and Stølan31} a ‘normal life’ worth living.^{Reference McKenna, Furness, Dhital, Park and Connally1} They aspired to having a safe place to live, family and friends, and paid work.^{Reference Livingston28,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Møllerhøj and Stølan31} Although they aspired to independent living, several service users recognised a need for long-term support from professionals as well as life-long medication.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Møllerhøj and Stølan31,Reference Olsson, Strand and Kristiansen33}

Several papers described how time was viewed as an opportunity for change.^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30–Reference Olsson, Strand and Kristiansen33} Some FMH service users had experienced a turning point in their recovery trajectory.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Olsson, Strand and Kristiansen33} This turning point was characterised by looking back on the past, and then looking forward to the future with a sense of hope.^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} One service user stated: ‘Seeing the progress and being able to move forward—keeps that hope going’^{Reference Livingston28} (p. 222). Olsson et al^{Reference Olsson, Strand and Kristiansen33} found that being able to weigh pros and cons of the past and the present and look back on their life gave FMH service users strength, because the future looked brighter than the past and this helped to strengthen the turning point process. In the study by Clarke et al^{Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} one service user stated: ‘So you get to leave all the bad behind you and be someone new. That's something to look forward to’ (p. 69). Valuing success and experiencing an understanding of their illness and past, were additional key features of this turning point, in addition to developing insight^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} and making a conscious decision to change.^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} A service user in the study by McKeown et al^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} said ‘It's all about me getting better. I see the point of the medication now. I've been really ill and now I'm moving on’ (p. 237). Another service user stated: ‘(…) I've had a lot of time to think about what I've done in the past. I've had to make an effort and make a conscious decision to change’ (25, p. 237).

Identity: identity work, coming to terms with trauma and past offences

The identity category was represented in 19 of the 21 reviewed papers (Table 2). Analyses revealed three new second-order subcategories related to rebuilding and redefining a positive sense of self: ‘working with one's identity’, ‘coming to terms with past offences’ and ‘coming to terms with trauma and having been victimised’. Forensic service users described how working with one's identity had been challenging as well as beneficial for their recovery.^{Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} They viewed coming to terms with their past offending as essential, as well as coming to terms with the experience of trauma and of having been victimised themselves.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Glorney, Raymont, Lawson and Allen27} Some stated the need for to accept the past,^{Reference Skinner, Heasley, Stennett and Braham34} to forgive oneself^{Reference Glorney, Raymont, Lawson and Allen27} and to leave the past behind.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} Others described how processing their crime in therapy was a major part of moving on.^{Reference Pollak, Palmstierna, Kald and Ekstrand14} Several participants in the study by Olsson et al stated that they suddenly felt a need to change their way of being.^{Reference Olsson, Strand and Kristiansen33} Working with their identities, service users described reflecting on and approaching themselves and life in a new way.^{Reference Olsson, Strand and Kristiansen33} Self-reflection and honesty toward themselves were mentioned as additional key elements in their identity work.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Cherner, Aubry, Ecker, Kerman and Nandlal24} Others stressed the importance of relationships with staff in developing their new identities when building up ‘this whole new person’^{Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} (p. 65). Service users described how this process of recovery was hard, painful and exhausting work.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} One participant in the study by Askola et al^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} stated:

Service users reported that they had had a lot of time to think about what they had done in the past.^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} Some service users described feelings of guilt, shame and remorse,^{Reference Zhong, Guo, Wang, Cook, Chen and Luo36} and they expressed a need for encouragement from staff to work through this particular recovery process.^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} One service user expressed:

Furthermore, one paper described how the role of the victim was important for moving forward, either through the fact that the victim survived or through the restorative effect of contact with the victim (on the victim's terms) or by helping them.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20}

Meaning in life: meaningful use of time on the ward and preparing for a meaningful life outside’

