Forensic Psychiatric Patients’ Perspectives on COVID-19 Prevention Measures: A Qualitative Study

ABSTRACT This article investigates how patients in forensic psychiatric wards in Denmark experienced the changes made to their everyday lives caused by COVID-19 prevention measures during the pandemic in 2020–2021. We used a qualitative ethnographic approach for collecting data and analyzed them using an inductive thematic approach. The empirical dataset consisted of 11 semi-structured interviews with forensic psychiatric patients from two medium secure wards. The patients emphasized the practical implementation of three aspects of the COVID-19 prevention measures that significantly impacted their everyday lives: communal meal time arrangements, tea and coffee serving (hygienic measures), activities with staff and other patients, use of PPE, i.e., facemasks (communal isolation measures), use of patients rooms for isolation, testing regimes, (individual isolation measures). Although the practical implementation of these prevention measures created everyday challenges for patients, they also provided opportunities for improving existing practices. This study illustrates how new ways of structuring and rethinking COVID-19 prevention measure practices can create possibilities for considering both patients’ needs and the need for such measures when implemented in forensic psychiatric wards.


Introduction
On 11 March 2020, Denmark went into lockdown to respond to the global COVID-19 pandemic.The main purpose of the lockdown was to ensure a functioning Danish health care system with the capacity to provide adequate treatment and care to COVID-19 patients and ensure that existing patient populations were protected from the COVID-19 disease (Sundhedsstyrelsen, 2020).When facilitating a health care system response to the COVID-19 pandemic, patients in confinement at secure forensic psychiatric facilities require special attention (Kinner et al., 2020;Wasser et al., 2020).Patients with severe mental illness have an elevated risk of acquiring COVID-19 and experiencing a poor outcome if infected due to several risk factors related to medicinal use, increased prevalence of co-morbidity, and lifestyle factors such as a sedentary lifestyle and smoking (Basrak et al., 2021;Brown et al., 2020;Chevance et al., 2020;Kennedy et al., 2021;Kozloff et al., 2020).In addition, patients in forensic psychiatric wards are often admitted for extended durations (Uhrskov Sørensen et al., 2020), and their social life and treatment generally unfold in shared facilities (Clarke et al., 2016).This results in significant social contact among patients and between patients and staff, thereby making them particularly vulnerable to COVID-19 (Benson et al., 2020;McMichael et al., 2020;Simpson et al., 2020).Studies recommend implementing measures such as social distancing within the secure units, isolation and detention of patients from the outside world, new rules for hygiene, sanitation, and the use of protective equipment, as well as restrictions on individual activities, social activities, and interventions to protect patients (Farrell et al., 2021;Wasser et al., 2020).However, special attention should be given to the impact of COVID-19 prevention measures on the care and treatment of patients sentenced to treatment to avoid triggering relapses and potentially setting back patient recovery (Lemieux et al., 2020;Zuffranieri & Zanalda, 2020).Therefore, Farrell et al. (2021) state that it is essential to study patients' experiences of living under COVID-19 prevention measures to inform the implementation of future pandemic responses in forensic psychiatry.This article departs from a study of two medium secure wards in Denmark.The paper aims to examine which type of COVID-19 prevention measures were implemented to prevent the spread of the disease, how forensic psychiatric patients in the wards perceived the implementation of these COVID-19 prevention measures, and how these affected the patients' lives in the ward to guide the development of future forensic psychiatric practices.

Materials & methods
The research team consisted of two anthropologists, the first and second authors, one consultant psychiatrist, and one social scientist.We used a qualitative ethnographic approach for data collection with an inductive thematic approach to data analysis (Braun & Clarke, 2006).We chose an ethnographic approach to explore human experiences in ways that acknowledge and underline the unique social and cultural contexts of those experiences.This approach is social constructivist and underlines the reflexive relationship between knowledge, its process of production, and the actors involved in the knowledge production process.

