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Abstract

Design:

Qualitative methodology, with an interpretative phenomenological analysis approach based on the analysis of the contents of the participants’ narratives.

Objective:

The main objective of this study is to interpret the meanings women attribute to lived experiences related to their participation in activities in the rehabilitation programs. Specific objectives: (1) To describe the meanings given to the activities in the rehabilitation programs of a forensic mental health setting. (2) To analyze the impact on health that participants attribute to those activities. (3) To identify possible situations of occupational deprivation.

Study Population and Total Number of Participants:

The study population is made up of women who participate in the rehabilitation program at Hospital Psiquiátrico Penitenciario de Alicante in Spain. The number of participants is established when saturation of data is reached.

Keywords

women gender forensic mental health services occupational therapy occupational deprivation qualitative research interpretative phenomenological analysis phenomenology

Contributions to Current Understanding

There is a need to carry out an in-depth study regarding the impact characteristics of forensic mental health services have on health among women in these settings, taking into consideration the women’s experiences and meanings they attribute to the different aspects of the rehabilitation program.

On the one hand, scientific literature lacks research findings which take the development of mental health care in forensic mental health settings from a gender-sensitive approach into account (Baker & McKay, 2001; Collier & Friedman, 2016; Gunn, 2004; Nicholls et al., 2015; Ribeiro et al., 2015; Sugarman & Dickens, 2015). In fact, research up until now has focused especially on populations of middle-aged white men, and therefore the results cannot be generalized to female populations (Baker & McKay, 2001; Collier & Friedman, 2016).

On the other hand, the practice of occupational therapy requires a wide spectrum of knowledge, broader than that generated by experimental research. This study aims to provide qualitative evidence to occupational therapy practice, extending the range of research in health sciences. This study on women’s experiences in forensic mental health settings in Spain is ground-breaking and a unique contribution to current research as well as occupational therapy practice both in Spain and around the world. Using a phenomenological approach, women’s reports of their lived experiences (in these contexts) have a knowledge base applicable to other similar settings.

Describing and interpreting the meanings that women attribute to activities in the rehabilitation programs provides useful information to gain a better understanding of women’s experiences and their needs to thereby develop more effective therapeutic programs that improve their wellbeing and quality of life (Baker & McKay, 2001; Long et al., 2008; McGauley & Bartlett, 2015). The information presented in this regard can be especially useful in designing and implementing sound intervention strategies for the care of women who live in forensic mental health settings providing or promoting equal opportunities among women and men. The contribution of this study follows this line of thought. Our main goal is to gain better knowledge of the characteristics of activities in the rehabilitation programs and their impact on women’s health.

The theoretical framework chosen in this study is structured around the concept of occupational deprivation (Whiteford, 1995, 1997, 2000). Since the mid-1990s, occupational therapy literature has shown a growing interest in investigating the restrictions imposed by social and health services when it comes to disease and disability. There is a need for additional qualitative research studies from the subjective perspective of women who receive these services (Braveman & Bass-Haugen, 2009; Townsend & Wilcock, 2004; Wilcock & Townsend, 2000).

The purpose of the study is to give a voice to women, capturing both their subjective experience and describing the common meaning that they give to their experiences (Creswell, 2013). Thus, a phenomenological approach was deemed most adequate for this study (Denzin & Lincoln, 2018).

Background/Study Justification

In its original sense, the concept of occupational deprivation was developed through empirical studies in prison environments that restricted performance of significant activities for individuals with mental illness (Whiteford, 1997). Whiteford claims that altering patterns of the use of time, habits, and routines, can cause disorientation, loss of feeling of effectiveness, a high suicide rate, sleep disorders and difficulties in acquiring adaptive skills that facilitate participation in the community. This concept aims to circumscribe a singular phenomenon; that situations of occupational deprivation are not a consequence of the inherent conditions of each individual but are due to external factors that persist over time (Craik et al., 2010; Cronin-Davis et al., 2004; Eggers et al., 2006; Molineux & Whiteford, 1999; O’Connell & Farnworth, 2007; Wilcock, 2015).

Other research studies have highlighted that the lack of opportunities to cry out meaningful activities in forensic mental health settings can cause boredom, depression, apathy, loss of skills and learned dependency (Craik et al., 2010; Farnworth et al., 1987; Rani & Mulholland, 2014; Whiteford, 2000; Wilcock, 2015). In addition, when safety measures are very restrictive, both therapeutic relationships and the effectiveness of treatments can be affected (Adams & Ferrandino, 2008; Adshead & Sarkar, 2005; Fitzpatrick et al., 2010; Martin, 2003; Rani & Mulholland, 2014). This in turn has an impact on the users’ health and quality of life (Craik et al., 2010; Perkes et al., 2015; Whiteford, 1997). Some authors maintain that secure unit conditions bring down people’s motivation (To et al., 2014) reducing their occupational performance and participation (Cronin-Davis et al., 2004).