All reviewed papers but one documented the service users’ need to experience meaning in life as well as an adequate quality of life while being an in-patient, in addition to an active and meaningful use of time (Table 2). Several activities were seen as beneficial for enhancing perceived quality of life, such as the opportunity to participate in recreational activities,^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23,Reference Cherner, Aubry, Ecker, Kerman and Nandlal24} paid work or work-related activities,^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Bowser, Link, Dickson, Collier and Donovan-Hall23,Reference Livingston28,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} and leisure activities.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Di Lorito, Dening and Vollm26} Service users appreciated spending the day in a purposeful way and acknowledged that keeping busy was good and important to maintaining mental health.^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32,Reference Olsson, Strand and Kristiansen33} One service user stated: ‘I've got quite a busy schedule here and if I didn't, I know that keeps me ticking over. I need that to keep me going. Being busy is good (…)’^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} (p. 236). An active use of time was viewed as essential for reducing boredom and improving mood,^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23,Reference Glorney, Raymont, Lawson and Allen27,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} as well as for reducing the risk of aggression and violence.^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Møllerhøj and Stølan31}

Several papers documented a call for more activities^{Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Møllerhøj and Stølan31} in addition to opportunities to experience joy.^{Reference Møllerhøj and Stølan31} Activities offered peace of mind and distraction,^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Bowser, Link, Dickson, Collier and Donovan-Hall23,Reference Di Lorito, Dening and Vollm26} but also provided a way to pass time, which was thought to be helpful.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20} However, service users needed to feel that the activities were meaningful to engage with them and to sustain their interest: ‘If they were too easy, too difficult, or repetitive then they were perceived as boring’^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23} (p. 39). Being allowed leave was considered as particularly helpful as it gave a taste of freedom and hope for the future.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Sustere and Tarpey35} Spending time outside the wards doing outdoor activities was also highly valued,^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Cherner, Aubry, Ecker, Kerman and Nandlal24,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Møllerhøj and Stølan31} giving service users a sense of freedom and a glimpse of normality.

Furthermore, several papers emphasised service users’ needs regarding preparing for life outside FMH services.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32,Reference Skinner, Heasley, Stennett and Braham34,Reference Sustere and Tarpey35} Service users wanted the content of care to support them in preparing for life outside of FMH hospital,^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} and to help them develop skills that they needed to achieve and maintain a good life.^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32,Reference Sustere and Tarpey35} They embraced education and training programmes to help them develop occupational skills.^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} These skills included skills to cope with difficulties and stigma,^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} support and skills at maintaining social relationships,^{Reference Zhong, Guo, Wang, Cook, Chen and Luo36} independent living skills, learning skills in decision-making and relapse prevention.^{Reference Cherner, Aubry, Ecker, Kerman and Nandlal24} Developing new skills came with additional beneficial effects including increased self-esteem and self-worth,^{Reference Clarke, Lumbard, Sambrook and Kerr13} a sense of achievement,^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} as well as feeling more prepared for discharge.^{Reference Sustere and Tarpey35} Furthermore, relevant training was viewed as a step toward successful community reintegration.^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} Service users linked having a reason to get up every morning and having much to lose, with a lower risk of reoffending.^{Reference Livingston28}

Empowerment: empowering collaboration within a frame of restrictions

Codes that were related to the process of empowerment constituted the second largest amount of the findings, followed by that of connectedness, and were reported by 20 papers (Table 2). The findings highlighted the needs of FMH service users for a sense of empowerment in a restricted life.^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} Service users called for clear goals in their care,^{Reference Cherner, Aubry, Ecker, Kerman and Nandlal24,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Olsson, Strand and Kristiansen33,Reference Skinner, Heasley, Stennett and Braham34} and felt themselves to be inadequately informed about the objectives of their care and treatment.^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference Sustere and Tarpey35,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} Although all papers stressed the need for a mutual collaboration in forensic care, many service users experienced a lack of collaboration and involvement.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Barnao, Ward and Casey22,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Olsson, Strand and Kristiansen33} One paper revealed that service users lacked knowledge about the legal processes of discharge, and were told to stay calm and follow the rules.^{Reference Zhong, Guo, Wang, Cook, Chen and Luo36} For those who had experienced some degree of collaboration and involvement in the delivery of their care, this was highly valued and seen as an important element of their recovery. Service users called for a mutual collaboration with health professionals about their care.^{Reference Barnao, Ward and Casey22,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} Mutual collaboration included sharing common views of interventions and goals, experiencing cooperation with health professionals, ‘singing from the same hymn book’ and being involved in their own care.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Marklund, Wahlroos, Looi and Gabrielsson29}

