Working within professional boundaries in forensic mental health settings: an adult attachment perspective

Background - Boundary maintenance within any healthcare context is important, due to the potential adverse impact on patients. The criminogenic nature of forensic patients means that boundary maintenance is pertinent for the safety of patients, staff and members of the public alike. Individual precursors of boundary crossings are relatively well studied. However, interpersonal risk factors which may affect employee perceptions about the seriousness and acceptability of boundary crossing behaviour within forensic settings has received less research attention. Aims and Objectives - The main aim of this thesis was to explore perceptions of boundary crossings and violations within forensic hospitals and the role which attachment tendencies may play in this relationship. 1. What does the literature suggest about the role of attachment tendencies on an individual’s workplace behaviour? (Chapter 2). 2. Is the Revised Experiences in Close Relationships (ECR: Fraley et al., 2000) a suitable measure for assessing attachment tendencies within the workplace? (Chapter 3). 3. What are the individual employee factors which may be associated with the perceptions of the acceptableness and seriousness of boundary crossings and violations within forensic mental health settings? (Chapter 4). 4. What is the impact of adult attachment tendencies upon the perceptions of the acceptableness and seriousness of boundary crossings and violations within forensic mental health settings? (Chapter 5). Method – To answer the first question, a systematic review was completed to explore the current literature regarding the role of attachment tendencies upon employees work performance (Chapter 2). A psychometric review was conducted to assess the reliability and validity of the ECR-R and its suitability for measuring attachment in the workplace (Chapter 3). Two pieces of empirical research using qualitative methods aimed to explore the relationship between perceptions of boundaries on organisational and interpersonal employee characteristics (Chapters 4 & 5). Overall Findings – The systematic review (Chapter 2) demonstrated that secure attachment tendencies were associated with professional and “help giving” behaviours at work; whilst anxious tendencies were associated with unprofessional and unethical behaviours which may have a negative impact on both the organisation involved, as well as individuals associated with that work place. The psychometric review of the ECR-R (Chapter 3) confirmed the validity and reliability of the tool for measuring adult attachment tendencies, both within romantic and occupational contexts. Empirical research demonstrated significant relationships between individual employee factors (Chapter 4), attachment tendencies (Chapter 5) and the perceived acceptability of boundary crossings, using vignettes, within a forensic setting. Employees who were either working within a therapy role or had more experience were more likely to view boundary crossings and violations as unacceptable compared to their colleagues. Additionally, the perceived acceptableness of boundary crossings and violations was higher in anxiously attached rather than avoidant attached employees. Conclusions – Healthcare professionals perceptions towards boundary crossings and violations is mediated by individual and organisational factors. Employees who have anxious attachment tendencies are more likely to perceive boundary crossings as acceptable. Additional research is needed to identify if this relationship applies to the actual engagement of boundary crossings or violations. Findings may help to support individuals through additional training in boundary maintenance and highlight the importance of regular supervision