Recovery at an Adult Psychiatric Day Hospital—A Qualitative Interview Study Describing Patients’ Experiences

Abstract Psychiatric Day Hospitals offer time-limited active treatment programmes that are therapeutically intensive, coordinated, and with structured clinical services within a stable environment. No previous studies have described patients’ experiences of recovery-oriented care at a Psychiatric Day Hospital in a Swedish or Nordic healthcare context. The aim of the study was to explore patients’ experiences of a Psychiatric Day Hospital with focus on patient recovery. A qualitative method was used; 12 in-depth interviews were performed with patients all analysed with content analysis. The theme that emerged was “A safe haven.” To do something routinely and meaningful during the days, feelings of security, and to gain increased knowledge about mental ill health were concepts which felt important and contributed to recovery. Feelings of belonging and prevention of loneliness were also highlighted.


Introduction
Psychiatric Day Hospitals, also known as Partial Hospital Programmes or Day Treatment Programmes are time-limited active treatment programmes which offer therapeutically intensive, coordinated, and structured clinical services designed to promote recovery within a respectful environment which instils hope.They usually provide a variety of therapeutic modalities and patient education, both in groups and individually (Lieberman & Guggenheim, 2016;Yanos et al., 2009).The Psychiatric Day Hospital provides an alternative to inpatient care for individuals with acute psychiatric symptoms that do not require overnight or 24-h monitoring (Heekeren et al., 2020;Kallert et al., 2007;Marshall et al., 2001;Rosie et al., 1995).
Psychiatric and mental health nurses have an important role in initiating an interest in recovery in mental health and in healthcare (Gabrielsson & Looi, 2019) and one of the important tasks is to work with best mental health nursing practice (Gabrielsson et al., 2020).Recovery can be defined as a personal process and a way to return to a constructive life despite the difficulties that mental illness brings (Bowen & Mason, 2012).Mancini et al. (2005) suggest that recovery is a unique and personal development process dependent on support and meaningful activities.One of the currently most accepted frameworks to understand personal recovery is a compilation of five interrelated recovery processes; Connectedness, Hope and Optimism about the future, Identity, Meaning in life, and Empowerment (CHIME) (Leamy et al., 2011).This is in line with Denhov (2000), who showed similar results from a patient's perspective in which continuous conversational contact, employment, social contact with relatives and friends, hobbies, and exercise emerged.Prevention of illness was of importance, several mentioned food, sleep, and exercise to avoid relapse.Attention to early symptoms was an important preventive measure to avoid further deterioration.
A significant contribution to the development of practicing a recovery-oriented view, has come from patients "in recovery." They advocated person-centred care, self-determination, and an increased focus on restoring functionality, and not only on symptom reduction (Davidson, 2016).Denhov and Topor (2012) believe that the relationship between professionals and patients is one of the most important factors in the recovery process.This was confirmed by Slade and Longden (2015), who demonstrated the importance of the staff supporting various aspects of the patient's recovery for a successful recovery process.Inpatient care working staff are often busy, their time is spent mainly with administrative work and department security instead of talking with patients and activities (Molin et al., 2016;Waldemar et al., 2018).A study by Glantz et al. (2019) highlights that nurses in psychiatric inpatient care report that administrating drugs and medications accounted for a large portion of their daily work.In a literature review by Schmidt and Uman (2020) on patients' experiences of psychiatric emergency care, it was shown that the care environments could be experienced as privacy-depriving and unpleasant, and staff input was experienced as both positive and negative.Patients' satisfaction and well-being after discharge were predominantly perceived negatively.Kallert et al. (2007) conducted an RCT study in five European countries where Psychiatric Day Hospitals were compared with 24-h inpatient care.They found Psychiatric Day Hospitals to have a similar impact on changes in psychiatric functioning, satisfaction with treatment and quality of life compared to inpatient care.In contrast, those who were cared for at a Psychiatric Day Hospital had better social functioning at discharge but also at 3 and 12 months later.An RCT study by Heekeren et al. (2020) found that patients with various diagnosis like for example psychotic disorders, affective disorders, and disorders of personality and behaviour, can be treated just as well in a Psychiatric Day Hospital as in inpatient care and demonstrated clear cost advantages favouring Day Hospital treatment.
According to Rosie et al. (1995), Psychiatric Day Hospitals can be an option for both patients who are in transition from inpatient to outpatient care, and patients who can benefit from more intensive care than given on an outpatient basis.Yanos et al. (2009) meant that Psychiatric Day Hospitals gave individually evidence-based and recovery-oriented programmes that helped patients in the transition from acute episodes.This can facilitate the development of coping skills, social skills, and disease management skills, as confirmed by Larivière et al. (2010) where patients after discharge from a Psychiatric Day Hospital described an ability to use the gained knowledge, strategies, and tools to continue their personal development at home.
It is a clinical experience and also scientifically shown that patients in psychiatric inpatient care may find it difficult to readjust to psychiatric outpatient care.There is often a feeling of stress, loneliness, helplessness, and a fear of feeling worse (Synovec, 2015).In addition, there is an increased risk of suicide in the first period after discharge from inpatient care.In a study by Cutcliffe et al. (2012), patients who were cared for after suicide attempts described their concerns, fear, and stress in connection with discharge.Biringer et al. (2017) disclosed the importance of finding interventions to facilitate the transition.Psychiatric Day Hospitals could play that important role as a transitional supportive form of care after discharge (Chijiiwa & Ishimura, 2020).
There are, as far as the authors can tell, no previous studies describing patients' experiences of recovery-oriented care at a Psychiatric Day Hospital in a Swedish or Nordic healthcare context.Therefore, the aim of the present study is to explore patients' experiences of a Psychiatric Day Hospital with focus on recovery.

