Feeling the Force? Working with boundaries in forensic mental health practice

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1 Feeling the Force? Working with boundaries in forensic mental health practice Dr Anne Aiyegbusi Director & Consultant Nurse, Psychological Approaches CIC

2 Structure Presentation from the experience of front line workers Nursing and PD bias Focus mostly on relational factors Consider the implications and impact of intense trauma and offending dynamics in services Use a clip from a training DVD to reflect what may be helpful for working with boundary phenomena in forensic services

3 Sources Own clinical, managerial and leadership experience 30+ yrs Experience of providing training, reflective practice and supervision to front line staff Literature Strategy and good practice guidance Own research

4 Forensic populations Intertwined trauma and offending dynamics those whose personal boundaries and sense of security have often been repeatedly violated, disregarded, undermined through early traumatising abuse and attachment experiences often in an intergenerational context gone on to violate, disregard, undermine other peoples boundaries and sense of security through criminal acts and pathological relating the meaning of the offending behaviour can be understood, and it can be put in the context of a cycling repetition compulsion that usually has its origins in childhood traumas (Morris, 2004)

5 Secure forensic settings Physical security: walls, locked doors, keys, radios clear boundaries Procedural security: searching, access to personal items, leave, escorts, visits, observations open to interpretation and slips Relational security: use of self, working alongside, 1:1 engagement, interpersonal interactions, therapeutic relationships, community meetings, social activities, user involvement, psychotherapy slipping and sliding along representative boundaries likely to be the norm

6 Relational risks Patient may seek a different relationship to the one offered: But also talking about schemas just now, what s going on in our head? We have to ask ourselves sometimes why we re asking these questions, why we re asking did you go out, are you married, do you live locally, how long does it take you to get here on the train? We have to ask ourselves, Why would we want to ask those questions? (Patient, high secure hospital DSPD service)

7 Relational risks I find the dual role they ve got.i don t mind the nursing, caring aspect of it but I don t like the security aspect of it. I think they are two separate roles and they complicate the ability to engage in a relationship. (Patient, high secure DSPD service)

8 Consider deeper motivations Thus it is that the SPD patient s observable behaviour not only masks what the psychological inmate is thinking or feeling but fails to convey that inmate s ambivalence about, and difficulty with, verbalising the true nature of his or her internal predicament. (The Prison of Personality Disorder, Norton, K. 1997)

9 Trauma and offending enactments and re-enactments We see these occur at the point at which boundaries are set Boundary testing, crossing etc may be closely related to attachment phenomena Activated attachment systems on treatment pathway Transitions, intense therapy, reviews etc Intense attachment experiences occurring in service All manner of relationship experiences, jealousy, separations and changes, staffing issues Establishing relationships heightened anxiety distorted model Complex care seeking and communicating need Including added purchase to projections Power / control / dependency / increase sense of security / soothing / seeking intimacy and belonging

10 Fear Events activating attachment system according to Bowlby 1969 Sickness Unfamiliar environment With strangers / Absence of attachment or support figures Alarming events in environment Events in PD unit that may activate attachment system Uncertainty about what will happen Struggling with emotional distress Newly admitted to hospital Not know anybody in new environment Familiar staff redeployed and replaced with stranger Disturbance created by other clients in the environment Difficulties experienced by family or other attachment figures Painful clinical procedures Non availability of attachment figure Loss of attachment figure In depth psychological / offending work Nurse to whom attached engaged with other patients Nurse to whom attached leaves transfer of ward discharge

11 The front line worker s task To be on the receiving end of an onslaught of painful and / or excruciatingly uncomfortable projections related to sequelae of unprocessed psychological trauma and offending which may include current exclusion and pariah status for boundary violations without retaliating, collapsing or colluding To work from a multi functional physical environment, moving from task to task with little if any space to think / reflect throughout a span of duty and keep their professional footing

12 The front line worker s task To engage in a wide range of tasks with multiple patients one to one sessions, physical health care, medication administration, social and domestic activities, shopping, searching, completing records often under close scrutiny and criticism without making mistakes May or may not have senior colleagues who are really open to understanding let alone validating and supporting them with the emotional impact of the task which can leave front line workers baffled as to why they are on the receiving end of such stress and hate - abandoned

13 Can the workers manage their task? Each of these two women who have done it were going through divorces, were going though that turmoil beforehand if you know what I mean, at home and so must have felt unloved and I can understand that and all that that involves but why that then leads to a relationship where [patient on the ward] can almost claim that he had sex with [former female worker] on the ward when no other staff were looking [RN, high secure DSPD service]

14 Can the workers manage the task? So erm, I mean we had a classic example with that [female health care assistant]..i think something was picked up by [patient on the ward] and she got her to start doing things for her outside her role like she brought in a needle and thread for her, she brought in over 50 DVDs for her, she brought in books for her, so you could see where that relationship was going. You could quite clearly see where it was going. I think she was very oblivious to that, erm, and when you put boundaries in place, she struggled massively with it to such an extent that she couldn t survive [in the service]. [RN, Women s Enhanced Medium Secure Service]

15 Forensic Settings Group analytic concepts worth considering and integrating: Location of disturbance, matrix, social unconscious, figure and ground Ward / wing as a social group whereby each member brings their internalised relational experience, that of their ancestry and other key networks and create an interacting field of conscious and unconscious processes. Protagonist(s) with particular valency will manifest a disturbance that others are also struggling with. Disturbance as a blocked communication requiring translation and making conscious. Traumagenic / criminogenic context of care giving and care seeking occur risk of perversity

16 What to do? Organisational honesty and support for the nature of task Create space to think for staff and patients Focus on attachment systems Reflective practice groups (relate, reflect, repair) Individual clinical supervision Training: for senior managers and leaders local need identify from incident reports etc attachment theory trauma and offending dynamics psychological containment group dynamics

17 Dr Anne Aiyegbusi Director and Consultant Nurse Psychological Approaches CIC

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