Close Encounters of the Forensic Kind: Ethical Dilemmas...

Close Encounters of the Forensic

Kind: Ethical Dilemmas, Boundary

Violations and Recovery

Cindy Peternelj-Taylor RN, MSc, PhD(c), DF-IAFN

Professor

Editor, Journal of Forensic Nursing

United Nurses of Alberta

Local 183 Education Day

December 16, 2014

Objectives1. Examine the role of boundaries in professional

therapeutic relationships within the forensic

milieu.

2. Explore issues and dilemmas unique to the

promotion of recovery for patients in secure

forensic mental health environments.

3. Explore matter-of-fact approaches to ethical

dilemmas in practice that bridge theory,

practice, and research within the forensic

milieu.

Personal Reflections…

• I believe that as human beings, we have all experienced struggles in relation to creating and maintaining therapeutic boundaries with clients in our care.

Personal Reflections Cont’d

• It is through such struggles

that our vulnerabilities are

exposed thereby providing

us with opportunities for

personal and professional

growth and development.

My Personal Objective

To encourage you

to think deeply

about what you do,

and what you

believe in.

Take a minute to reflect upon…

• The One questions

you would like

addressed today; and

• One hope you have

for this workshop.

Ethical Dilemmas

Boundaries are really

a question of

ethics…

• “What is the right

thing to do?”

• “How should I

act?”(Bergum, 1994)

Boundary Violations (BVs)

Boundary violations represent a failure of

ethical reasoning by professionals”

(Adshead, 2012)

The Importance of Boundaries

Paradoxically, the very relationship that

offers the promise of healing, also

exposes practitioners of all disciplines to

the hazards of overstepping their

professional bounds.(Collins, 1989, p. 153)

Scope of Boundary Violations• Boundary violations are a distressing reality of

clinical practice

• Forensic environments – often described as

“hotbeds” for potential problems

– Infractions can be relatively trivial or serious

– Complex nature of the clients psychopathology and

treatment needs

– Seductive pull of helping

– Professional isolation

– “Too hot to handle”

• Celenza (2007) suggests that rather than

ask the question:

– “why therapists violate boundaries?”, perhaps

we should ask instead “why therapists don’t

violate boundaries more often”

Education and Training• Orientation often negates how to be a

healthcare professional within a secure

environment.

• Token education in many basic education

programs; little regarding feelings of sexual

attraction.

• Lists of do’s and don’ts - but rarely discussed in

relation to the development of the therapeutic

relationship (alliance, transference,

countertransference).

Client Vulnerability and

Psychopathology• Clients are vulnerable by virtue of their

status; often uncertain about BVs and how

they will be addressed

• Clients often conceptualized as the threat

they pose; professional the victim of

circumstance

• Many clients skilled at manipulation (Faulkner & Regehr, 2011; Peternelj-Taylor, 2012)

Professional Vulnerability• Struggling with attachment issues, not

cared for in other aspects of life.

• Seductive pull of helping coupled with dual

obligation of custody and caring

• Personal life stressors > role reversal,

inappropriate self-disclosure > target.

Erosion of Treatment Boundaries

Pilette et al. (1995) have identified two

common problems:1. The inability to differentiate the professional

relationship from a social relationship; and

2. Attempting to have personal needs met through

the professional-client relationship.

Understanding Boundaries in

Professional Relationships

• Creation of Boundaries

• Boundary Crossings

• Boundary Violations

– Sexual Boundary Violations

• Fiduciary Responsibilities

• Othering

Creation of Boundaries

• Metaphorically, boundaries mark territory

• “Relational space” is created

• Clients and therapists explore treatment

issues within the safety of the therapeutic

relationship

– Also referred to as the therapeutic frame

Boundary Crossings

• May or may not be harmful – more of a

descriptive term, assessed on a case by

case basis

• Departures from established practice

• Can lead to boundary violations(Gutheil & Gabbard, 1993; 1998)

Boundary Violations

• “actions that blur, minimize, or disrupt the

professional distance” (Marquart et al., 2001)

• Transgressions that are clearly harmful or

exploitive

– e.g. sexual exploitation, touch, dual roles,

self-disclosure

Defining Sexual Boundary Violations

• “any kind of physical contact occurring in the

context of a therapeutic relationship for the

purpose of erotic pleasure” (Celenza, 2007).