Method
In accordance with the aim of the study, a qualitative method was used.Twelve in-depth interviews with a descriptive-inductive approach were performed with patients who received care during a 6-week programme at a Psychiatric Day Hospital.The interviews were analysed using manifest and latent content analysis according to Berg (2009).

Context
The relevant Psychiatric Day Hospital is located at a university hospital in southern Sweden.
Patients are admitted either from the Psychiatric Emergency Department directly or from inpatient care, with diagnoses including affective disorders, emotionally unstable personality disorders, crises or eating disorders.The interdisciplinary team includes nurses, specialist nurses in psychiatry, assistant nurses, doctors, and psychologists.There is also an employee with personal experience of his/her own mental illness, a peer support.The patients are admitted to the Psychiatric Day Hospital for 6 weeks, initially with closer contact which becomes less frequent over time.The Psychiatric Day Hospital offers several activities such as physical activity, relaxation exercises and various psychoeducational interventions often in a group therapy setting.The aim is to make the patients active, to obtain structure in their everyday life and to increase their ability to find new strategies to succeed in their life situations.Patients will hence be better prepared for discharge and reduce their need for inpatient care.

Participants
The inclusion criteria were patients who received care and attended the 6-week programme at the Psychiatric Day Hospital.Patients with eating disorders were excluded since other treatments were offered and longer care was needed.Participants should master the Swedish language verbally and in writing.Patients with ongoing alcohol or drug abuse, confusion, and dementia, were excluded from the study.
Posters provided information about the study at the Psychiatric Day Hospital, and prior to discharge the patient received written information about the study.Patients who considered participation filled in a reply letter which they could leave in a box at the ward or send to the interviewer in a pre-paid envelope.Before the interview, the participants were given the opportunity to ask questions about the study before they signed a consent.
Twelve patients participated in the study (Table 1).Ten of the patients reported depression as reason for seeking care.Three participants also reported suicidal thoughts or attempts.One patient stated a bipolar disorder, and another described the diagnosis as unclear.Six patients had received inpatient care before admission to the Psychiatric Day Hospital and six participants were admitted from the psychiatric emergency department.All patients were offered contact with outpatient psychiatric care after discharge from the Psychiatric Day Hospital.Two patients had sought psychiatric care previously during the past 12 months.Only one patient had been cared for at the Psychiatric Day Hospital once before, but for the others, it was their first opportunity.

