Being Able to Be Yourself: The Lived Experience of Female Patients in Forensic Psychiatric Care

Abstract People in Sweden who commit at least one crime and suffer from a severe mental disorder can be sentenced to forensic psychiatric care. The aim of this study was to describe and gain a greater understanding of the female patients’ experiences of their life situation while being cared for in forensic psychiatric care. Interviews with 15 women were conducted and analyzed with a phenomenological hermeneutical method. The results showed the care and the care environment to be dualistic. The women had to be aware that a close neighbor could also be an enemy. They received care in an environment that was unknown, frightening but at the same time a place where they felt secure, and which was predictable.


Background
People who commit crimes in Sweden are, regardless of their mental state at the time of the crime, viewed as responsible for their actions and can be sentenced to forensic psychiatric care (Kumpula, 2020).This is a specialized field where the purpose is to provide treatment for offenders with severe mental disorders, with a focus on the mental health of the patients as well as on the safety of the general public.The care takes place in an intersection between the legal system and the healthcare system (Lundqvist & Schroder, 2015) and it is important to understand how these affect each other and that no part can be fully separated from the other.Conflicts may thus arise between the perspectives of caring for the patients' illnesses and improving their mental health, while at the same time considering issues of safety generated by legal requirements to deal with the risk of criminal recidivism (Lundqvist & Schroder, 2015).Female patients constitute a minority in forensic psychiatric care (RättspsyK, 2021) and their needs cannot be assumed to be the same as for their male counterparts (Aiyegbusi, 2001;Tolland et al., 2019).
Women with complex needs tend to be treated in wards with a high level of security (Aiyegbusi, 2001;Tolland et al., 2019), despite having less serious index offenses than the male patients.The women often present with self-harm and aggression toward both other patients and caregivers and are responsible for more aggressive incidents than male patients (Tolland et al., 2019) and they tend to react indirectly by using verbal abuse and gossip (Smith et al., 2020).Patients point to a lack of communication and environmental conditions as the reasons for their aggressive behavior, while caregivers appear to regard the patients´ illness as the reason for the aggressive behavior (Lundqvist & Schroder, 2015).There is however, a lack of evidence about, and guidelines for, reducing such behavior among female patients in forensic psychiatry.
Being incarcerated entails having to adjust from a normal way to lead one's life.For example, having to live close to others, adhere to strict rules and having fewer opportunities to make decisions about their care and also about their own lives.According to Purkey et al. (2018), it is important to include patients in decisions about their care and to support their empowerment, which are two of the five principles for trauma informed care.Another study highlights the risk that women receive less social support from their families if they are incarcerated far away, and that they can sometimes lose custody of their children (Bridges et al., 2020).It is important for people who are incarcerated that their basic needs are met, that their psychological symptoms are managed, that they can gain a greater level of autonomy, can identify social groups and can understand the rules, procedures and policies of the institution (Bridges et al., 2020).Women in forensic psychiatric care were found to be more vulnerable to sexual harassment in a study by Quinn and Happell (2015), which is something people with mental illness are more exposed to than the rest of the population.Only a few studies have focused on the experiences of female patients in forensic psychiatric care and how the care affects them.
The women find themselves in a new environment and with new social interactions that create a new situation for them and it is thus important to understand their current life situation but to also have knowledge of their previous experiences.Ayala et al. (2018) describes the new context that differs from previous ones by applying Luhmann's ideas about system theory, and states that the new system is not comprehensible when only looking at the parts, but also needs to be understood in terms of the functional differences between the system and the environment.Further knowledge about the experiences of women in forensic psychiatric care could be helpful for caregivers and managers in this context in the planning of the care environments but also in planning the individual care to be provided.

Aim
The aim of this study was to describe and gain a greater understanding of the patients' lived experiences of being a female patient in forensic psychiatric care.

