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The Challenge of Ethical Relationship Boundaries in Mental Health
Roles and relationships
People can play multiple roles in their lives that both relate to other people and imply certain things about what they do. If you are a parent or informal carer, for example, it is expected that you provide physical and emotional care to your children, relatives or friends.
If you are a service user of mental health services, there is an expectation that you comply with the care and treatment offered to you. And if you are a nurse manager, you are expected to comply with the terms of your job description and adhere to professional guidelines.
One OU student wrote: 'Conflicts between home and work life are the most relevant. The responsibilities of both can sometimes cause friction when there is not enough time to manage everything.'
Although your list will reflect your own situation, there are several challenges that affect all roles and relationships:
• role conflict
• role ambiguity
• role incompatibility
• role blurring or reversal.
Role conflict occurs when someone is expected to carry out two or more contradictory roles in the same situation, while role incompatibility happens when there is a mismatch between people's expectations of roles. Role incompatibility appears to be similar to role conflict but, while the latter suggests that resolution is possible, the former suggests that there is no solution to the challenge presented by incompatible roles. Role blurring and reversal can occur when workers talk about their personal troubles to service users.
The boundaries between people who are in relationships with each other are often defined by the roles these people play. The difference in power between service users and workers imposes one such boundary.
Power and relationship boundaries
Within mental health practice there is a power imbalance in relationships between workers and service users. At its starkest, workers have the power to forcibly medicate and detain service users against their will under mental health legislation. Service users have no such power.
Dowding (1996) writes of two concepts of power: 'power to' and 'power over'. ' Power to' has been described as outcome power, meaning the ability to bring about, or help to bring about, outcomes. An example is a service user's decision to tell family and friends about their mental distress.
'Power over', which has been described as social power, is the ability to use incentives to bring about desired outcomes.
Incentives are often employed according to the 'carrot and stick' formula, where praise can be the positive incentive, or 'carrot', and the threat of punishment can be the negative incentive, or 'stick'. In both cases, the person with 'power over' uses the incentives to obtain their desired outcome.
Dowding points out that achieving outcomes by using power over others can be done blatantly or subtly. He describes incentive structures that involve a broad range of benefits and costs that arise from one or other kind of behaviour.
An example of this from the 1980s is of the 'token economy' schemes in psychiatric hospitals, where cigarettes were awarded for good behaviour (Sheldon 2004).
In mental health services, the exercise of social power is wide ranging. For example, with the professed intention of helping out, professionals can 'take over' certain situations and by doing so, in the eyes of many service users, introduce or perpetuate paternalistic power relationships and prevent self-determination and autonomy.
The power of professionals is often bolstered by mental health legislation. There may be implicit or explicit recognition that behaving in one way but not another results in implementing legislation leading to, for example, compulsory detention. Service users may be told that, if they refuse to go into hospital as voluntary patients, they will be admitted formally under mental health legislation.
Challenging relationships: the example of observation
Mental health practice is fraught with ambiguities and paradoxes. This is illustrated by the practice of continuous observation, usually by nurses, which is intended to 'manage' people considered to be at risk of harming themselves or others.
The following case study explores issues raised by this practice.
In the following interview extract, Charis, a service user but previously a worker in mental health services, shares her four months' experience of continuous observation with Siobhan, who has been a psychiatric nurse since 1984.
Charis says: 'It was a very traumatic experience. It was incredibly intrusive and invasive to me and I am a very private person.
'I was interacting with a lot of different nurses at different levels and the way the boundaries were broken very much depended on who the person was.
'Some of the people would share too much, and it became quite burdensome. I used to hear about other people's mental health problems; their lives, traumas and difficulties.
'I found myself carrying it around and then I worried about them within the role, and I worried about what I'd disclosed and said to them and the impact it might have on them.
'Nurses that were with me at night were there all night. How to keep them awake? If they weren't awake they could get into trouble and I was very concerned about those kinds of things.
'I helped them with their space and their needs, but that had to stop because you are doing it for 24 hours a day and I didn't sleep for most of those three months. It became very claustrophobic.'
She continued: 'Some of the agency staff openly admitted that they got good money for sitting in a chair all night reading or doing their course work -- or even sleeping, some of them.
'I find it really hard to cope with some of the habits of the people who were with me. I had one girl with her feet on my bed picking her toe nails with nail clippers and leaving her cuttings on my bed.
'It was like: "Christ, this is my space, you know. How dare you? What am I to you, you know? Am I nothing? Am I not even human? Am I not here, you know?" You wouldn't go into a stranger's house and do that and yet she was in my bedroom doing it.
'It is like an assumed intimacy, and yet you are not intimate. They are watching you shower. They are watching you poo, whatever else, and you have to put up with it. But why should you put up with them doing their nails?'
Siobhan says: 'Continuous observation is about different kind of boundaries. It's about physical boundaries, emotional boundaries, person-to-person, person-to-patient, professional-to-patient boundaries.
'Sometimes you are on continuous observation with someone who is asleep but often times you are walking around with someone and sitting by them, so it really varies. Sometimes it's very comfortable and relaxed and you talk about general things. Other times it's very uncomfortable.