Setting & participants
The study took place at a Danish medium secure forensic psychiatric hospital.Patients were recruited from two wards (A and B), with a total of 32 patients.The patients did not receive financial compensation for participating in the study.
We used convenience sampling (Thorne, 2016) and invited all 32 patients from the two wards to participate in the study.Eleven male patients (N = 11) agreed to participate in semi-structured interviews (Ward A, n = 4; Ward B, n = 7).No questions were asked concerning the patients' psychiatric diagnosis or age, as it was not relevant to the scope of the project.According to previous official census data collected by Central Denmark Region, patients in the medium secure wards are primarily men suffering from schizophrenia or another psychotic disorder,a substantial proportion have a substance use disorder, and many have been convicted for violence and/or persondangerous crime (Hemmingsen, 2018).
All patients were asked about the length of their stay in the ward, and this ranged from 1.5 months to 5 years, with an average length of 2.2 years (median 2 years).Most patients had been in the same ward since the beginning of the COVID-19 pandemic in Denmark, a few had moved between medium secure wards, and few patients entered during the pandemic.
Key staff members facilitated the recruitment process.An introduction letter containing information about the project was emailed to staff at the wards.This letter was then handed out to patients at the wards.The second author provided information about the study at staff and patient meetings.Patients were informed that the second author had no authority in the ward and could not influence treatment.Both patients and staff were informed that data from the interviews were considered confidential and that confidentiality would be maintained throughout the research.It was agreed with staff that interviews would only be allowed if the safety of the patient and interviewer could be ensured.One patient was excluded based on this criterion.

Data collection
We collected two types of data: 1) textual data on measures made within the wards regarding COVID-19; and 2) interview data regarding patient perspectives during these restrictions.
The second author collected documents, such as e-mails, informational material, and schemes to create an overview and timeline of COVID-19 measures within the forensic psychiatric department.The data were validated through conversations with staff members.The data collection for the document study used in the presented analysis took place in March-April 2021.
The second author carried out field visits to build trust and inform about the study.
The second author carried out semi-structured interviews in May-June 2021.Data from the document study regarding COVID-19 prevention measures at the wards and existing literature on COVID-19 prevention measures in mental health services came to inform the interview guide.The guide was developed in discussion with the research team.During interviews, patients were asked open questions regarding their experience living in the wards during the pandemic.Patients were also asked open questions regarding what they had experienced as significant prevention measures.Lastly, patients were asked how they had experienced specific aspects such as social contact and distancing, ward activities, hygiene and sanitation, and testing and vaccine practices during the pandemic.Interviews lasting 15-60 minutes took place in meeting rooms within the wards; they were audio-recorded and subsequently transcribed verbatim.The research team provided supervision throughout the data collection.

Data analysis
Our approach was inspired by Braun and Clarke's (2006) thematic analysis, in which analysis is gradually developed and validated through multiple readings of the data.First, we familiarized ourselves with the data through field observations and the collection of documents concerning the COVID-19 prevention measures on the wards.After each interview, the second author wrote down initial thoughts in field notes.After transcription of the interviews, the first and second authors actively read through the data while taking notes and marking ideas for coding.Following Hammersley and Atkinson (2019), we understand the analysis as an iterative process in which ideas help understand the data while the data are, in turn, used to develop ideas and, consequently, the analysis.Thus, the process of familiarization took place throughout the analysis phase.Based on the first reading, initial codes were developed and used to code the dataset in NVivo 12 and organize the data into initial groupings.Potential themes were identified from these initial groupings, and a visual map was drawn.The mapping process worked to highlight potential relationships between the initial codes and broader themes, which were included in the coding.Coding was conducted by second author.Coded material was read and discussed with first author during the coding process.The codes were afterward continuously discussed in the research group with third and fourth authors.Based on the coding, a picture of significance emerged.All themes were reviewed by first and second author at the level of the coded data extracts to ensure coherence; both codes and themes were then combined, refined, separated, or discarded based on a continuous review.Finally, a review of the complete dataset took place to ensure that the themes and subthemes accurately represented the dataset as a whole.From this, three central themes stood out as crucial and were further refined, named, and explored through a thorough analysis.The analysis was written down by the first and second authors and discussed with the research group.

Ethics
This research project followed the code of ethics for qualitative research formulated by the American Anthropological Association (www.ethics.americananthro.org).The research project was registered at Internal Registration at Central Denmark Region (file number: 1-16-02-192-21) and conducted following General Data Protection Regulation guidelines.Furthermore, guidance was sought from the National Committee on Health Research Ethics (en.nvk.dk).In accordance with Danish law, approval by an ethics committee is not required when no biomedical intervention is performed.Therefore, the regional ethics committee deemed approval unnecessary as this research study consists of self-reported data (Appendix 1).
Informed signed consent was obtained before each interview based on oral and written information about the research project.Before each interview, we repeated that consent could be withdrawn at any time.We removed all names and identifiable details to anonymize results.Participants and wards have been anonymized.