Methods
This qualitative study has a phenomenological hermeneutic approach.Data were collected from interviews with female patients (n = 15) in five different forensic psychiatric settings in Sweden between December 2019 and March 2022.Semi-structured interviews allowed the participants to talk about thoughts and ideas related to their personal experience in forensic psychiatric care.Most (n = 12) of the interviews were conducted as face-to-face meetings, while three of the interviews were conducted digitally, either via telephone or video calls, due to the Covid-19 pandemic.The same questions were put to all the participants, e.g."Tell me, what has it been like for you since you came to this forensic psychiatric ward?" "How has the forensic psychiatric care influenced your care process?".The questions were in some cases rephrased in order to be understood by the participants.

Participants
The chief medical officer at five forensic psychiatric care settings approved the study to be conducted at their hospital.The psychiatrists in charge of different wards were asked to suggest female patients suitable for participating in the study.The inclusion criteria were: 1) registered as a woman in a gender binary system 2) sentenced to forensic psychiatric care after conviction for at least one crime 3) received forensic psychiatric care for at least three months 4) being in such a mental state that would not entail harm for the participant or the data collector 5) being an inpatient, most of the time, during the time for the interview.
The initial oral and written information about the study was given to prospective participants by the data collector or by research assistants who were not part of the research team.Participation was confidential, voluntary and the participants had the possibility to interrupt the interviews at any time or withdraw from the study without providing a reason.A brief information and reminder of this was given prior to the interviews, while they also signed an informed consent form.The data collector and the participants, one at a time, were either alone in the room or by the computer/ telephone during the interviews.A few of the participants, however, chose to have a caregiver with them.
The interviews were conducted at a time and place suitable for each participant and lasted from 5 to 90 min (Mean = 32 min).The participants varied in ages (from approximately 20 to over 60), had different psychiatric diagnoses and some of them had previous care experiences from other forensic psychiatric settings.All the women in this study were sentenced to forensic psychiatric care after having committed a crime.All of the participants spoke Swedish while three of them had it as their second language.The participants were cared for in forensic psychiatric settings with high, medium or low security.

Analysis
The interviews were transcribed verbatim and the analysis conducted in accordance with a method suitable for presenting a person's lived experience in a narrative form with a substantive content (Lindseth & Norberg, 2022).The analysis was performed by all the researchers, the first and last authors carried out the initial analysis, whereafter the second and third authors validated it, no software was used in this process.The analysis started with a naïve reading, in which the text was read several times, facilitating a phenomenological attitude in order to find the content of the text.A naïve understanding of the content was thus created.The structural analysis, which also has a phenomenological attitude took place in the second step.Meaning units, comprised of sentences, were created as concisely as possible and expressed in everyday language before being reflected on in relation to the naïve reading.Sub-themes were formed by grouping similarities and differences in the text and then further condensed (Table 1).This part was conducted several times to see whether the subthemes could stand for themselves as a part of the text but also be important for the whole text.
The transcribed text was viewed objectively in the structural analysis and the themes, generated from the sub-themes, were reflected on in relation to the naïve reading.The hermeneutical interpretation compelled the researchers to consider the text in different ways before the result was fully formulated.As a third step, the text needed to be put in a context and it was thus reflected on in relation to a theory and other results.A system theory was chosen, which was helpful for understanding the importance of the context for these females and how they were affected by the environment and the interactions with caregivers.These are aspects that cannot be seen as separate entities due to the constant interaction between them.By utilizing a theory and results from other studies the researchers could gain a comprehensive understanding of the text and the phenomenon of being a female patient in forensic psychiatric care.

Results
The analysis generated five themes, which are presented here and further explained in the text after the naïve reading; 1) Being yourself and being confirmed about who you are, 2) A need to understand, be understood and taken seriously, 3) Being involved in a meaningful and comprehendible everyday life, 4) Feeling (un)safe in an (un)predictable and (un) known environment, 5) The desire to help despite being vulnerable.
During the interviews the participants spoke about doctors, registered nurses, and staff at the wards.All these professionals will be termed as caregivers in the following text.