Increased knowledge about illness and treatment as well as legal procedures was helpful when presented with choices. Conversely, a lack of information was seen as unlikely to help service users to become more independent and promote their recovery.^{Reference Sustere and Tarpey35} Furthermore, if the reasons for decisions were explained or if the service users were invited to express their opinions about them, then decisions were easier to accept.^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} Regaining freedom, independence and autonomy were the ultimate goals of many FMH service users. Marklund et al^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} concluded that service users ‘… dreamed of living on their own, starting work, having a meaningful everyday life, and being free’ (p. 4). Furthermore, to have access to treatment programmes and medication was viewed as important to being able to recover.^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32}

Safety and security: feeling safe and being secure, experiencing safe care pathways and self-management of risk

A prevalent finding in almost all papers was that service users needed to feel safe and secure, which meant being protected from hostile people and environments and the active practice of self-management of risk. The majority of findings in this new main category were related to self-management of risk of violence and/or relapse to criminality. These findings were present in twelve of the reviewed papers. Self-management of risk comprised ‘taking responsibility for own actions’ and ‘health-maintaining and risk-reducing strategies’. Taking responsibility for own actions included ending their denial of their mental health difficulties and their offending behaviour,^{Reference Skinner, Heasley, Stennett and Braham34} and staying out of trouble.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Barnao, Ward and Casey22} Skinner et al quoted one service user who stated: ‘You have to understand that you're the one that committed that action, so it helped me become more responsible’^{Reference Skinner, Heasley, Stennett and Braham34} (p. 94). In the study by Askola et al,^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} one patient stated: ‘It is important to be honest with yourself. Ultimately, you only screw up yourself. I have the rest of my life involved, and it motivates me’. The importance of motivation for taking responsibility for own actions was also highlighted by Olsson et al.^{Reference Olsson, Strand and Kristiansen33} They describe how FMH service users, who had earned trust of treating physicians and got outside privileges, would be unwilling to take risks that might lead them to lose what they already had achieved.

The significance of being able to staying out of trouble was highlighted by several FMH service users.^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Livingston28} In the study by Livingston,^{Reference Livingston28} one service user said: ‘You have to be able to stay away from problems with the law’ (p. 217). Similarly, a service user in the study by McKenna et al^{Reference McKenna, Furness, Dhital, Park and Connally1} stated that recovery is to: ‘… keep out of jail, keep off the street, keep out of hospitals, and not relapse (…)’ (p. 65). Sustere and Tarpey^{Reference Sustere and Tarpey35} cited a service user who stated that ‘recovery means … being able to manage your problems and living in the community without re-offending and so looking after yourself’ (p. 621). Several health-maintaining and risk-reducing strategies were described to be helpful for becoming more confident in coping with difficulties and risks. Health-maintaining strategies included taking medication,^{Reference McKenna, Furness, Dhital, Park and Connally1,Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21,Reference Livingston28–Reference Møllerhøj and Stølan31,Reference Olsson, Strand and Kristiansen33} staying away from drugs and alcohol,^{Reference Livingston28,Reference Møllerhøj and Stølan31} and developing new health-promoting skills such as relapse-prevention skills, coping strategies, medication management and social skills.^{Reference Cherner, Aubry, Ecker, Kerman and Nandlal24} Many service users found participating in different programmes as particularly helpful in developing new skills.^{Reference Livingston28,Reference Skinner, Heasley, Stennett and Braham34,Reference Sustere and Tarpey35} Some felt that religion helped them to reduce their risks as it provided rules for them to live by: ‘The Ten Commandments tell me I must not steal, must not kill, mustn't do a lot of different things, and if follow those, then I won't, I won't relapse, ‘cos a relapse for me would constitute violence’^{Reference Glorney, Raymont, Lawson and Allen27} (p. 193).

