Gambling and hidden practices in forensic psychiatry: a qualitative study of ambivalence, autonomy, and negotiated care.

Introduction: This is the first qualitative study to examine how gambling becomes entangled with everyday life, relations, and recovery within medium-secure forensic psychiatric care in Denmark. The aim is to understand how gambling and financial management are experienced and understood by patients and staff, providing insight into how gambling practices intersect with ward life, clinical relations, and recovery processes. Methods: Semi-structured interviews were conducted with eight patients and seven staff members. The study followed an interpretive descriptive design and employed reflexive thematic analysis. Attention was given to participants' accounts of gambling, money management, and the institutional conditions that shape these practices. Results: Patients described gambling as a way to manage boredom, relieve restlessness, and maintain a sense of agency, while also recognizing patterns of loss, debt, and relapse. Gambling was intertwined with attempts at self-regulation, familial involvement, and, at times, other addictions. Staff accounts were fragmented, ranging from viewing gambling as benign recreation to identifying it as a clinical concern linked to impulsivity, mood instability, or conflict. Across interviews, financial autonomy emerged as a central domain. Hidden economies, including informal loans and undisclosed debts, operated outside institutional visibility, complicating therapeutic relations and limiting staff capacity to intervene without eroding trust. Discussion and conclusion: Gambling emerged as an ordinary yet disruptive element of ward life, shaping autonomy and clinical relations and creating secrecy in relations. The discussion suggests that clearer expectations, routine enquiry, and responsive financial support could help address harm caused by gambling without undermining trust. Such measures may strengthen recovery processes, although the impact will depend on how they are integrated into the relational fabric of secure care.