Building and sustaining therapeutic relationships across treatment settings: a qualitative study of how patients navigate the group dynamics of mental healthcare.

Background: Therapeutic relationships are vital for patients with complex and long-term psychosocial needs, yet such patients often face fragmented and unstable relationships within mental healthcare. These patients are more often than others moved between treatment settings and caregiving teams. Statutory obligations strain the relationships with frequent hospitalizations adding to the burden This study explores how these patients perceive and navigate therapeutic relationships, highlighting both positive and negative experiences across various treatment settings.

Methods: This is a qualitative study with a narrative approach utilizing in-depth interviews focusing on participants personal experiences and perceptions. We utilized purposive sampling to recruit patients with extensive hospitalization experience, operationalized as more than four admissions within one year or more than four successive weeks of hospitalization. Our sample consisted of 16 participants, twelve women and four men. The interviews were analyzed using a holistic-content approach.

Results: We found that therapeutic relationships were built on healthcare professionals recognizing and addressing patients' needs and advocating for their interests within the service system. Participants described therapeutic relationships as sources of collaboration, stability, and support but found them challenging to sustain due to fear of rejection and institutional barriers. Successful relationships worked as a vital buffer, offering protection against malpractices and depersonalized care.

Conclusion: Therapeutic relationships play a crucial role in supporting patients with complex needs, but relational dilemmas and malignant group dynamics often impede their development. Mental healthcare services have an ethical responsibility to foster and maintain therapeutic environments and professional cultures that enable personalized care, while maintaining boundaries through reflective practices.