Results
During the COVID-19 pandemic, the following prevention measures were implemented within the participating forensic psychiatric wards: frequent hand hygiene, patients receiving close instructions in hygiene, frequent disinfection of surface areas, social distancing, limitation of physical touch, restricted/ limited exit privileges, limitation of traffic and activities across wards, limitation of usage of public transportation and the department bus, and no visits or homemade food (Appendix 2).While just a few measures are highlighted here, they generally resonated with the COVID-19 prevention measures outlined in the literature (Farrell et al., 2021;Lemieux et al., 2020;Li et al., 2020).Furthermore, the prevention measures were changed and updated throughout the pandemic to fit current knowledge.In late October 2020, additional measures were introduced, such as: obligatory face masks or visors for staff members and visitors, updated safety measures concerning individual isolation for potential cases of COVID-19 infection, and full protective gear for staff interacting with a potential carrier.Regular weekly testing for COVID-19 were initiated primo January 2021 for the staff and in early February 2021 for the patients.Finally, the patients were offered their first and second vaccinations during March and April 2021.Although the patients were asked about all these measures throughout the interviews, they particularly emphasized the following practical implementation of certain prevention measures as giving rise to experiences of both challenges and potentials within the forensic psychiatric wards: communal meal time arrangements, tea and coffee serving (hygienic measures), activities with staff and other patients, use of PPE, i.e., facemasks (communal isolation measures), use of patients rooms for isolation, testing regimes, (individual isolation measures).In the following, we elucidate the practical implementations of these prevention measures and how patients experienced them.

Hygienic measures
During the COVID-19 pandemic, attention to hygienic measures within the wards was intensified as a vital part of the prevention strategy.This included frequent hand hygiene from both staff and patients, disinfection of the surface areas several times a day and especially during shift changes, staff serving all beverages and food, as well as different social distancing measures, such as moving the tables and chairs around in the common areas to ensure distance.While these changes were all noticed by the patients, two measures, in particular, stood out: 1) relocation of the tea and coffee cart and 2) rearrangement of the dining tables in the common room.

Who is serving the tea and coffee?
While facilities for tea and coffee were made readily available and accessible on the wards prior to the pandemic, these facilities were locked away inside the kitchen for a substantial length of time during the pandemic.This prevented the patients from serving their own tea and coffee.Instead, they became dependent on staff members to get the beverages from the kitchen.This shift away from self-serving coffee and tea was emphasized by patients in the interviews.As an example, a patient stated: For example, that they didn't fetch the coffee cart, they didn't bring it out, and stuff like that.
This limitation upon their access to tea and coffee was acknowledged in the interviews as increasing their dependency on a staff member's availability.A patient noted: You had to get hold of a staff member to get a cup of tea or a cup of coffee or stuff like that.That was what was a little different.
In the data, having to find a staff member to get a cup of coffee or tea was mentioned as giving rise to feelings of losing agency and freedom in their daily life at the ward.A patient underlined: They are not always there.Then you have to sit and wait for them and stuff.Sometimes they are in a meeting in the office or just talking there.Then it is not always that you have . . .then you have to sit and wait for them to come.
For these patients, this shift in the agency concerning coffee and tea was seen as a small but critical marker separating the time before and after implementing COVID-19 restrictions.A patient said: Yes, we also made coffee for ourselves that time before Corona.Now they are the ones who make it.