• “when a healthcare professional displays

sexualised behaviour towards a patient or

carer...acts, words or behaviour designed to

arouse or gratify sexual impulses or desires” (Council for Healthcare Regulatory Excellence, 2008)

A Real Eye Opener

I have seen many staff members actually leave their jobs to be with offenders; in my career at least a dozen. One day I actually stopped counting because there were so many. A nurse that started the same day I did, left within a year, so that was my first real eye opener.

(Krista)

Fiduciary Responsibility

One in which a person with particular

knowledge and abilities accepts the trust

and confidence of another to act in that

person’s best interest (Penfold, 1998, p. 19)

Othering

• Othering is a negative form of engagement that can lead to stereotyping, stigmatization, and discrimination;

• Defining the other, and engaging in othering is a complex phenomenon revealed within a relationship of power.

(Canales, 2000; Peternelj-Taylor, 2004)

• Alienation

• Marginalization

• Stigmatization/Labeling

• Oppression

• Internalized Oppression

• Decreased Social and Political Opportunities

(Bunkers, 2003; Canales, 2000; Lammie et al., 2010; MacCallum, 2000)

Consequences of “Othering”

Professional Stigma• How is professional

stigma experienced

by forensic nurses?

• How is professional

stigma manifested?

Common Questions:– Why would you want to work there?

– Can you really help them?

– Aren’t you afraid of getting hurt?

– How can you stand working with

those clients?

And

– Why would anyone want to work with

them?

– What’s the matter with you?

Laura states:

We are even afraid to engage with them (the inmates). Not only do they need engagement, but we are often hesitant, because of how they may misinterpret it, or how the nurse might be vulnerable herself.

Continuum of Responses

Zone

of

Helpfulness

- Under-involvement

- Boundary Violations

- Over-involvement

- Boundary Violations

(National Council of State Boards of Nursing, 1996)

Maggie recalled...We hated to see it happen, but we couldn’t talk her out of it. Her role got really blurred. It was really hard for all of us, you know we had said things to her, but you can say all you want to some people, but they are going to do what they want to do anyway. At first, we noted that she would share her coke with him, during interviews, and then we learned that she even put money into his account within the facility – that’s really crossing the line. The therapeutic nursing wasn’t there anymore. She wound up quitting but she still maintained a relationship with him, and he ended up getting federal time. So I have seen that line crossed.

Maggie continued...Once the other inmates caught word of what was going on, they would try and muscle this inmate to try and get something from this nurse. You could see the snowball effect that was happening. But the distrust that followed amongst the correctional staff and the rest of the nursing staff was really evident.

Impact of Boundary Violations

• Risk to the individual client

• Risk to other clients

• Risk to co-workers

• Effects on other co-workers and their

professions (Herlihy & Corey, 2006)

• Jeopardizes the security of the facility

and/or compromises the integrity of the

employee (Worley et al., 2003)

“Those who cross boundaries place themselves, their peers, and others including the patient, in a position of compromised security and personal safety” (American Nurses Association, 2007, p. 15).

Are clinicians victims of

circumstance?

• It is not uncommon for clients to be

confused about the nature of the

therapeutic relationship

• Double standard often exists

(Peternelj-Taylor & Yonge, 2003; Schafer & Peternelj-Taylor, 2003)

Professional Relationship versus

a Social Relationship

• Clinicians involved in the

“dance of relationships”

(Brown, 1994)

• Therapist is the one who

leads, carefully considering

each step for its ultimate

benefit or risk to the client

(Peternelj-Taylor & Yonge, 2003)

• Clearly SBVs with offenders have serious

clinical, ethical and legal implications.

• Offenders are skilled at manipulation and

exploiting situations for their personal gain,

thus contributing to a blurring of the lines

of responsibility when sexual boundary

violations do occur (Faulkner & Regehr, 2011)

Another eye opener for Krista...There was a nurse who had worked for many years on the unit…She was always making sure that everyone else maintained their boundaries, and I remember her questioning me about things that I was doing with my clients. But she was also a nurse who ended up leaving with an offender -- in the end she was off doing everything that she had preached that you shouldn’t do… On that final day when she left, it was clear what had happened -- we all felt really betrayed…That was difficult.

Sheryl recalled...

I happened to be shopping in another city and popped into a Tim Horton’s for a coffee. I saw the patient and then I saw the staff member – you should have seen the looks on their faces. As I was driving home, I started to think about some of the things that happened on the unit, and all of a sudden it started to come together for me. That was the first time, I had experienced anything like that! I remember talking to other staff about this when I went back to work, saying I might be crazy here, but this is what I think. The staff replied “oh yeah, we know.” I am thinking to myself, my God, how did I miss all this stuff?