Data collection
All one-to-one depth interviews were conducted by the first author.The interview started with demographic questions followed by a dialogue of four open-ended pre-set questions: How did the care at the Psychiatric Day Hospital affect your recovery?Can you tell me about your experience of being cared for at the Psychiatric Day Hospital?What was positive with the care and what was challenging during the care?Explorative questions were asked to learn more from the responses.The last interview question was: Is there anything else that we have not covered that you want to add? Through a dialogue from these pre-set questions, the participants shared their experiences of being cared for at the Psychiatric Day Hospital with focus on their recovery.Nine of the interviews were conducted in an office at an outpatient psychiatric clinic.Due to the pandemic, two participants preferred to be interviewed by telephone and one by videoconference.The interviews were conducted between October 2020-July 2021.All interviews were audio recorded and for confidentiality reasons, the audio file with the interviews and the decoded transcribed interviews were saved on a USB stick.The consent forms signed by the participants, were kept separate from the recorded and decoded printed interviews.No one at the current Psychiatric Day Hospital was told who participated in the study.The results are reported at group level so that no informant can be identified, and it is not stated where the study took place.
The interviews lasted for a total of 10 h and 33 min and had a range of 32-72 min.According to the principle of data saturation in qualitative research, interviews terminated after 12 interviews because the collection of more data did not provide any new useful information (Polit & Beck, 2014).The interviews were transcribed verbatim.The total transcribed material consisted of 185 pages (Times new roman 12, line spacing 1.5).

Analysis
After transcription of the interviews, the texts were read several times to gain familiarity with the data; they were then analysed with qualitative content analysis according to Berg (2009).Both manifest and latent analyses were used to acquire a deeper meaning of the material.The meaning units, describing the participants' experiences of the Psychiatric Day hospital and how it had affected their recovery, were identified, and selected from the text.The meaning units were then condensed, which according to Berg (2009) means that they are shortened without important information being lost.After that, meaning units were coded, and subcategories were created which Berg (2009) refers to as axial coding.Similar sub-categories were compared and analysed, and categories with a higher level of abstraction were created.The categories led to the theme that summarises and reflects the message.The author, (MM) moved back and forth between the data and the various stages of the analysis throughout this process.One of the authors (KÖ) participated in the analyses for confirmation of results.Examples of the analysis process are presented in Table 2.

Ethical consideration
Ethical approval was given from the Ethical Review Agency, Uppsala.Ref. 2020-02849.All participants were informed in writing and verbally about the study and that they could withdraw at any time.A guarantee of confidentiality was given.Informed consent was obtained from all participants.Before the interviews, the authors reflected on any emotional effects the questions might have on the participants and on the risk for mental health detoriation.The participants had the opportunity for supportive conversations with two pre-named nurses at the Psychiatric Day Hospital if needed.

Results
The analysed material resulted in four subcategories, two categories and a main theme A safe haven (Table 3).

A safe haven
Feelings of being safe arose from the narratives.A warm and permissive atmosphere along with feelings of being understood and supported were experienced by the patients.The atmosphere also contributed to feelings of acceptance, and the Psychiatric Day Hospital was perceived as a place where you could be yourself.Feelings of security and acceptance contributed to the recovery.
I felt good about getting there and that… I have like nothing that you feel good about except sitting on my balcony or watching TV, it's like my gold nuggets and it's like not much and… Yes, so it felt good to go there and have it as a goal every day, to get to a place where I felt good -or felt good, it helped me anyway.( 12 The Psychiatric Day Hospital were a safe haven in contrast to direct discharge from the clinic and prevented feelings of loneliness.Calmness and a homelike environment contributed to feelings of security and peacefulness.The narratives highlighted an increased sense of freedom along with increased responsibility for oneself, a new phase in the recovery process was developed.Continuous support and guidance were highlighted in the narratives.