Mealtimes
Communal mealtimes for staff and patients are common in forensic psychiatric wards in Denmark and, according to staff, are believed to serve a social function by strengthening social ties among patients and between patients and staff.Communal meals also function as a way of enacting what life might be like after discharge.Prior to the pandemic, all meals were shared at one long table in the middle of the common room, where staff members used to join the patients during mealtimes and partook in both chatting and eating side by side with the patients.By staff, these meals were called "therapeutic meals."As a prevention measure, this long table was dismantled into small tables fitting groups of four, therapeutic meals were prohibited, and staff had to eat elsewhere.In the interviews, these changes to the communal meals were perceived as fraught with ambivalence.According to patients, communal meals could function as a measure of social exclusion and social inclusion.As an example, a patient argued how he preferred the new groupings of tables: We have put each table separately so that you can sit differently (. ..)Before, people always had a special seat, they wanted to sit there.But now you can just take any seat.And it is still the same anyway for us, you are sitting at a table with two or three others.It is not really the same as if you would like to sit all the way at the end [of the long table ].So there isn't any of that, you know, "hey, that is my seat, I usually sit there!"As also seen in the quote, the data revealed that hierarchies existed within the patient group.Breaking up the long table into smaller groups of tables helped to blur the seating hierarchies that had otherwise been apparent to the patients.While the long table only had two end seats, the new table structure provided many equal seating arrangements at the different tables.As highlighted by the patient, the new table plan led to fewer conflicts regarding seating and a greater sense of social inclusion.
When talking about the missing staff members at mealtimes, a patient pointed out how there being only patients present created opportunities for connecting with other patients: According to the patient, eating without the staff members meant that the patients talked more among themselves.However, this patient's viewpoint was in stark contrast to most of the accounts from the other patients; another patient noted that: Especially during weekends when there is a little calm and quiet, there is not all that running around, then it is really cozy [Danish: hyggeligt] to sit together and eat with the staff and sit and talk for a bit.It gives kind of, well yeah, it gives some coziness and a little real-life or whatever you say.
Accordingly, the majority of patients emphasized the social contribution of staff members during mealtimes; eating with the staff created a "cozy" atmosphere.When staff and patients shared mealtimes, it gave a sense of "a little real-life" through reciprocal social interaction and conversations.A patient pointed out: Of course, it creates more atmosphere when there is a staff that you like among you.It creates a more [positive] atmosphere.It creates a different vibe that you can talk about things you share, like interests.For example, when you sit with [certain staff members], then it creates something different by sitting at the table with someone that you can identify with.
Thus, the patients saw the shared mealtimes as enabling an identification between patient and staff, as these moments were characterized by the similarities between individuals rather than the differences.Thus, patients generally welcomed the presence of staff members during mealtimes and felt that they helped promote a normalizing and socially inclusive atmosphere.

Communal isolation
To isolate all patients in each ward from the outside and from other wards, the department instituted communal isolation, also known as cohorting.Here, the measures included, among others: the restriction of activities across wards, ensuring ongoing activities within individual wards, limitation/restriction of visitors, as well as the limitation/restriction of therapeutic trips and activities outside the forensic psychiatric hospital.

Activities with staff and other patients
In the early phases of the COVID-19 pandemic, many activities were canceled or contained within each ward.All of the patients noted that time had slowed down during the pandemic.A patient reflected: Well, the days have also been very slow.Time has gone slowly and . . . the days have not gone fast either, so you miss that thing.That something else is happening other than just being in the ward.So it has been extra hard.
When asked about what benefits the patient got from going on trips and activities, a patient noted: It was that question of freedom that we talked about earlier.But it is good to get out of the ward and get a little break from your typical day, right, so you don't just go around here, back and forth in the hallway, or sit and stare at a wall or the television.There is not so much to do here after all.So that's why I work out a lot and other stuff.It makes the time go.
In interviews, patients pointed out that activities, visitors, and trips were significant parts of everyday life for the patients on the wards and contributed considerably to their well-being and sense of doing something meaningful with their time.
The limitation of visitors also included those catering to specific needs of the patients, such as the grocer and the barber.In practice, this meant that in some instances, staff members filled different roles than they might have done previously.When asked about what it was like to be in the ward with the prevention measures, a patient emphasized: Then it is good that you have the staff.You know, who kind of can . . .well yes . . . in the beginning, there was one of the staff who was allowed to cut my hair, so she could cut it sometimes, so that was good.
The patient specifically emphasized one grooming situation in which he interacted with the staff in a way that they might not have done prior to the lockdown of the forensic psychiatric wards.While this situation could be perceived as entailing mundane grooming activities, the fact that this particular moment was shared with the interviewer points to how the patient viewed it as a significant experience.Other activities were also seen as constituting such significant experiences.These activities could also include watching movies together.A patient noted: Then we would watch some movies with some of the others in my room and stuff like that, you know . . .so that was pretty good.(. ..)So that was nice.They have been good enough, for sure.
Thus, these experiences were seen as significant and by patients also perceived as means allowing them to strengthen their relations with the staff.Moreover, the patient in the quotation highlighted situations that were not shaped by the patient's illness, but rather their interests (films), values (not looking unkempt), and how staff in collaboration with the patient promoted a sense of normality and social inclusion through these situations despite severe preventative isolation measures.