Naïve reading
Being in a forensic psychiatric setting generates different feelings, where the same experience for the women could be felt both positively and negatively.The location of the forensic psychiatric care created a distance from family and friends leading to feelings of missing someone.The longing to meet them increased, which seemed beneficial for the contact with relatives.Many came to the conclusion during the care process that they wanted to start a family of their own.However, they were at the same time worried this might not happen if they were incarcerated during the period of life when they were most fertile.Receiving treatment in a forensic psychiatric setting increased the distance from the environment and surroundings that previously were factors that impacted the risk of mental ill health.They were not allowed to have personal belongings in their rooms that could be interpreted as dangerous, for example tweezers and razors.These were taken care of by caregivers, and they had to ask for them, sometimes in front of other patients.
By not having these they felt less responsibility and as though the caregivers did not trust them.This generated thoughts about being more difficult to reintegrate into society.
There was a norm for the "forensic psychiatric patient" and in order to conform to this norm the women had to adapt their identity.Living in these settings entailed being impacted by other patients and their behavior.The women felt frightened when other patients sexually harassed them or were physically aggressive in other ways.They experienced expectations about how they should be calm and reserved, while the male counterparts were allowed more space and to show aggressive and more verbally disrespectful behavior.
The possibility of having a caring relationship with caregivers could be affected by the uncertainty concerning the duration of the care.The women felt insecure in their communication with caregivers because they were afraid their behavior could be used against them and extend the duration of the care even further.They understood that they needed to receive care but wished for clarity and structure with guidelines informing them what to expect during their hospital stay.It was important that caregivers were supportive and helped to motivate the women.If the caregivers did not make themselves available and approachable, the women became distressed, which could show itself in aggressive behavior or resulted in a need for further medication, despite the longing for verbal communication.Another factor that increased stress and generated a need for more medication was whether the women experienced a lack of activities, or if the content of their care was not beneficial.Caregivers had the possibility to impact the care and the power to guide patients in a direction suitable for caregivers, while the women wanted health-promoting strategies focused on them as individuals.

Being yourself and being confirmed about who you are
Being treated in forensic psychiatric care generated a variety of feelings and experiences, which had both physical and psychosocial impact.This was shown by a deterioration in their mental health but also in their physical well-being in terms of weight gain and amenorrhea.Despite these negative experiences, the time they received care provided them with opportunities for respite and a distance to what they had previously done and experienced.It was possible to stop and reflect during the hospital stay.
well, I've actually become a little more calmer and healthier and I can look back on what I did that it wasn't good and I knew that then but it was a way of calling for help (Respondent 10) The women felt caregivers were unable to see them as a whole person, focusing more on the patients' mental health and processing the crime that had been committed.Meanwhile, the physical body with a somatic illness was disregarded and this was assumed to be cared for after the forensic psychiatric care.
You don't get any help because they have no knowledge, no education, nothing.They become passive instead, and don't give a damn because they don't know how to do.They have a The psychiatric treatments felt meaningless if the women were unable to understand why they were given the specific treatment.It was essential to understand and receive beneficial treatment strategies in order to assimilate the given care.
It (the care, author's remark) isn't the best because it's up to you to gain insight yourself (Respondent 1) Communication with relatives improved during incarceration and it became clear for the women that they needed a social network after discharge, so they could be part of a social context even when reintegrated in society.Being in a forensic psychiatric setting provided the opportunity to be part of a social context and to feel meaningful.A lack of a social context increased the risk of committing new crimes leading to a return to forensic psychiatry.
They longed for social context, being in a relationship and creating a family of their own.Simultaneously, they suffered, and were frustrated this might not happen because the duration of their stay was during what they considered to be their reproductive years.
Well I'm 34, it is time for me too, it's not only that I feel a longing, I also feel the importance of the biological clock and that makes me feel stuck like I don´t even know if I will get a baby.And that the forensic psychiatry has taken my life away from me, it feels that way that it could possibly be like that.And that's like taking away the finest thing in a human life (Respondent 2) The women spoke of experiences of verbal and physical sexual harassment, which were mostly by their male counterparts on the ward and occurring there or outside in the hospital surroundings.This became demanding and to avoid the repugnant feeling of being sexually harassed, they avoided participating in activities and adjusted the way they dressed.Their identity as females was reduced by the fact that clothes provided by the hospital were not particularly suited to meet women's needs.A lack of support for parts of the female body, such as breasts and clothes in wrong sizes, made the women uncomfortable.
Caregivers made the women feel responsible for the sexual harassments and it was the latter who were told to stay in their room and stay out of the area where the male patients were.They also felt it as a violation of their female identity when they were forced to take contraceptives in order not to become pregnant during the care.
The caregivers and the doctor say I have to take contraceptives as though I… would have sex with them, the boys in the ward.And I don't want to take contraceptives (Respondent 7) After all, they could understand the importance of taking prescribed medication for their mental health in order to feel better.
if you don´t administer your insulin then it's oops and it's the same with my disease, if I don´t administer my medication then it becomes a real bloody hell (Respondent 5) Receiving forensic psychiatric care impacted the women and could be devastating for their identity but also helpful in enhancing it.They talked of struggling to find and rebuild their identity where the distance to the community outside could be helpful for rebuilding the identity that they previously had prior to their drug use or criminal activities.They needed to be heard and seen to get the help they desired.The so-called "female characteristics" of being humble and kind were discarded in favor of being straightforward and tougher.At the same time, they were not allowed to claim the same space as male patients, because of unspoken norms of women being calmer and more withdrawn.They had to adjust to a male-dominated world but were expected to not give up on the fact they were women.
I don't think you're seen for the person you are either, and are treated in that way, instead you are supposed to be like a robot in the way they expect you to be, it's not possible for the whole person to be who one is, humble, sensitive, kind, you have to be tough but at the same time being honorable towards them, the sensitivity that we woman have is suppressed in one kind of way, that's how I feel (Respondent 2)