Feelings of belonging
It was important for recovery to have a place to stay, to feel belonging and to break loneliness.The company of others with similar problems provided a social context with less loneliness and isolation.
The patients emphasised the importance of structure in everyday life.Getting to and from the Psychiatric Day Hospital became a goal, which was helpful for recovery.
It was somewhere I went when it was eight o' clock in the morning.It was not a job, but it was a place to go to, a context to be in.( 5) The Psychiatric Day Hospital was perceived as lifesaving and contributed to feelings of belongingness and self-worth.
When I got there, I just cried and had … I felt really bad.When I woke up in the morning, I had suicidal thoughts but somehow when I started at the Psychiatric Day Hospital, I felt very secure when I was there.Regardless of how I felt in the morning, I went there.( 2) The care structure with a successive decrease in days at the Psychiatric Day Hospital increased independency and contributed to recovery.However, feelings of insecurity arose when discharge from the Psychiatric Day Hospital was too early.An increased risk of suicide was also described when too many days passed between visits to the Psychiatric Day Hospital.
When care was shortened to only Wednesdays and Thursdays first week, I went to the Psychiatric Day Hospital, but then there were Friday, Saturday, Sunday, Monday, and Tuesday, then there were many days like…On Sunday, sorry to say, I took pills again.( 4) The importance of sharing experiences was central for patients' recovery.The support and being able to share everyday strategies were perceived as rewarding and helpful for recovery, and social gathering was experienced as beneficial.To be able to reflect on mutual problems in the company of others and be able to talk about everyday topics were important.The Psychiatric Day Hospital was also an arena for new social contacts.
The best thing for me was to meet other people with mental illness.It gave me so much that we were all sick, there were certain things that we had in common, even though we were all sick in different ways.But talking to others about my illness, well, I do not do so anywhere else.It was very permissive; no topics were off the table, and we could laugh at our own worries while we could go down deep and talk about our concerns about the side effects of medications.(12) It could be difficult to be open about oneself in the beginning, but it became easier over time and then it gave a sense of self-affirmation.A sense of hope arose hearing other people sharing their experiences of living and coping with mental ill health.
We started to talk there, even the other patients did.First, they shared their experiences.I mean, those who had been there the longest, the ones who were starting to get better, so they shared their experiences and at the end, I was the one who shared my experiences.Yes.shared with others.'So, I talked with the others about….you are not alone.(2)

To receive guidance in life
Educations given at the Psychiatric Day Hospital were perceived as rewarding and the participants emphasised the importance of gaining increased knowledge.It provided understanding and new knowledge about mental ill health.Patient educations were expressed as helpful and provided guidance for the future as well as for self-growth.
Yes, it was like these schools, you get the tools as well as how to deal with your anxiety and what to do to get your self-esteem back as well, because self-esteem was lacking.( 11) The available support at the Psychiatric Day Hospital was also important.Staff and peer support encouragement was highlighted as crucial for recovery.
I really want to point out the importance of someone believing in you and that the feeling that someone genuinely cares about your well-being is kind of super important and I really felt it there.( 9)