Interacting face-to-face
The restriction of visitors within the forensic psychiatric units enhanced the importance of the relations within the wards, as these became the only face-to-face interaction that patients would have every day.This already limited faceto-face interaction was further challenged by the introduction of masks as a prevention measure, as it was made obligatory for staff members to wear them whenever moving around the wards.Among patients who were relatively new to the ward, the masks that staff wore made it difficult to establish close relations with staff.A patient noted: Patient: It is harder because you cannot see when people smile.In that way, it can be a bit harder, I think (. ..).You just get a look from the eyes.You can't see whether they are smiling at you or what it is.I tried several times, where somebody then says, "but I was smiling at you."Because I asked, "why are you looking at me?" and then he says, "well, I am just smiling at you."Well, I couldn't see that because he was wearing a mask.
To these patients, masks were experienced as making it harder to read the staff member's facial expression, and therefore a smile might be interpreted as a hostile stare.In contrast, other patients who had been longer in the ward were more positive and emphasized how the period had been beneficial in strengthening relationships: You get a little closer to people.Also, just when everything has shut down, you get more attached to the people you're stuck with.You get like a bond in some way.So that is positive, where there's also the bad, right.So . . .but I don't think it has been hard here in any way.(. ..)That is this thing with getting a bond with the people that you are around -surrounding you.Having good experiences even though everything is closed.
For patients admitted to the ward prior to the introduction of masks and therefore already knew and recognized the different staff members, the masks did not have a significant effect.Instead, the patient highlighted how closer connections and relations with the staff on the ward were built, which contributed to the patient's feelings of doing meaningful activities.
Thus, while patients experienced the lack of activities, trips, and visitors as negatively affecting their well-being during their everyday life on the ward, and the introduction of masks was perceived by some patients as creating relational barriers, others experienced a strengthening of relations within the wards as they interacted with staff members in alternative ways than they might previously have done.

Individual isolation
As part of the COVID-19 prevention measures, it was specified that a patient suspected of being infected would be isolated in their room until the test came back negative.The isolation could last from a few hours to more than 24 hours.A verified case of infection could cause the patient to be isolated for several weeks until they were symptom-free and tested negative for COVID-19.
When patients talked about infection, the possibility of being isolated in their room was a significant concern.A patient said: Yes, that is actually what I think has been the worst.That fear of being isolated.
Although a patient might have worried about infection, the possibility of being isolated was emphasized as the cause of fear.This reaction corresponds with how most patients stressed the fear of or unwillingness to be isolated when talking about infection and not the potential health implications that an infection might have.As another patient commented: It would be bad if you got it .Then you would go and be in the room for 14 days to three weeks, ha!That would be hell.Well, wouldn't it?Thus, individual isolation in one's room would mean a severe loss of freedom.Another patient pointed out that almost all patients, in some ways, leave their rooms for the common areas: But I think that everyone else feels the same way.They, too, want to know if they are infected so that they can leave their room.After all, there is rarely anybody that you don't see for two weeks because they stay in their room for that long.Not really, no.Some people, they can stay in their room for maybe a day, but then they will come out again.Most people feel like that too.
The patient argued that most patients did not want to stay in their rooms for long periods but instead entered the common areas to see other patients and staff members.Previously patients were not placed in isolation in their rooms except in cases of prescribed shielding.The threat of individual isolation in one's room was thus seen as both a loss of freedom and a loss of social interaction with the other patients and staff members.

Testing and ambivalence
While the weekly testing for COVID-19 was another preventative measure introduced to the wards, it had different meanings within the patient group.Some patients argued that the weekly testing was a means of protection against suspicion of infection and the isolation that might follow.A patient stated: The problem is that if you cough and it is a natural cough, then you still have to go to your room because they don't know if you're infected.So that is why I get tested, to be sure that I don't . . .now I haven't just coughed twice, and then they say, "well, you're probably infected, and now you have to isolate yourself in your room."There are several of the patients who were isolated without knowing if they were infected.So that is why I get tested right away.
The weekly test enabled the patient to move about the ward without fear of being isolated due to a cough.Thus, the testing granted the patient a sense of security and empowerment by minimizing the risk of individual isolation.According to this patient, in case of suspected infection and the ensuing possibility of isolation, he would be able to show the negative test result and thereby avoid isolation.However, another patient argued that testing did quite the opposite: But it (testing) has to be done, right.Even though we are . . .a lot of people, they can just say, "I don't want to."And still, I did it every time.(. ..)I think it has to be done.That is what I do.I mean, if I get asked to do something, I do it.(. ..)I quickly learned that is the way to move forward.(. ..)But you are walking around and being like a little afraid of it, right, because what then if you are positive?Then you have to be isolated, and . . .so that is something that has really played on my mind a lot.Then you're thinking, "Oh no, oh no, oh no."Because I have been isolated a lot, I hate it.(. ..)It triggers you.
This comment highlights how the testing became a triggering event that reminded the patient of the possibility of being isolated.Thus, while most patients worried about being individually isolated in their rooms, the practice of weekly testing had different meanings, both as a means of protection and as a triggering event of re-traumatization.