A need to understand, be understood and taken seriously
The women wanted to be seen as human beings and to feel their life experiences and mental health were taken seriously, which became evident every now and then during their treatment.When caregivers were supportive and open to receive the women´s narratives, they felt a connection and conversations became beneficial when caregivers focused on them as individuals.The women had to take care of their feelings and mental health by themselves when these conversations did not take place.In some cases, they were able to talk to and receive support from other patients or their own relatives.Requesting medication could be a reason to contact caregivers on the ward and beneficial conversations could reduce the need of medication.
Can we speak for 15 minutes (patient illustrates asking the caregivers, author's remark) Yes, I only need to do one thing first (refers to answer from caregivers, author's remark) It's the only thing I demand of you, it's not medication, I need to speak and share my thoughts about how I feel, you must remember dammit, that I'm the only girl here (Respondent 5) The women felt insecure and lost trust in caregivers when the communication was incomprehensive or when caregivers only communicated with each other.On the other hand, they experienced they were treated with respect and seen as a human being when caregivers gave of their time, listened and were considerate.If they were helped finding strategies to cope with varying mental states, they felt positive about the contact and how caregivers worked together with them.
No, she could see when I was feeling bad, she … what's it called she was very dependable and talked a lot… and … she took it in a very positive way when you were feeling sad or angry, that you came and talked, so no, she was good (Respondent 15) The experienced restrictions in communication and contact with society outside the forensic psychiatric setting could generate positive feelings about daily changes of caregivers, where the caregivers could be a new person to focus on and speak with.Simultaneously, it could be negative for the continuity of the care if they had to retell their stories and experiences to different caregivers on regular basis.Caregivers were experienced as having different levels of training and abilities in dealing with subjects the women needed to talk about.Caregivers were not always prepared and sufficiently open to listen to the women's narratives and on some occasions caregivers distanced themselves from patients on the ward by closing the ward office door.They became unavailable and let the women take care of their feelings by themselves.The women assumed it was the caregivers' duty to be in the ward office and, on those occasions, the women did everything not to disturb them.At the same time, a frustration arose when they noticed caregivers were in the ward office not only for work but also for private reasons.
Can you understand me, you don't get heard anywhere?… then they can sit there with their damn feet on the table and google and listen to music and look at clothes to order, what the hell, you should go out on the ward for fuck's sake, you're getting paid for this (Respondent 5) Feelings of frustration appeared when the women needed contact and the caregivers were unavailable.The women worried something was about to happen and the conversations held in the ward office were about them as individuals.This increased the psychosocial distance between caregivers and the women and hindered a natural communication.If they were unable to understand what was going on in their surroundings, they could perceive themselves and the caregivers as opposite poles.Caregivers who were explicit and confirmed the women´s feelings helped them understand the care processes.It was positive to maintain rules and routines since this could create a structure in the environment, which encouraged them as individuals but also in relation to the care process.A structure with a clear framework could provide conditions for improved behavior.but I need the limits and it will become safe for me.I think it can be a bit too lax when it… there are not so many routines, you don't know what to expect (Respondent 1)