Small Group Activity

Transforming Practice Through

Leadership

• Individual leadership

• Collective leadership

• Administration/Organization

• Education

• Professional Codes and Standards for Practice

Individual Leadership: Self-Awareness,

Self- Monitoring, and Reflective Practice

• Self assessment guides/inventories(Epstein, 1994; Pilette et al., 1995)

• Self-care strategies

• Spot “tests”

– Would I say/do this in front of my colleagues or

supervisors?(Gallop, 1998)

– Is this clinical intervention made for the benefit of

therapist, or for the sake of the client’s therapy?

(Simon, 1999)

Caution Signs• Discussing your intimate or

personal problems with clients

• Keeping secrets

• Believing no one else can meet the client’s needs

• Spending more time with a favorite or special client

• Client is paying special attention to you

• Flirting

Slippery Slope:

What if you have concerns?• Is the behavior consistent with your profession’s code of

ethics?

• Do the behaviors contribute to the therapist-client relationship?

• Who benefits from your actions – you or the client?

• Is this behavior you would want other people to know about?

• If you told a respected colleague about your behavior, how would he or she respond?

Collective Leadership:

Peer Debriefing and Group Approaches

• Supportive work environment

• Accountability partner (Rusthon et al., 1996)

• Group supervision

• Triumvirate model (Melia et al., 1999)

Powerful Culture of Loyalty• Frequently fuels a “conspiracy of silence”

(Frais, 2001; Penfold, 1992; 1998)

“Often one of the things I

notice when these

boundary violations come

out, there’s been

knowledge in the

particular community, but

nobody wanted to say.

Its like they see but they

don’t see it” (Coe & Gabbard, 2012)

Employer’s Responsibilities

• Nurturing a supportive work environment

• Providing clinical supervision

• Investigating promptly

• Offering Employee Assistance Programs

• Facilitating continuing professional

development

Education

• Undergraduate

• Graduate

• Orientation, Continuing Education and

Staff Development

Professional Codes and

Standards for Practice

• Need meaningful Practice Guidelines

– Not simply lists of “do’s” and “don’ts”

• “No clear one-size-fits-all answers”(Pope et al., 1993)

Guidance

• Standard 1 – Therapeutic Relationships

– A Registered Psychiatric Nurse establishes

therapeutic relationships that are safe,

informed, confidential and reliable with

appropriate boundaries focusing on the

wellbeing of a client; a RPN refrains fro

inappropriate relationships.

(CRPNA, 2013, pp. 6-7))

D. Preserving Dignity

• Nurses maintain appropriate professional

boundaries and ensure their relationships are

always for the benefit of the persons they serve.

They recognize the potential vulnerability of

persons and do not exploit their trust and

dependency in a way that might compromise the

therapeutic relationship. They do not abuse

their relationship for personal or financial gain,

and do not enter into personal relationships

(romantic, sexual, or other) with persons in their

care (CNA, 2008, p. 11)

Codes of Ethics/

Standards• Codes alone do not promote

ethical practice; instead

they provide a springboard

for further education and

dialogue regarding matters

of concern(Peternelj-Taylor & Schafer 2008; Storch,

2007)

• When it comes to SBVs – clinicians know

that what they are doing is wrong, they

don’t need to read it in their Code of Ethics

to know so.

(Celenza, 2007)

Final Analysis

• The idea of firm, intractable boundaries as a way

to guarantee ethical action in professional

helping relationships may be a comforting one.

However, it is a false comfort.

• Issues surrounding sexual boundary violations

are extremely difficult, and solutions to dilemmas

in practice equally complex.

(Austin et al., 2006)

Boundaries

• Grounded in therapeutic integrity

– Knowledge, experience and clinical judgment(Peternelj-Taylor, 2002)

Unfortunately…

Judgment comes with

experience

Experience comes from

poor judgment…

Issues Related to RecoveryRecovery is a process in which people living with

mental health problems and illnesses are

empowered and supported to be actively engaged

in their own journey of well-being. The recovery

process builds on individual, family, and cultural

and community strengths and enables people to

enjoy a meaningful life in their community while

striving to achieve their full potential

(MHCC, 2009, p. 122)

More of Recovery

“Recovery” refers to a

satisfying, hopeful, and

contributing life, even

when there are ongoing

limitations caused by

mental health problems

and illnesses.