All factors aforementioned are especially relevant in the case of women living in forensic mental health settings. The literature highlights that security measures for women are inadequate in relation to the risk they pose in such settings. Despite the small number of women in relation to the number of men living in these settings, they have a higher chance of being admitted to secure units, where they stay for longer periods (Lart et al., 1999; McKeown et al., 2003; Sarkar & Lstro, 2011; Thomas et al., 2005). This increases their vulnerability of suffering occupational deprivation in these settings (Collier & Friedman, 2016; Parkes & Freshwater, 2015; Ribeiro et al., 2015). In spite of this, as stated earlier, scientific literature lacks research findings from a gender-sensitive approach.

The findings described above justify the need for additional research on conditions of occupational deprivation among women living in forensic mental health settings in Spain as currently, there are no studies in the literature using a phenomenological approach to specifically explore the experience of women.

Objectives

The main objective of this study is to interpret the meanings that women attribute to their lived experiences related to their participation in the activities of the rehabilitation programs in a forensic mental health setting, and their impact on health.

To achieve this main objective, the following specific objectives were established: (1) To describe and interpret the meanings given to experiences related to their participation in activities in the rehabilitation programs of the Hospital Psiquiátrico Penitenciario de Alicante; (2) To interpret the impact on health that participants attribute to those activities; (3) To identify possible situations of occupational deprivation.

Explanation and Justification of Method

To achieve the objectives of our study, a qualitative approach, specifically an interpretative phenomenological analysis approach (Alase, 2017; Smith et al., 2009; Smith & Shinebourne, 2012) based on the analysis of the contents of the participants’ narratives (Creswell, 2013), was selected. This methodological approach is consistent with the main goals of the study as it includes descriptions and interpretations of the women’s experiences, focusing on the lived experiences of the participants in the study (Moustakas, 1994). After analyzing and interpreting the women’s narratives, we were able to explore, describe and understand the meanings they attributed to their lived experiences related to their participation in activities in the rehabilitation programs at the Hospital Psiquiátrico Penitenciario de Alicante.

An interpretative phenomenological analysis approach is used to include an interpretation of the meaning that lived experiences have within their specific social context. Interpretative phenomenological analysis is a phenomenological research approach that systematically and thoroughly reflects the women’s lived experience. Husserl (1931) in Larkin et al. (2006) argues that everyday experiences are either first-order activities or second-order mental and affective responses to those activities. Interpretative phenomenological analysis is concerned with examining subjective experience, and in this study the subjective experience of study participants is related to either the activities in the rehabilitation programs or the feelings and thoughts associated with them. In addition, interpretative phenomenological analysis concurrently defines the ontological and epistemological underpinnings of our research. The meaning the participants’ attributed to their lived experiences were considered to be of key importance due to their contextualized circumstances (Larkin et al., 2006).

This methodological approach is an innovative and unique contribution to the subject matter, and it may be useful for qualitative researchers in their quest to conduct qualitative research studies.

Materials and Methods

Study Period

The study was carried out between June 17, 2016, and December 31, 2019. The fieldwork was conducted from July 1 to December 31, 2016.

End of the Study

The study concluded in December 2016.

Scope of the Study

This is an occupational therapy study in a forensic metal health setting, specifically in the Hospital Psiquiátrico Penitenicario de Alicante, with women who are participating in rehabilitation programs. The study was carried out in five phases (Figure 1). The occupational therapy program in the Hospital Psiquiátrico Penitenciario de Alicante rehabilitation unit is made up of a team of five professionals. Intervention is based on training and social inclusion both within and outside the forensic metal health setting. The occupational therapy program promotes participation in daily living, vocational, and leisure activities in the form of workshops within the unit, the establishment of programed therapeutic outings in the community, and the generation of links with other community foundations using an individualized therapeutic approach.

Figure 1.

Flow chart of research stage in the study.