Being involved in a meaningful and comprehendible everyday life
Various activities, such as sewing, cleaning or taking a walk helped to make progress and created an opportunity to focus on their mental health.Being activated also increased the possibilities of avoiding extra medication and allowed thoughts to disperse.Simultaneously, a lack of activation could increase negative thoughts and lead to negative experiences of the caring situation.
You can't be anything else but depressed in here when you don't have anything to do (Respondent 6) Activities helped maintain routines and create structure in their everyday lives.It was also helpful to maintain the ordinary everyday functions they had prior to coming to the ward to facilitate for the discharge process.you want to do as many ordinary things as possible so you don´t forget that while you're in custody (Respondent 1) Time until discharge was experienced as uncertain, and not knowing when the care was over created a lack of control and understanding of their own lives.They were helped dealing with these uncertainties if they received a time frame and if the caregivers clarified the care process and what was needed to achieve for discharge.However, they often felt their considerations concerning what they should achieve were neglected, and instead the caregivers determined the content of the care.
You want to decide by yourself … I wanted to participate but I didn´t dare to say it in front of the doctor … I have to say, all the time, okey okey and listen to her, so she won´t withdraw something (Respondent 7) The women felt they were unable to participate, or were not given opportunities, to understand what was happening in their care.Not knowing what was required to make progress in the care process created a feeling of not being able to plan their lives, whether it was in relation to mental health or reintegration in society.Possibilities to plan their lives became difficult when they did not participate, when the communication levels were deficient, and the clarity decreased.
You can´t plan your life, because your life is on hold… but I can take that because of what I did, but not knowing for how long, you should have a time perspective (Respondent 11)

Feeling (un)safe in an (un)predictable and (un)known environment
The environment in a forensic psychiatric setting was filled with stimuli with high noise levels, sharp lights and large wards, which had a negative impact.Furthermore, they had to take the constant presence of caregivers into consideration, and also the mental health and presence of other patients.Many of the women described experiences of sexual harassment, which were both verbal and physical and occurred in the ward or hospital surroundings.
I had forgotten to lock my door, then he only came in and said yes shall we have sex, it can feel good for both of us, and he' d barely said hello to me before.I said it is, you can go out of my room immediately because I don't want to be a part of this.Then I got a real hell every time I saw him, he started hitting the walls and things like that, so I felt he was unpleasant (Respondent 4) It was abhorrent knowing they could not get away from the person who committed the sexual harassments because the physical environment was limited, and they were both confined in the same space.
They felt exposed in the environment, and there was no sense of a home-like atmosphere.They were unable to get some of the necessities of daily life, for example razors and tweezers, without help from the caregivers, this created a feeling of being marginalized in relation to society.
When their freedom of movement was restricted and they were unable to access these necessities, they experienced caregivers trusted them less and gave them fewer responsibilities.It was intrusive having to ask for things they needed to take care of their hygiene.Not having these necessities combined with aggravating circumstances such as the design of showers could hinder them from taking care of their personal hygiene.
Despite the limitations described above, the restricted physical environment together with caregivers who set boundaries of what was deemed as acceptable behavior, the women had positive experiences of the caring environment.Caregivers, rules, and routines could be restricting, but at the same time constituted security in daily situations where caregivers were supportive in reintegration into society.The women differed in how they coped with possibilities of being socially active and fulfilling daily activities.They perceived unspoken requirements to be socially active as most of the activities on the ward, such as dining, required social interaction.
yeah, I perhaps mean it's compulsory care and to get food and to participate in activities or just to participate in the care it's necessary to be socially active (Respondent 1) Being socially active was also a requirement when they wanted help from caregivers, for example, to unlock a door.They felt caregivers opened the door when they wanted to, not when they were asked to.This created a feeling of caregivers using their position of power, they could be intimidating by acting in a way that was contrary to the women's wishes.This sense of a power situation could be seen when caregivers made the women aware they could lose access to activities if they misbehaved.
then I voiced my opinions much more than I do now, now I don't dare because one of the caregivers said if you get angry then they'll cancel all of your leaves of absence (Respondent 7)