'And clearly, particular dilemmas and challenges happen around intimate activities, for example when they go to the toilet or the shower, and then it's clearly much more challenging. It very much depends on the person; it depends on how well you know them; and it depends on their ... I suppose on the kind of mental distress they are experiencing.'
She continued: 'I think I would not like this to be me but, from a professional perspective, you are acutely aware of your duty of care. You are acutely aware that this is someone who is deemed "high risk". And it takes a lot of professional judgement then and there, as it were; you make these judgements on a moment by moment basis.
'You know, for example, if you think about it in terms of rights, we as professionals should be acutely aware of patients' rights: rights to life, rights to dignity and so on.
'And in your mind, at that moment, you might think: "Okay, if this person is at serious risk ..." You are trying to safeguard their life, effectively. Sometimes it really does feel like that.
'Also, you are very aware that, as a professional and as a citizen and as a person, you want to preserve their privacy and dignity as much as you can. And so it is really about fine judgement, I suppose.'
One OU student wrote: 'I would feel totally dehumanised by the experience but I think it's also degrading for the observer.
'It puts people into roles and relationships that might not sit naturally with them. It might keep people safe but it also seems to put barriers between people, whether other workers or other patients. It seems that the professionals are more concerned with the end result, rather than how they get there.'
The dichotomy identified by Charis and Siobhan, and some of the arguments for and against continuous observation, are in Box 1.
There are no clear cut answers to the dilemmas and challenges presented by continuous observation but it can highlight issues of power in relationships and relationship boundaries in mental health services.
Regulation of boundaries
What are the ethical issues involved here and how should they affect the regulation of relationship boundaries?
You may have found yourself saying: 'It depends'. Indeed, while it seems that there is no single correct answer, the concept of 'appropriateness' offers a way forward. How then do you proceed to do the right thing? Where do you find guidance?
You might think that you regulate your relationships well enough without guidance, but special issues arise out of relationships between workers and service users, such as the imbalance of power and possibility of exploitation, and the need for openness and transparency, which make some regulation necessary.
Professional documents or codes, statements of values or legislation may therefore be helpful (Box 2). These guidelines and statements give no specific guidance on what constitutes acceptable or unacceptable behaviour but they are based on certain values that presume what is, and therefore what is not, acceptable or appropriate.
Delegates at a web based conference organised by the Mental Health Foundation last year on the role of values in mental health proposed a 'national framework of values for mental health' that:
• recognises the role that shared values play in shaping the views and attitudes of individuals, in and across all stakeholder groups
• develops the means of identifying and addressing the diversity of values held by individuals in and across all stakeholder groups
• identifies the 'given' values that are essential to the partnership process and that all stakeholders need to adopt
• protects the heritage and knowledge of all stakeholders in the partnership process.
According to members of the National Institute for Mental Health in England (NIMHE), underlying the conference was a belief that 'values in mental health reflect and interact with values in society as a whole'.
They also pointed out that 'values are particularly important in the field of mental health with its complex interplay of issues around trust, power, responsibility, risk, safety, "duty of care" and service user empowerment' (NIMHE Values Project Group 2002).
Writing about the Department of Health's National Service Framework for Mental Health, Fulford et al (2002) note that the standards are overtly values based.
However, they also note that there is little reflection on the planning, delivery and commissioning of services where the values embodied by these standards come into conflict. Fulford et al 2002 describe two themes:
• A key theme of the national service framework (NSF) is the user centred approach but 'users', like any other group of people, present a diverse range of personal and collective values. These values relate to their beliefs, aspirations, cultural backgrounds and lifestyles, as well as their experience and understanding of mental health problems and expectations of services. So an 'acceptable' intervention and a 'good' outcome for one may be 'unacceptable' and 'bad' for another.
• Another key NSF theme is the emphasis on multidisciplinary teams. Again, teams are very diverse, and different team members have different skills and different values. A social worker may be concerned with risk, for example, a nurse or psychiatrist with compliance and a manager with client throughput. Mental health organisations themselves have different corporate values that may not be shared by other agencies or accord with those of their staff or users and family members
Activity 1: Allow 15mins
Under the headings 'roles', 'relationships', and 'challenges', list the roles you play in everyday life how these connect with relationships and any challenges you have encountered.
Activity 2: Allow 30mins
Relate the following questions to yourself:
What would it be like to be under continuous observation?
What would it be like to observe and follow another person around in this way?
What might be good about it?
What might be bad about it?
How helpful are boundaries?
Box 1: Arguments for and against continuous observation
• Values life
• Provides a 'holding space'
• Can foster mutual respect
• Can be therapeutic
• Person feels 'special'
• Emotional intimacy
• Safety and protection
• Intensive worker involvement
• Whose life is it anyway?
• Can be perceived as punishment
• Diminishes privacy and dignity
• Is custodial and antitherapeutic
• Person feels like a child
• Physical closeness
• Deprivation of liberty and autonomy
• Lack of continuity and encourages disinterest
- Nursing Management; The challenge of relationship boundaries in mental health; Oct 2004; Vol. 11; Issue 6.
Reflection Exercise #4
The preceding section contained information about the challenge of relationship boundaries in mental health. Write three case study examples
regarding how you might use the content of this section in your practice.
What are the nine arguments for continuous observation?
To select and enter your answer go to .