Psychiatric inpatient care may either support recovery or contribute to harm, depending on how care is delivered. Persons with severe dissociative states represent a particularly vulnerable group within psychiatric inpatient settings, with risk of retraumatisation and adverse experiences. Trauma-informed care has been proposed as a key approach for improving psychiatric inpatient care and supporting recovery among persons with trauma backgrounds, including those with severe dissociative states. However, trauma-informed care has not previously been examined in relation to this group, and research on psychiatric inpatient care for persons with severe dissociative states remains limited. This underscores a need for increased knowledge in this area. The overall aim of this thesis was to explore psychiatric inpatient care for persons with severe dissociative states, with focus on dissociative identity disorder and trauma-informed care. This thesis employed an overall descriptive, qualitative design and includes four studies with different designs to address different aspects of the overall aim: scoping review (I), qualitative social media study (II), qualitative interview study (III) and qualitative focus group study (IV). Materials consisted of peer-reviewed studies and theses (I), written texts from social media (II), interview transcripts (III) and focus group discussions transcripts (IV). Participants were persons with severe dissociative states (III) and mental health nursing staff (IV). Data were collected through scoping review methodology (I), from three different social media sources (II), semi-structured interviews (III) and focus group discussions (IV). Data were analysed using scoping review methodology (I), phenomenological hermeneutics (II), qualitative content analysis (III) and interpretive description (IV). 

The overarching synthesis, Between safety and harm, highlights that persons with severe dissociative states must navigate a persistent paradox in psychiatric inpatient care: it is expected to offer safety yet may simultaneously expose them to harm. This unpredictability in itself further contribute to the harmful experiences. The four themes, A need for recognition, A need for shared authority, A need for staff to be there and A need for predictability illustrate the conditions under which psychiatric inpatient care can shift from being a source of risk to becoming a context that consistently fosters safety. Together, they point to how psychiatric inpatient care can be shaped to better support persons with severe dissociative states by mitigating retraumatisation and strengthening the foundations required for genuine safety. The findings suggest that the uncertainty inherent in caring for persons with severe dissociative states in psychiatric inpatient care can be managed constructively by explicitly acknowledging its presence rather than attempting to eliminate it. An epistemic justice perspective, which emphasises knowledge derived from lived experience, highlights the importance of listening to patients and recognising their experiential knowledge. In doing so, it supports professional judgement as a means of navigating uncertainty. In line with this, trauma-informed reflection may provide nurses in psychiatric inpatient care with the professional grounding required to refrain from premature conclusions. Such reflective practices create space to take time to understand patients’ experiences, thereby supporting more responsive and attuned clinical decision-making. This approach aligns with trauma-informed and recovery-oriented principles and has the potential to contribute to more equitable psychiatric inpatient care. To enable this, staff require sufficient time to listen to patients in order to develop contextual understanding, as well as opportunities for reflection to strengthen professional judgement. Thus, this thesis describes potential and challenges for trauma-informed care in psychiatric inpatient care for persons with severe dissociative states, and suggests a need for trauma-informed psychiatric inpatient care for persons with severe dissociative states, as this may contribute to more recovery-oriented and equitable care. It also aligns with the key implications of this thesis, namely to enable psychiatric inpatient care to move closer to safety than harm: recognising persons for who they are, sharing authority, being present, and promoting predictability. Future research should further include persons with severe dissociative states and focus on how trauma-informed care can be meaningfully implemented in psychiatric inpatient care to support recovery.