The desire to help despite being vulnerable
The women described how they were supportive to other patients but lacked the possibility of talking about this with the caregivers.They felt they were left alone to deal with and process both their own, and in some cases, other patients´ mental health.Being supportive was a natural undertaking and something they often did.They experienced that they took a caring attitude in relation to other patients when listening to them continuously.It felt positive when they could talk to other patients about their own emotions and experiences, due to a mutual understanding of the situation.Despite the willingness to support others, knowing about their crimes and mental health could be difficult to deal with, and these between-patient conversations sometimes resulted in new knowledge about other patients' crimes.It could be frightening knowing about the capacity of others to carry out various forms of physical and sexual acts of violence.
well it, yes you get scared that you can get in the way, such as being in the wrong place at the wrong time.It doesn't feel good at all so you try as quickly as possible to escape if you have the opportunity (Respondent 3) Their previous life experiences and not knowing the other patients resulted in fear of what the latter were able to do.Feelings of discomfort arose when they witnessed other patients' mental illness, self-harm or even attempts to commit suicide.When other patients' mental health deteriorated, the women could immediately be affected in a way where they felt worse as well.They did not want to do something intimidating to others and wanted to avoid being misinterpreted.They lost a bit of their personality when hoping to be accepted and they were worried about other people's reactions and thoughts about them as women.

