relating following aggression women's medium secure services

219 Pages·2016·3.72 MB·English

by  Computing Labs

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RELATING FOLLOWING AGGRESSION
WOMEN'S MEDIUM SECURE SERVICES

Cheontell M. BARNES BSc (Hons) MSc

A Thesis submitted for the degree of Doctor of Clinical Psychology

Department of Health and Human Sciences

UNIVERSITY OF ESSEX

JULY 2015
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ACKNOWLEDGMENTS
Firstly I would like to sincerely thank the frontline staff who took part in this study and
offered their time, experiences and thoughts. You deserve much recognition for your work
with women, and the difficulties you face in your role as caring professionals. I greatly
appreciate your contributions. Thank you.
I would like to gratefully acknowledge my research supervisors for their consistent
support throughout this study. I would like to thank Dr Peter Appleton for his unwavering
enthusiasm, motivation and commitment as a research supervisor. Through your knowledge
and expertise, you have provided many new insights. I would like to thank Dr Peter Beazley
for helping to make this study possible. Your forensic expertise and critical reflection have
helped me move forward with this study. I hope this research is a valuable contribution.
Finally I would like to thank Dr Susan McPherson for her early contributions in the makings of
this study.
I would like to thank Dr Anna Kershaw, for always being so kind and lending an ear.
Your wise words, guidance, appreciation and understanding have maintained my sanity. To my
family and friends who have consistently been there for me. Special thanks to Claire, Sophie,
Phoebe, Lauren, Lucy, Rainie, Louise and my fellow trainees. I would particularly like to thank
my mum and dad for being amazing, for providing me a ‘secure base’, and supporting me to
follow my heart.
Finally I would like dedicate this piece of work to Andy. You have suffered silently and
patiently. You have been my rock throughout this journey, always there when I need you.
Thank you.
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RESEARCH SUMMARY
Background: Women in medium secure services can present with aggressive behaviours and a
high level of risk to self and others. Research suggests frontline staff are frequently the victims
of, or witness to aggression by forensic inpatients. The therapeutic relationship is proposed as
central to therapeutic outcome, but may be jeopardised by inpatient aggression. Staff perceptions
of the therapeutic relationship and aggression have not been explored in women’s medium secure
services. The study aimed to develop a theoretical model grounded in frontline staff perceptions
of the therapeutic alliance and aggression in a women’s medium secure services.

Method: The data from 13 semi-structured interviews conducted with frontline staff was
analysed using Constructivist Grounded Theory methods.

Results: The tentative descriptive theoretical model “Relating Following Aggression” emerged
from the interview data. Contextual information supports five core categories, and the related
sub-categories. The findings propose the therapeutic relationship is intrinsically linked to
boundaries, and boundary violations could result in relational deterioration. Aggression affected
the emotional and psychological wellbeing of the participants, and compromised the staff-patient
relationship. The participants were fearful of aggression occurring in their workplace which
resulted in them spending less time with the women and withdrawing from the therapeutic
relationship.

Conclusion: The findings reveal the complexity of the frontline staff-patient relationship in
women’s services. Aggression occurring between frontline staff and women can seriously
compromise the therapeutic relationship through a crossing of the boundary line and a perceived
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breach of trust. Greater support for both the frontline staff and women is required. Future research
is recommended.

Keywords: Frontline staff, women, aggression, forensic, therapeutic relationship, Constructivist
Grounded Theory.
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STATEMENT OF TERMS
Aggression and violence. Multiple interchangeable definitions of violence and aggression are
provided in healthcare research. This study uses the National Institute of Clinical Excellence
(NICE, 2015) definition which subsumes violence and aggression:

“Violence and aggression refer to a range of behaviours or actions that can result in harm,
hurt or injury to another person, regardless of whether the violence or aggression is physically
or verbally expressed, physical harm is sustained or the intention is clear” (NICE, 2015, p.15)

Frontline staff: The term frontline staff refers to staff working, on shift, in direct contact with
the women. This includes registered nurses of differing grades and support staff including
support workers and healthcare assistants.

Female forensic Inpatient: Throughout this thesis I refer to the female inpatients as
‘inpatients’ ‘patients’ or ‘women’. The terms patient, client and service user were used
interchangeably by other researchers, and by the participants.