Measurements and Intervention

Three techniques were used to collect data for the field study: an in-depth interview (Brinkmann & Kvale, 2015; Denzin & Lincoln, 2018; Fontana & Frey, 2005), participant observation (Angrosino, 2012) and a fieldwork diary (Sampieri & Torres, 2018; Valles, 2000). The data collection process was structured in two stages. The technique used during the first stage was participant observation. During this period, we had the chance to actively collaborate in the activities proposed by the institution, together with the population of the study. During the second stage, an initial script was designed for the individual interviews, using open-ended questions, based on related studies carried out in similar contexts. After initial trials, the questions were reformulated to explore other topics which were not considered initially but arose during the pilot test (Carpenter & Suto, 2008). The women were initially asked to talk about their recovery in general, but later were asked to focus on the activities carried out during their stay in the Hospital Psiquiátrico Penitenicario de Alicante. Personal interviews were conducted by the same researcher (DTE) between July 1 and December 31, 2016, with an average duration of 1 hour and 30 minutes. Interviews took place in two different areas arranged to maintain privacy and only members of the project were allowed in. The interviews were conducted, and the reactions of the women interviewed were written in the fieldwork diary once the interview ended. The fieldwork diary served an additional purpose to include specific contextual characteristics of the mental health setting to gain a better understanding of daily routines and protocols as well as the interaction among staff and the women. Data collection was not preconfigured, rather it was flexible and adjusted to different emerging events. Throughout the study, researchers participated in continuous reflection focusing on the women’s own lived experience and leaving out their own subjective opinions and experiences in the interpretation of women’s narratives. Data collection ended once all the information was compiled and data saturation was reached. In addition, throughout the fieldwork process, the research team had conversations with the professionals of the hospital and with the team in charge of the women in the institution. This allowed the team to complete data triangulation and protect the validity of the qualitative data used in the study.

Sampling/Recruitment

Participants

The selection of participants was carried out between July 2016 and August 2016, following a theoretical purposive sampling process.

Selection Criteria

Inclusion criteria: (1) Minimum age requirement of 18; (2) Admitted to the Hospital Psiquiátrico Penitenciario de Alicante for a period longer than 3 months; (3) Engaged in the rehabilitation program in the women unit of the Hospital Psiquiátrico Penitenciario de Alicante.

Exclusion criteria: (1) Did not agree to participate in the study; (2) Had difficulties understanding and/or responding to questions in the interview; (3) Experiencing an acute psychotic episode.

Withdrawal criteria: (1) Voluntary repeals from the study and/or transferred/discharged from institution.

Recruitment Strategy

First, we got in touch with an occupational therapist that was part of the team working in the treatment area of the Hospital Psiquiátrico Penitenciario de Alicante. This therapist was a key informant regarding information about the context of the institution and in helping to arrange the first face-to-face meeting with the subjects of our study. Then, we organized a meeting in which we explained the goals of our research study to the women and we asked for their voluntary participation.

Justification of the Sample Size

Interpretative phenomenological analysis studies are conducted using relatively small sample sizes, and the goal is to find a reasonably homogeneous sample (Smith et al., 2009). The purpose of conducting interpretative phenomenological analysis research with women is to gain more knowledge and a better understanding of the participants’ perceptions and lived experiences.

Data Handling/Analysis

Data Coding

Data coding was conducted following three generic cycles (Alase, 2017). See Figure 1 (Round 10).

Data Analysis

To analyze data, researchers followed the guide set forth by Moustakas (1994). First, all researchers (DTE, PMM, GER, MATV) reviewed the transcriptions independently and generated a list of significant statements (Creswell, 2013). This process was carried out with the help of the computer program ATLAS.ti 7.5.18 (Scientific Software Development GmbH, Berlin, Germany). Next, the significant statements were grouped into larger units of information (units of meaning), following a constant comparison procedure and a recursive analysis strategy, according to an inductive approach (Schensul & LeCompte, 2013). No previous analysis criteria or hypotheses were established. The next step was a textural description of the women’s experiences (what participants experienced). Following that, we developed a structural description to reflect how the activities were experienced within their specific context. Finally, researchers wrote a composite description of the phenomenon incorporating both the textural and structural descriptions (Creswell, 2013). The combination of the textural and structural descriptions is used to convey an overall essence of the participants’ experiences that correspond to the purposes of the study (Giorgi, 1997). Observations of the fieldwork diary were used during the coding and analysis process of the women’s narratives.

Ethical and Legal Aspects

Once the main purpose of the study was described and accepted by the Hospital Psiquiátrico Penitenciario de Alicante the research protocol was evaluated by the Ethics Committee of Secretaría General de Instituciones Penitenciarias (SGIP) and it was accepted on the 17th of June 2016. Code: SGIP 2/05.