Comprehensive understanding and discussion
Being a female patient in forensic psychiatric care appears to be impacted by physical and psychosocial aspects generated by the care.However, it could also be the other way around, the design and physical attributes of the wards need to be adapted to meet risks and vulnerabilities of patients being treated there.These aspects appear to correlate with each other and interact in both directions.To be able to understand female patients in forensic psychiatric settings, and, for them to understand their surroundings, it is important to see how they affect and are affected by relationships and factors such as the design and physical attributes.Different relationships are created and maintained during the care process, and some of them appear favorable, while other appears to be more harmful.It is important to understand how different aspects are suitable or not for each other.Ayala et al. (2018) described the importance of the system theory and that, for example, communication could not occur without social interactions and also the importance of the opposite way.No part could function by itself without being affected by the other.According to Von Bertalanffy (1950), the system theory aims to show how different factors affect each other.It entails seeing the whole system, not divided into parts, but how they affect different factors dependent on each other.The women who are human beings placed in this setting must be seen as one part, while the forensic psychiatric care with its design, physical attributes of the hospital building, and the interpersonal relationships must be seen as other parts.Those aspects need to be seen as complementary to each other and cannot be totally separated to understand the women's life situation.They all have a meaning for the women's mental health and progress in the care.
Forensic psychiatric inpatient care is often provided on wards with both male and female patients, while if a person is sentenced to prison the prison facilities are divided by gender.Being together with male patients was both positive and negative.The women needed to adapt to a normative male behavior and tone down some of their normative female characteristics.They also needed to act in a certain way in order to be heard and seen, while at the same time they were supposed to be calm and behave correctly.The results reveal only a few aspects that can be assumed to be gender-specific, for example amenorrhea and unsuitable clothing, while other experiences such as the risk of violence from other patients, may also be experienced by male patients in forensic psychiatric care.In another study, women were found to be particularly vulnerable due to the male patients´ behavior (Bartlett & Somers, 2017).Female patients in forensic psychiatric care are a minority group and the care is carried out in an environment commonly adapted to the needs of male patients.Caregivers need awareness of the different needs of male and female patients (Kumpula et al., 2022), as it cannot be assumed that these needs are similar (Aiyegbusi, 2001;Tolland et al., 2019).System theory can help to explain how the female patient can be formed because of something but also as a part in something.The system theory (Johnson, 2019) highlights the importance of seeing that everything exists in a context where relationships are circular and without an absolute truth, where a dualistic focus helps to understand people in their surroundings.Efforts to change and adapt both the physical and psychosocial environment are required when providing care to different individuals specially when the length of stay can last several years.Caregivers must be aware of how the patients´ risks and vulnerabilities impact others but also how the women experience their life situation in the care whether it is due to gender or not.
The physical, psychological, and sexual harassments, both verbally and by actual physical abuse affected the women's behavior on the ward, they changed their clothing style in order to avoid sexual harassments.Other studies have shown women in forensic psychiatric care as more vulnerable to sexual harassments and that people with mental illness seem to be more exposed to this than the rest of the population (Quinn & Happell, 2015).Studies describe the importance of talking about sexual health (Bartlett et al., 2010;Hales et al., 2006) but there is a lack of studies focusing on the experiences of being sexually harassed while being incarcerated.
The results of the present study showed the importance of patients and caregivers talking to each other and that the latter needed to approach each woman as an individual and provide each one with opportunities to share experiences and thoughts with someone who has a genuine interest in them.Similar findings were found in a study by van Daalen-Smith et al. (2020) where the women spoke of the importance of communication and of feeling that they were being cared for.Valuable conversations could ensue for the women in the currently study when they were allowed to speak about subjects they considered meaningful, instead of subjects that the caregivers thought were needed.Sometimes, the caregivers chose not to engage in conversation with patients in favor of doing other things, which increased the dissatisfaction for the women.In a study by Long et al. (2012), caregivers who "listened" were perceived as empathetic and caring.Different types of conversations are valuable for improving health outcomes (Rydenlund et al., 2019).According to Hörberg et al. (2012), the forensic psychiatric care was generally perceived as isolated, unconnected and an unstable existence by the patients, and they only experienced small elements of the care as warm.Furthermore, it has been shown that the need for opportunities to have a conversation could arise at any time of the day (Rydenlund et al., 2019).By listening to the patient, caregivers make an ethical promise that the patient's story will not cause any harm.When patients share their suffering without being judged by caregivers, the suffering is made less harmful, and the patients can more easily find strategies to cope with their lives (ibid).In order to create a ward with a caring environment, it is important for caregivers to have knowledge about and competence in communicating, but also to show respect and empathy and not only focus on the patients' mental illness (Long et al., 2012).These aspects, together with the result in this study, can be compared with trauma informed care, where Purkey et al. (2018) describes the five principles: trauma awareness and acknowledgement; safety and trustworthiness; choice, control and collaboration; strengths-based and skills-building care and finally cultural, historical and gender issues.These principles indicate the importance for caregivers to understand how different trauma (for example, substance use) affect someone's experiences in life and how previous experiences can result in different coping strategies.The principles also indicate the importance of physical and emotional safety, including decision-making about the treatment and supporting the women's empowerment.According to trauma informed care, it is also important to incorporate processes sensitive to a person's personal and social identity.
The present study showed that it was difficult to have a natural communication with caregivers who stayed in the ward office.This place was one of several parts of the ward where only caregivers had access.The women felt a loss of empowerment when they were restricted or not able to enter some places in the ward by themselves.If caregivers did not open doors when they were asked to, it was perceived by the women as them using their position of power.It is important, according to the system theory, to see the human being as a person and not to separate the human being from things that can be constructed manually, for example, a care environment (Johnson, 2019).The forensic psychiatric care needs to take both these factors into consideration, where for example boundaries can be both positive and negative.The participants mostly considered the existence of rules and routines about how to behave as positive.According to the system theory, the aim of having rules and routines is to create order rather than disorder, and different systems can develop by integrating with their surroundings, irrespective of whether it concerns cells as molecules or in a social community with human beings (Von Bertalanffy, 1950).The women were afraid their actions could affect caregivers' thoughts about them, which caused them to adjust their actions and behavior accordingly.They sometimes went to their rooms to keep out of places the caregivers frequented.They adjusted how they expressed emotions to avoid being punished.They felt dejected while not knowing how long it would be before discharge and they were afraid their actions could prolong the length of care.The authors in another study (Pollak et al., 2018) described the patients experiencing hopelessness by not knowing when the care process was nearly over.Kanyeredzi et al. (2019) found that the patients could act in any way they wanted to but tried to avoid this so that their behavior would not affect the care process negatively.
Female patients in forensic psychiatric care have experiences which appear to be somewhat dualistic where the same experience can have both positive and negative aspects.For example, routines, rules, and caregivers can in one way inhibit the women, but on the other hand these are factors that can help the women improve their mental health.

