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: [email protected]