Several papers described the need to feel safe and protected on the ward to support recovery.^{Reference Shepherd, Doyle, Sanders and Shaw12,Reference Clarke, Lumbard, Sambrook and Kerr13} Service users were vulnerable to being victims of intimidation and violence on wards,^{Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25} and they needed protection from violence from fellow service users as well as from a hostile public.^{Reference Clarke, Lumbard, Sambrook and Kerr13} The presence of staff contributed to the feeling of safety and being protected,^{Reference Møllerhøj and Stølan31} and quieter wards felt safer and nurtured the motivation to change.^{Reference Olsson, Strand and Kristiansen33} Safe care pathways included safe transitions as well as safe plans for the future. Service users wanted to know that there was a plan for their independent living and a vision of transition to out-patient care,^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} as well as, eventually, a safe place to live.^{Reference Møllerhøj and Stølan31}

Four papers highlighted the dual role of restrictions, showing that although restrictions could often be a barrier to personal recovery, they could also be helpful.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} One example was a prohibition on alcohol consumption, which was found helpful by some.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20}

Another example was the prevention of crime through internment,^{Reference Pollak, Palmstierna, Kald and Ekstrand14} as well as the prevention of their injury or death: ‘If I hadn't been interned, I would be six feet under by now (…)’^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20} (p. 928). Moreover, one paper described how adherence to rules was seen as a way of showing respect to those who helped them as well as respect for the law.^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32}

Disconnectedness

Several studies pointed out that many service users had limited social networks, sparse social support and suffered from loneliness and isolation.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Glorney, Raymont, Lawson and Allen27,Reference Møllerhøj and Stølan31,Reference Skinner, Heasley, Stennett and Braham34,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} Many service users felt disconnected from staff and expressed feelings of ‘us and them’ and being socially excluded.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Barnao, Ward and Casey22,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Olsson, Strand and Kristiansen33} Not being respected and not having sufficient or any trust in staff were highlighted as barriers to recovery.^{Reference Clarke, Lumbard, Sambrook and Kerr13,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Olsson, Strand and Kristiansen33} For example, some experienced that certain staff members would not greet them or that staff members abused their power.^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} Some service users felt that the strict policies around physical contact limited social interaction.^{Reference Di Lorito, Dening and Vollm26,Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} One service user stated: ‘For me mostly it's just missing having that interaction with people’^{Reference Di Lorito, Dening and Vollm26} (p. 945). Furthermore, three papers^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Barnao, Ward and Casey22,Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} highlighted the dilemma of disclosure, where service users did not trust their relationships with care teams or therapists enough to disclose any difficulties that could hinder a planned leave or activity. One service user stated: ‘(…) I don't think anyone really lets on [about] everything going on in their head’^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} (p. 238). Another service user reported: ‘Personally, I'd never ask for an appointment with the doctor and say that there is too much noise and too many impressions, and that I, I don't know how to handle it, I might be denied my leave’^{Reference Pollak, Palmstierna, Kald and Ekstrand14} (p. 234).

Hopelessness

Many FMH service users described how a sense of hopelessness could challenge their recovery. They related the sense of hopelessness to their experience of isolation, segregation and loneliness,^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} and uncertainty about future discharge or length of stay.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Olsson, Strand and Kristiansen33,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} For example, one participant in the study by Marklund et al^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} said: ‘I absconded because of the hopelessness, that I am never getting out of here, regardless of if I behave well year after year, I am still not getting out.’ (p. 239). Furthermore, hopelessness was linked to the lack of involvement and loss of confidence in staff,^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} being subjected to disempowerment,^{Reference Sustere and Tarpey35} never being free from past crimes^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} and broken promises from staff.^{Reference Olsson, Strand and Kristiansen33}