(MHCC, 2012, p. 12)

What about recovery and the

forensic patient?• Particularly challenging for persons under

forensic purview.

• Detention, hospitalization, and incarceration are

opportunities for recovery, the person has to be

an active participant in the recovery journey,

which can be trying when the person is not

voluntarily seeking treatment. (McLouglin, Geller, & Tolan, 2011; Simpson & Penney, 2011)

Recovery Includes:• clinical recovery (symptom relief);

• functional recovery (life-skills);

• social recovery (social inclusion);

• personal recovery (satisfying life living with

illness); and

• offender recovery (redefinition of self and

coming to terms with the offence)(Drennan & Alred, 2012)

Hope, empowerment,

self-determination and

responsibility are

considered the building

blocks of recovery.

(MHCC, 2012)

Small Group Activity

Questions

• What challenges so you encounter when

trying to embrace a recovery orientation

when working in forensic mental health?

• What strategies can you embrace as a

way of fostering and promoting recovery

among your forensic mental health

clients?

Fostering Recovery• supporting hope;

• engaging in respectful dialogue;

• strengthening the working alliance;

• attending to personal strengths;

• bridging security and therapy; and

• supporting personal responsibility. (Drennan & Alred, 2012; McLouglin et al., 2011; MHCC, 2012; Simpson

& Penney, 2011)

• I do think you have to be a nurse that

gives a shit…you have to be a nurse who

honestly wants to be there. That honestly

wants to be the best for their patients and

wants the best for their patients…I think it

is a challenge because I mean it is tough.

I had to question myself -- like how can I

work there? I have to give a shit about a

fellow human regardless of what their

other stuff might be.

• And that I think is important. Because if

you are not going to care, and you are not

going to be genuine, and you are not

going to do the best you can for them then

don’t work there. (Joanne)

• The fact that it is a forensic unit. The

security issues are always there, it is

always on your shoulder. It is always

something that you have to be thinking

about. You know you just have to be

aware of what is going on in your

environment. (Sheryl)

Keep in MindIt is the clinician’s

responsibility to do more for

the person when the

person can do less, and do

less for the person when he

or she is able to do more.(McLoughlin, Geller, & Tolan, 2011)

Connecting Across Difference

• Pay attention to ourselves as nurses– Be aware of our own vulnerabilities, blind spots, and hot spots

• Continually look around – How is power operating? Resist the view of “Nurse as Expert”

• Assume a stance of inquiry– How we think about and talk about difference shapes our approach

(Doane & Varcoe, 2006)

Inclusionary Othering• A positive form of engagement

leading to empowerment and

transformation.

Power is born when caring

others value another and

believe in human potential.(Zerwekh, 2000)

In the Final Analysis

It is through the other that we feel our

common humanity – our own fragility,

and our own dependency. It is through

being in-relation, being engaged that we

can truly care for the other, and

ultimately, care for ourselves.

(Hoffmaster, 2006; Peternelj-Taylor, 2004)

• Canales (2010) states that

the first step toward

emancipatory knowing

within the context of

difference is learning to

think about self as other, in

relation to other. To begin

this process requires

engagement in self-

reflection (p. 31).

Think About Self as Other

To care for someone,

I must know who I am.

To care for someone,

I must know who the other is.

To care for someone,

I must be able to bridge the gap

between myself and the other

Jean Watson

Summary

• Recovery is possible, even for forensic mental

health clients, in secure settings

• Security and treatment within forensic settings

are requirements of one another and not

dichotomous goals

• Demands that we think carefully how we deliver

care, in a spirit of partnership, respect, and

involvement even when being coercive.

Closing Thoughts: Promotion of a Moral Community

“a workplace where ethical values are

clear and are shared, where ethical values

direct action, and where individuals feel

safe to be heard” (Rodney et al., 2013)

A Moral Community Requires that:

• Health care professionals think and talk about the ethics of their practice;

• That they are encouraged to learn, reflect and share their ethical challenges; and

• That they will be supported and provided with resources by managers and senior administrators.

(Storch, 2007)

For Further InformationCindy Peternelj-Taylor

Professor

College of Nursing, University of Saskatchewan

Phone: 1-306-966-6238; Fax: 1-306-966-6609

Email: cindy.peternelj-taylor@usask.ca