Discussion
In examining forensic psychiatric patients' perspectives on the implementation of COVID-19 prevention measures (Appendix 2), we found that they particularly emphasized the practical implementation of three types of measures as giving rise to both challenges and potentials.
(1) The implementation of new hygienic measures made hierarchies among the patients visible by changing the mealtime table arrangement.It also showcased the importance of small acts, like serving oneself coffee or tea, to make patients feel a sense of autonomy.
(2) The communal isolation of the patients was further problematized by the obligatory use of face masks among staff, which especially challenged the creation of therapeutic relations between staff and newer patients.Despite such additional challenges, we found that patients still experienced meaningful moments within mundane activities in the wards.
(3) Finally, the weekly testing for COVID-19 and the risk of individual isolation were connected with ambivalence and fear for the patients.
We will discuss each of these measures individually.

Hygiene and autonomy: tea and coffee
The inspection and disinfection of food and utensils before dispensing to patients has been recommended as a crucial hygienic measure to prevent the spread of COVID-19 in forensic psychiatric units.(Lemieux et al., 2020;Li et al., 2020).In our study, hygienic measures were implemented that influenced patient access to coffee and tea as the cart was locked away in the kitchen.This prompted patients to highlight their increased dependency on staff members' availability.Though it may intuitively seem like a minor intervention, according to Clarke et al. (2016), having access to tea and coffee may provide patients with essential feelings of increased freedom and empowerment in an otherwise restricted environment.Our study found that the dependency upon staff following the hygienic measures left patients with experiences of lacking agency and freedom.This lack of freedom resonates with studies by Tomlin (2020), who argues that not having access to tea and coffee may exacerbate feelings of being further restricted among forensic psychiatric patients.According to Tomlin, such feelings could potentially act counterproductive to the patients' recovery processes.It is necessary to enforce hygiene standards during pandemics, however our findings suggest a need to implement balancing measures to prevent a lack of patient autonomy.By implementing other ways of serving tea and coffee, for example, by providing an individual thermos for each patient, compromises may be found that promote both hygiene and patient autonomy.

Hygiene and power hierarchies: communal meals
While there is a scarcity of literature concerning meals in forensic psychiatry, preparing meals and dining socially may be considered a skill to be learned as part of patients' rehabilitation (Farrell et al., 2021).Likewise, other research on institutional care in mental health settings has highlighted how meals may help facilitate stronger relationships between patients and staff (Alaszewski, 1986).In addition, in a study of therapeutic communities, Clarke (2017) argued that meals function as rituals promoting change and processes of learning and person-building.Jenkins (1998) noted that communal eating [Danish: faellesspisning] is the foundation of living together in Denmark.
Communal eating is a means and a goal in the social production of coziness [Danish: hygge], and the fact that eating together in Denmark is a social process that lies at the heart of life in Danish society (Jenkins, 1998).Studies define hygge as the foundational and idealized Danish social ethos that mandates closeness, warmth, relaxation, an informal atmosphere, and reciprocity stressed by equality (Hansen, 1980;Jenkins, 2014).This echoes with our study in which reciprocity, stressed by equality and the creation of stronger relationships, were seen as the explicit foundation of the mealtime social interactions between patients and staff.Communal meals were seen as an opportunity for social interactions and conversations that were reciprocal and not defined by the power relations otherwise present in forensic psychiatric wards (Martin & Street, 2003;Terkildsen et al., 2021).In our study, patients underlined how the COVID-19 measures implemented, which meant that meals were now eaten in new and smaller groups, created greater inclusion between staff and patients alike.However, Douglas (1972) notes that meals are practices of inclusion and exclusion and, importantly, carve out hierarchies.This presence of hierarchy, inclusion, and exclusion in meals resonates with the experiences of the forensic psychiatric patients in our empirical material.We found that for some patients, meal arrangements had led to exclusion within the patient group.Much of the literature concerning power-hierarchies within forensic psychiatry focuses on relations between patients and staff (see, (Terkildsen et al., 2021).Our findings of patient hierarchies here echo studies by Bartlett (2015), who notes how everyday interactions between forensic psychiatric patients also serve to either create, sustain, or enhance social hierarchy and social subdivisions among patients.Our study demonstrates that by implementing COVID-19 measures that changed the layout to several small tables, previous practices of hierarchies and social exclusion during mealtimes were experienced as less prominent by the patients.Interestingly while these practices of social hierarchies during mealtimes were not previously noticed, they were revealed by the changes and special measures during the COVID-19 pandemic that made underlying patient dynamics visible.It identifies a need for further research on patient hierarchies in forensic psychiatric wards in general and how these unfold within social activities and everyday practices.