Discussion
The study's findings confirm that treatment at the Psychiatric Day Hospital adds more structure to daily life and offers opportunities for social interaction and improves coping mechanisms.The results further confirm that a Psychiatric Day Hospital focuses on recovery that strengthens patients' empowerment, and that the findings support the result of previous international studies (Agrest et al., 2018;Larivière et al., 2009).Research on recovery in adult Psychiatric Day Hospitals appears limited, and as far as the authors can tell, this is the first study in a Swedish or Nordic context.This study contributes by demonstrating from patient's perspective that more open forms of care such as Psychiatric Day Hospitals with greater focus on recovery should be beneficiary to psychiatric patients.Psychiatric Day Hospitals can provide access to services such as peer support, recovery, education, and the encouragement of social integration.Furthermore, the results differ from studies on inpatient care, where patients describe that inpatient care consists of waiting in an environment that is confusing, with rules and routines that are perceived as inconsistent (Lindgren et al., 2015).This is verified in a review by Cutcliffe et al. (2015) who reported an inpatient healthcare environment of control, coercion, lack of personal contact with predominantly medical treatment and a lack of focus on recovery.
In contrast, it was emphasised in this study that there were social interactions with other patients and staff of importance for recovery at the Psychiatric Day Hospital, which are confirmed in studies on Psychiatric Day Hospitals from Canada and Argentina (Agrest et al., 2018;Larivière et al., 2009).In these studies, it appeared that the patients learned about themselves, their illness, strategies, and valuable life skills which led to recovery as well as empowerment.The participants in the present study described that it was easier to develop a structure to their day at the Psychiatric Day Hospital, which even at home improved routines and was thus favourable for a longtime recovery.To be helpful in sharing experiences and giving each other advice on useful strategies was promoting own recovery.The group activities facilitated recovery by enabling social connections and reducing isolation.This is in accordance with Agrest et al. (2018), who emphasised the importance of interpersonal relationships and shared experiences to facilitate recovery.Nolan et al. (2011) believes that although there is support from staff and fellow patients in inpatient care, patients feel alone following discharge and have difficulties finding structure in their everyday life, which may be caused by the lack of structural empowerment care and focus on recovery as seen in the Psychiatric Day Hospitals.The more inpatient admissions, the more difficult it seems to be for patients to see recovery as an option.
Participants in the study by Agrest et al. (2018) felt that an overly heterogeneous group functioned well in everyday activities and could be fruitful but could also become an obstacle to recovery.In this present study the company of others who had similar problems gave a feeling of less loneliness in his/her situation by self-recognition.However, the study by Larivière et al. (2009), was supportive of group experiences which seemed to encourage reflection and introspection, but for some it could be experienced as challenging as described in the current study.Other feelings of insecurity that were described from some of the participants concerned the discharge from the Psychiatric Day Hospital to Outpatient care.These feelings could be reduced by better communication between different forms of care.
The present study found that the participants appreciated the form of care that the Psychiatric Day Hospital offered.The open form of care was described as calm and provided a homelike environment producing an increased sense of freedom, which in turn was perceived as positive for recovery.
The structure with a gradual reduction of the number of days spent was positively perceived, as patients felt they could be increasingly independent.In addition, it has previously been shown that patients who have stayed at Psychiatric Day Hospitals have better social functioning after their discharge compared with patients who were cared for in inpatient care.This may be a result of the patients' ability to remain in their home environment during the period of care (Kallert et al., 2007).
According to Slade et al. (2012), the evidence base for recovery is growing slowly.An important challenge for the development of evidence-based care is to ensure that people who are directly affected by the research, both those who use mental health services and those working as carers, are involved as partners in the development of scientific knowledge (Slade et al., 2012).In the emergence of a psychiatry that focuses on personal recovery, the goal is to develop open forms of care with recovery-oriented efforts (Bejerholm & Roe, 2018).Slade et al. (2014) argue that mental health care systems must focus on promoting hope and faith in those affected.According to the participants in this study, this will be achieved by supporting self-determination, ensuring access to a wide range of services such as peer support, recovery education, and the promotion of social inclusion, which are offered by Psychiatric Day Hospitals.

Methodological consideration
To ensure the rigour in the scientific process, the concepts of credibility, transferability, and dependability have been addressed to achieve trustworthiness (Guba & Lincoln, 1989).Activities at the current Psychiatric Day Hospital may have been limited by the ongoing Covid-19 pandemic, which might have affected the result.A sample of 12 patients may be perceived as small, but each individual story was considered unique and representative of the study purpose.The fact that patients with psychosis are not treated in this unit may limit the results of the study.The study participants were of different ages, genders, and had previous care experiences.A selection of participants with varying experiences increases the possibility to elucidate the research question from different aspects (Polit & Beck, 2014).

Conclusion
This study elucidates patients' positive experiences of a Psychiatric Day Hospital and how it promotes their recovery.The findings suggest that this open form of mental health care provides help through a feeling of safety, a secure context and guidance to promote recovery.Psychiatric Day Hospital care and other forms of open care should therefore be further developed within mental health care.

Table 1 .
Demographic data of the study participants (N = 12).

Table 2 .
) examples from data analysis.
(6) I think it was interesting to hear.I don't know about things like other patients experience their situation with anxiety and so on, so I think it was probably quite valuable.

Table 3 .
Overview of the findings.