Forensic Service: The terms ‘forensic’ and ‘secure’ are used interchangeably to refer to the
secure and forensic service throughout the document.
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CONFIDENTIALITY
In accordance with British Psychological Society (2010) guidelines, all names of individuals
and services where the research was undertaken have been replaced with pseudonyms in order
to protect the identity of those who participated in this thesis. I have also ensured that any
identifiers in the data were removed, to ensure the finding are not traceable back to staff
members.
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CONTENTS

CHAPTER ONE: INTRODUCTION 12
Chapter overview 12
Part 1 Current context of research and clinical practice 13
Women’s secure services 16
Tripartite care 18
Relating Theory and women’s secure services 19
Attachment Theory 20
Attachment theory in relation to women’s secure care 23
The therapeutic alliance 25
Care control dichotomy 29
Addressing relational ruptures 30
Aggression in healthcare 30
Aggression in forensic settings 30
Aggression in women’s forensic services 31
Theories on aggression 32
Attachment Theory 32
Psychoanalytic/psychodynamic theory 32
Social Cognitive theory 33
Impact of aggression 34
Social Defences theory 36
Part 2 An exploration of staff perceptions of forensic inpatient aggression 37
Search strategy 39
Process of synthesis 47
Results of synthesis 47
Safety first: a culture of its own 48
Being security minded 50
Relating in the forensic system 54
Reacting to aggression 57
Juggling professional roles and ethical tensions 58
Research aims and questions 61
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CHAPTER TWO: PHILOSOPHICAL AND METHODOLOGICAL FRAMEWORK 63
Overview of chapter 63
Part 1 Methodology 64
Introducing grounded theory methods 68
Constructivist grounded theory 69
Part 2 Method 71
Participant selection 71
Inclusion and exclusion criteria 71
Sample characteristics 72
Sampling and saturation 73
Procedure 74
Ethical approval 74
Recruitment 77
Managing data 78
Data analysis 79
Constructivist grounded theory methods of analysis 80
Part 3 Considering ethics 84
Quality assurance 86
Part 4 My reflexive position 90

CHAPTER THREE: FINDINGS 97
Chapter overview 97
Part 1 The emerging theoretical model: Relating Following Aggression 98
Part2 Context 101
Contextual information taken from the participant’s accounts. 102
Constructing mental illness and personality disorder 102
Construction of the forensic service 104
Changing referrals 105
Accessing support 106
Part 3 Main theoretical model 107
NAVIGATING “THE INVISIBLE LINE” 107
Giving a “little bit of yourself” but not too much 108
Negotiating the physical aspect of the relationship 110
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BITING THE HAND THAT FEEDS YOU 112
“Whatever support you offer they will abuse it” 113
“We are staff we are not punch bags” 114
Attacking the “good relationship” 115
A betrayal of trust 116

PERCEIVING A CHANGE IN RELATIONAL STYLE FOLLOWING 117
AGGRESSION
Caring from a distance 117
‘Cooling off’ the helping relationship 118
Burning bridges 120

TRANSGRESSIONS, RETALIATING, AND RISING TO AGGRESSION 121
“Losing yourself in the heat of the moment” 122
Provoking aggression 123
Being protected by patients 124
“Bearing grudges” and “Asserting Power” 125

“WE BLEED AND BRUISE JUST LIKE EVERYONE ELSE” 127
When it gets “inside you” 127
Feeling “burnt Out” 129
Feeling frightened 130
“Watching your back” 132
Fearing allegations 133
“Getting on with it”: tolerating aggression 135
Developing a “thick skin” 137

CHAPTER 4: DISCUSSION 139
CHAPTER OVERVIEW 139
Part 1 Overview of the theoretical model 140
The theoretical model and existing literature 141
Literature on aggression in forensic services 141
Literature on the therapeutic alliance 145
Novel findings 147
The theoretical model in relation to theories of aggression 152
Attachment theory 152
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Psychodynamic/psychoanalytic theory 153
Social Defences theory 156
Part 2 Review and clinical implications 158
Strengths and limitations 158
Implications of the current research 160
Clinical Implications 162
Conclusions 166

REFERENCES 168

APPENDICES
A The Revised Theory of the Therapeutic Alliance (RTTA), (Ross, Polaschek and 186
Ward, 2008)
B Noblit & Hare (1988) Seven Phase Approach 187
C Inclusion and Exclusion Criteria for Metasynthesis 188
D Email From Professor Kindy 189
E CASP Tool Appraisal 190
F Extracted Themes From Metasynthesis 192
G Identified Themes and Frequency Of Occurrence 194
H Grix’s (2010) Building Blocks 195
I Approval Forensic Board Meeting 196
J Trust Ethics Approval 197
K University Ethics Approval 199
L Ethics Amendment 200
M Trust Approval Amendment 203
N University Approval Amendment 204
O Invitation To Participate 205
P Information Sheet 206
Q Poster 209
R Sample Interview Schedule 210
S Line by Line Coding Interview 3 212
T Focused Coding Interview 2 213
U Memo After Interview 5 214
V Between Comparison 215
W MAXQDA Categories 216
X Memo On Early Categories 217