Negative identity experience: stigma as an offender

Several papers described how FMH service users experienced stigma as an offender and how this stigma challenged their recovery. Some felt that this stigma was a barrier to their contact with family and friends, whom they feared might be afraid of them.^{Reference Zhong, Guo, Wang, Cook, Chen and Luo36} The experience of being stigmatised had negative effects on their self-esteem.^{Reference Askola, Nikkonen, Paavilainen, Soininen, Putkonen and Louheranta21} Many service users were troubled with self-stigma and feelings of guilt.^{Reference Barnao, Ward and Casey22,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} One service user stated: ‘I don't think I'm ever gonna get out of here. And it [is] understandable. I've done some heinous things. But I think I deserve another chance. And it's gonna be really hard for me to get one’^{Reference Nijdam-Jones, Livingston, Verdun-Jones and Brink32} (p. 164). Another service user said: ‘The stories about me as a monster have reached the psychiatric casualty department long before I arrive myself’^{Reference Møllerhøj and Stølan31} (p. 595). The feeling of being constantly tracked and by the possibility of going back to prison caused additional stress.^{Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20} Furthermore, they assumed their criminal history would hinder future paid work.^{Reference Di Lorito, Dening and Vollm26,Reference Zhong, Guo, Wang, Cook, Chen and Luo36}

Lack of meaning

A major drawback to recovery was the lack of meaningful activities and meaning in life, particularly on in-patient wards. Some service users reported that their lives on hospital wards felt worthless.^{Reference Zhong, Guo, Wang, Cook, Chen and Luo36} Some reported a poor quality of life: ‘It's not life, it's more of an existence. You just get on with your routine, day in and day out’^{Reference Di Lorito, Dening and Vollm26} (p. 946). Lack of meaning was linked to the lack of meaningful activities,^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23} restrictiveness^{Reference Di Lorito, Dening and Vollm26} and the fact that responsibility was taken away from them.^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23} Boredom was frequently mentioned as a challenge. Being bored was characterised as ‘a long wait’,^{Reference Pollak, Palmstierna, Kald and Ekstrand14} having nothing to do,^{Reference Olsson, Strand and Kristiansen33} and a monotonous and repetitive everyday life.^{Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Zhong, Guo, Wang, Cook, Chen and Luo36} Importantly, boredom was seen as a risk factor for aggression and violence,^{Reference McKeown, Jones, Foy, Wright, Paxton and Blackmon30} as well being experienced as harmful for their mental health. Boredom represented a lack of distraction from symptoms. Service users would use sleeping to alleviate boredom, and subsequently stay in bed.^{Reference Bowser, Link, Dickson, Collier and Donovan-Hall23} Furthermore, service users were concerned about how they were wasting their time and wasting their lives.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Marklund, Wahlroos, Looi and Gabrielsson29,Reference Olsson, Strand and Kristiansen33}

Disempowerment

Finally, more than half of the findings relating to challenges and barriers to recovery concerned disempowerment. Service users felt disempowered by negative staff attitudes or neglect, and by rules and restrictions perceived as punitive or pointless and to which they would adapt with resignation. Some also pointed to the lack of resources, such as staff shortages, as an additional source of disempowerment. Several service users in the studies reviewed highlighted a lack of collaboration in their treatment and care. Instead, they would follow the rules and keep ‘feeding the beast’ – or meeting other people's expectations – just to be able to earn their leave or other rewards.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Aga, Laenen, Vandevelde, Vermeersch and Vanderplasschen20,Reference Livingston28} One service user stated: ‘You'd better listen to what the staff say and follow their rules as it's their game and not mine so I have to resign myself to these weekly talks’^{Reference Pollak, Palmstierna, Kald and Ekstrand14} (p. 235). However, some found that although they had ‘behaved’ and followed their care plan, things did not move forward.^{Reference Marklund, Wahlroos, Looi and Gabrielsson29} Several service users spoke of loss of freedom and choice in a restricted life, and the feeling of being powerless.^{Reference Pollak, Palmstierna, Kald and Ekstrand14,Reference Barnao, Ward and Casey22,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Olsson, Strand and Kristiansen33} Furthermore, the uncertainty of indefinite time of internment was a great challenge. Some mentioned the lack of clarity in treatment and plans, which counteracted experiencing control in life.^{Reference Shepherd, Doyle, Sanders and Shaw12,Reference Clarke, Sambrook, Lumbard, Kerr and Johnson25,Reference Marklund, Wahlroos, Looi and Gabrielsson29} Others spoke of a lack of a cohesive and united approach to rehabilitation.^{Reference Barnao, Ward and Casey22}