These research procedures were carried out according to bioethical principles established in the Belmont Report, along with the Declaration of Helsinki and the Convention on Human Rights and Biomedicine of the European Council.

The study follows 29 out of 32 items of the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007).

Confidentiality of the Information

All information created and gathered during this study follow the Spanish Organic Law 3/2018 of 5 December on Personal Data Protection. To guarantee confidentiality of the informants, all the information was collected individually and classified using an alphanumeric code, only known by the researchers. Once the interviews had been transcribed, the original audios were destroyed. Finally, all documents containing sensitive information were deposited in a protected system at the Faculty of Health Sciences (Universidad de Castilla–La Mancha) to which only the investigators have access.

Informed Consent

A meeting was organized in which researchers explained the goals of the study to the women and verbally informed them of the implications of their participation. It was emphasized that all information gathered would be handled confidentially. Women were informed that their refusal to be interviewed would not have any consequences, and they could cease to participate in the interview at any time. Finally, those who agreed to participate signed a document of Informed Consent, as well as a participation withdrawal document (Supplemental Appendix I).

Rigor

To strengthen and ensure the trustworthiness of the study three strategies were followed.

Credibility

To raise the credibility of data three triangulation procedures were established: (a) Triangulation of methods, using three techniques to obtain information (participant observation, in-depth interviews, and fieldwork diary); (b) Triangulation of data sources, obtaining information from various sources, participants, staff, and managers; (c) Triangulation of researchers, both in the process of data collection and in the analysis process.

Additionally, an interviewer training was conducted, to teach the interviewers how to carry out the in-depth personal interviews, as well as prolonged engagement in the field of study (9 months), which included an exercise of reflexibility through a deliberate and systematic process of self-examination (Dietz, 2011).

Dependability

A stakeholder checklist (Lysack et al., 2006) was administered during a meeting with the informants of the study, with the goal of having the investigators check out the assumptions and emerging interpretations of the women within the data his strategy helped to ensure both accuracy of the facts and information gathered in the study as well as the corroboration of as investigators’ inferences by those who experienced the events (Lysack et al., 2006; Mertens & Laenen, 2019).

Transferability

The strategy followed to improve the transferability of findings was a rich, detailed, and thorough description of participants, places, events, and characteristics of the study (Erlandson et al., 1993; Stake, 2010).

Implications for Research and Dissemination

This research study is unique and innovative as it provides an in-depth exploration of the lived experiences of women living in forensic mental health settings. The methodological approach selected uniquely contributes to the subject matter, because it provides rich, detailed, and thorough information by focusing on women’s experiences. As such, it may also be useful for qualitative researchers in their quest to conduct phenomenological studies.

The study’s findings may be useful in designing, implementing, and modifying sound intervention strategies for the care of women as well as provide and promote equal opportunities among women and men within forensic settings. In addition, the study can be useful in decision-making for managers of organizations, and for those responsible for the design, implementation, and evaluation of the activities within rehabilitation programs.

Finally, this study in as much as it can get precise details that are similar to other contexts can serve as a guide for other researchers in similar contexts, both in Spain and in other countries.

Supplemental Material

Supplemental Material, sj-pdf-1-ijq-10.1177_16094069211013157 - Women in Forensic Mental Health Services: Lived Experiences and Meanings Attributed to Activities in Rehabilitation Programs. Study Protocol

Supplemental Material, sj-pdf-1-ijq-10.1177_16094069211013157 for Women in Forensic Mental Health Services: Lived Experiences and Meanings Attributed to Activities in Rehabilitation Programs. Study Protocol by Desiré Traver-Edo, Gemma Escuder-Romeva, Miguel-Ángel Talavera-Valverde and Pedro Moruno-Miralles in International Journal of Qualitative Methods

Footnotes

Authors’ Note

This work has been carried out within the framework of the Interuniversity Doctoral Program in Gender Studies: Cultures, Societies and Policies.

Acknowledgments

The authors wish to thank all the women interviewed for their participation in the study. We would like to thank the HPPA for their support with conducting the study, especially to Pedro S., Laura V., and Ariella H. that collaborated with them to recruit the participants for the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this paper.

Funding

The author(s) disclosed receipt of the following financial support for the research study: The main researcher received a research grant from the Official College of Occupational Therapists of Castilla La-Mancha (COFTO-CLM) to carry out this research. Additionally, the main researcher received financial support from National System of Grants and Subsidies of Spanish Government in 2020 (ID code: 1590992848245) for authorship and publication of this article.

ORCID iD

Miguel-Ángel Talavera-Valverde

Supplemental Material

Supplemental material for this article is available online.

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