Conclusion
Women who receive care in a forensic psychiatric context are affected by the physical design of the environment and by interpersonal communications, but as described above, none of these can be totally separated and they affect each other in both ways.It is important to acknowledge the women as individuals and take them seriously, as well as to help them to understand themselves and their surroundings, for example, with strategies for their mental health and rules on the ward.It is also important for the women to be understood in their situation, in terms of their health and also the environment in which they find themselves at present.By creating opportunities for participation and a meaningful daily life with activities the women can be helped to feel safe in the environment, despite there being a risk of being hurt physically and/or psychologically.

Clinical implications
This study was designed to allow women to narrate experiences of being patients in forensic psychiatric care.Caregivers can be helped to gain an understanding of aspects affecting women and their care by increasing their knowledge about the women's experiences.These aspects, such as the harassments from other patients, the design and physical attributes of the ward and interpersonal interactions are important to highlight and it is important to see how these are combined in a system and cannot be separated, while the care is provided.Caregivers and ward managers can be helped to gain an understanding of the women's experiences and how these can be dealt with in order to provide good care and help the women improve their mental health while minimizing the risk for criminal recidivism.

Limitations
The narrative about a person's experiences of a special part of their life situation has been facilitated by using a phenomenological hermeneutic approach.This approach has been useful in the current study since it helped to focus on phenomena while at the same time interpreting the participants' narrative.The results present true narratives but it is important to keep in mind that the whole truth can never be understood (Lindseth & Norberg, 2004).
There are certainly people in this context who have male gender but who are considered by themselves and their surroundings to be a woman.To increase the study's clarity, the authors chose to only include participants with female gender in accordance with the gender binary system.
The interviews were carried out in a face-to-face meeting or digitally, which may have affected the interviews.Sitting close to the person who asks these, sometimes sensitive, questions might be experienced as more supportive than when doing it digitally.We have no way to control for how this could have affected the results but must acknowledge it as a limitation.
The analysis made it possible to focus on the core of the women's narratives.It was important to present the results in a way reflecting the spoken words.By discussing the text among the authors during the analysis, it was clear that the result did reflect the narratives collected.
Forensic psychiatric care is dominated by a male perspective in several ways, and it was in the beginning difficult to avoid focusing on gender differences.The authors discussed whether it was important to focus on the similarities and differences of being a female patient compared to being a male patient during the analysis.These discussions resulted in determining it was the women's life situation as experienced by them that needed to be in focus, irrespective of whether these experiences were feminine or masculine.

Table 1 .
analysis according to lindseth and norberg (2004): examples from women's experiences of forensic psychiatric care.