Communal isolation and meaningful activities
Group activities both at the ward or outside in the community may present a potential challenge to forensic psychiatric services as they carry a high risk of spreading COVID-19 infection (Lemieux et al., 2020;Li, 2020;Tomlin, 2020).As a result, many forensic mental health institutions recommended closing such activities during the onset of the COVID-19 pandemic (Farrell et al., 2021).This resonates with our hospital case in which the formalized activities outside and between the wards were canceled along with the influx of visitors.As a result, patients experienced fewer and sometimes even a lack of meaningful activities.Kennedy (2022) recommends that patients should be provided extensive and variated meaningful activities every week to facilitate recovery.Lack of meaningful activities could lead to adverse effects among the patients in mental health care (Xiang et al., 2020).Farrell et al. (2021) note that it is essential to continue to provide meaningful activities in times of pandemics.This requires focusing on adapting activities to the ever-changing situation of the pandemic.We agree with this approach but add that those meaningful activities may also be conducted with staff outside more formalized forms.As the influx of visitors was restricted due to the COVID-19 prevention measures, the patients in our study experienced that their relations with staff became increasingly vital to make meaningful activities at the wards.This valuable relationship with staff echoes existing research where wellestablished patient-staff relations are acknowledged as essential to the everyday success of recovery practices (Clarke et al., 2016;Horvath, 2000;Mann et al., 2014;Marshall & Adams, 2018;Mezey et al., 2010;Møllerhøj, 2021).Our study demonstrated how to the patients, staff participation in otherwise mundane activities, such as cutting hair or watching movies, exactly helped create meaningful alternative activities when the formalized activities were otherwise restricted.Therefore, we infer that by participating in mundane everyday activities with patients, staff may help ameliorate the potential adverse effects of restrictions upon formalized activities.
Communal Isolation, Personal Protective Equipment & patient-staff relations Implementing personal protective equipment (PPE) such as face masks by staff is a vital method to reduce the risk of spreading COVID-19 infection in mental health care settings (Enos, 2020;Percudani et al., 2020).However, special attention needs to be given to facemasks in forensic psychiatric settings where patients are admitted for longer periods and where their use may produce adverse effects (Enos, 2020;Farrell et al., 2021).For example, the interaction with staff wearing face masks or face shields may be experienced as destabilizing for some patients (Farrell et al., 2021).Current forensic psychiatric literature highlights the importance of creating a stabilizing environment when patients first arrive on the ward and how trust is crucial when building relations between patients and staff (Askola et al., 2017;Marshall & Adams, 2018).Askola et al. (2017) comment that although a patient might be suspicious of the staff when first arriving, trust can be built if staff display openness in their daily contact with patients.However, using PPE in patient-staff interactions may prohibit the reading of vital non-verbal communication (Pal et al., 2020).Studies suggest that this could lead to signs of empathy and of being in a positive mood becoming overlooked (Mehta et al., 2020).According to Dondé et al. (2021) using PPE may, therefore, potentially act counterproductive to establishing strong reciprocal relations that are essential to care.Our analysis displays similar points demonstrating that, specifically, newer patients perceived the use of face masks as a relational barrier to building trustful relations.According to patients, when the staff wore face masks due to the COVID-19 prevention measures, it hindered the openness of facial expressions and enabled a higher degree of misunderstandings in the communication between staff and patients (See, (Dondé et al., 2021) on "bias").In contrast, however, for the patients who had been in the wards prior to the introduction of the prevention measures, the requirement for staff to wear masks was not considered a relational barrier, as interpersonal relations and trust, had already been established.Therefore, these patients were, able to sustain positive therapeutic relations despite the lack of facial cues.This discrepancy may be significant in light of potential future pandemics because it implies that the duration after admittance to a ward greatly influences the effect of the implemented measures regarding face masks upon establishing and maintaining therapeutic relations between patients and staff.According to Farrell et al. (2021), special policies and guidelines for using PPE must be created to accommodate forensic psychiatric services' unique needs.Our study suggests including the benefit of using visors instead of face masks for therapeutic relations when formulating such guidelines.Further attention may be needed to develop staff approaches that can minimize the adverse effects of face masks upon therapeutic relations for patients who have recently arrived in the wards.

Testing and isolation: safety and freedom
Testing and subsequent isolation in case of a positive test result are vital strategies to quickly curb a potential outbreak of COVID-19 in forensic psychiatric wards.However, serious consideration should be given to such measures as they may be experienced as punitive, further transgressing an already limited feeling of individual freedom (Russ et al., 2020;Tomlin, 2020).
Testing and subsequent isolation may also raise ambivalent feelings.In addition to experiences of being stripped of their rights, feeling controlled, powerless, and longing for freedom, some psychiatric patients may also experience isolation as a form of safety and protection (Lindgren et al., 2019).These feelings of ambivalence are also echoed in our material.As we showed in the empirical data, weekly testing was met favorably by patients and seen as a means of protection against COVID-19 and individual isolation.Nevertheless, testing was also experienced as a triggering event that would induce fear as a reminder of the possibility of being individually isolated.Patients perceived fear of isolation as particularly troubling because the isolation often happened in their respective rooms.According to Hörberg and Dahlberg (2015), the heavy monitoring of patients within forensic psychiatric services means that patients may perceive their rooms as places of "conditional freedom" (p. 6).This may explain why patients associated individual isolation in their room with fear and a severe loss of freedom.Establishing feelings of being in a safe and caring environment, in which possibilities for feelings of freedom and empowerment are also allowed to unfold, is vital to strengthening patients' processes toward health (Clarke et al., 2016;Hörberg & Dahlberg, 2015;Tapp et al., 2013).Therefore, particular attention needs to be given to implementing COVID-19 isolation measures in ways that balance between ensuring high protection of patients and staff and ensuring patients' feelings of freedom (Farrell et al., 2021; see, also (Russ et al., 2020).Based on our study, to avoid patients developing adverse perceptions of their rooms, i.e., as places of confinement, we, therefore, recommend future research to take up this issue and provide insights regarding alternative modes of isolation, in which a better balance between ensuring patients' feelings of freedom and the safety of patients and staff from the risk of disease may be obtained.

Implications for future research and clinical practice
Our findings point to the importance of including patient perspectives in research to guide future forensic psychiatric practices and the practical implementation of pandemic prevention measures, which has also been called for in the discussed literature.This study highlights the importance of small practices that might easily be overlooked in everyday clinical reality.Patients emphasized small details and activities that had tremendous potential for creating a positive change when many other measures were perceived by patients as restrictions.First, there is a need to rethink everyday practices to ensure that patients experience as much autonomy as possible within the forensic psychiatric setting, for example, through small changes such as providing each patient with an individual thermos for tea and coffee when otherwise they would have no access to them.In addition, in contrast to the literature, patients' rooms were not viewed as "conditional freedom" but with fear as they were used to isolate potentially infectious patients.As patient rooms are also used for prescribed shielding, more research is needed to explore this finding further and investigate the potential effects of such ambivalence.While much of the clinical focus within wards has highlighted meals as therapeutic practices, there is a scarcity of research on meals as social practices.Thus, the COVID-19 prevention measures have opened a window into the workings of forensic psychiatric wards in ways that reach beyond the pandemic, such as with the emphasis on patient hierarchies.There is a need for research to explore further aspects that may well have been laid bare by the changes made due to the COVID-19 pandemic.
This paper has highlighted patients' perspectives and provided guidance to alleviate the potential adverse effects when implementing COVID-19 restrictions in practice.However, clinicians should always consider safety in the ward and the specificities of the individual patient's mental health condition when working with this guidance and adapt it accordingly.

Limitations
The empirical data collection took place from April 2021 to June 2021, which meant that the interviewer was largely dependent on participants' recollections of events happening from the beginning of lockdown up to when the interviews took place.Therefore, important aspects of the participants' everyday lives during the pandemic may not have been recollected.Our study represents the experiences of 11 patients.We acknowledge that additional experiences could have emerged had the remaining patients at the two wards participated.This study provides a snapshot of the patients' experiences during a specific period but cannot comment on any future developments or how the pandemic may impact the patients in the long term.Finally, although we provide information about existing patient perspectives, the study cannot offer conclusions regarding any outcomes concerning the changes and measures introduced during the COVID-19 pandemic.
I don't care that much whether they eat with us or they don't.I actually think it is better if they don't eat with us.(. ..)Because . . .you don't talk with the staff while you . . .now I actually talk with [the other patients].So for me, then I don't care if the staff are where they are now.