Restoring the balance of power after acute care interventions
How to give conflict a voice so that challenges and differences of opinion can be brought into the open
How to give conflict a voice so that challenges and differences of opinion to be brought into the open
When users of mental health services are in the acute phase of their illness and considered to be at high risk, intervention by a clinician can result in a damaging and non-therapeutic relationship.
There is a clear imbalance of power and threat that is not in favour of the service user.
But a therapeutic relationship can still be achieved as long as the expectations of the clinician and service user around the management of risk are discussed, observed and reflected on as an ongoing process.
Identifying expectations builds a collaborative dynamic, with less chance of ambiguity or false promises on either side. Collaborating about what needs to be done helps to equalise power between them, as both have a share in it.
Forced hospital admissions, for example as an intervention by a crisis and home treatment team, are used as a last resort to contain and manage risk. But how do we get back to a therapeutic relationship in which power between them appears to be more balanced?
Debriefing the service user helps somewhat: being able to talk about the rationale, how the service user is managing now, what could be done differently next time and any positives.
Alongside this we need to keep having a conversation about expectations, and how they have changed after this breach in the relationship.
Giving conflict a voice
Research (Safran et al 1990, Gersh et al 2016) has long suggested that a rupture in the therapeutic alliance can help the relationship, so could forced admission end up strengthening the relationship between the service user and therapist?
In any human relationship there is a dynamic arising from differences of opinion and giving conflict a voice allows challenges and differences of opinion to be brought into the open. This should be no different when we work clinically with service users.
This enables the conversation to move towards a discussion around the expectations of the clinician and service user. Only when we are aware of our own expectations and those of the other person can a therapeutic relationship flourish and maintain an equal footing.
Agreement to work together
Service users entering the care of a crisis and resolution home treatment team are considered to be at high risk.
They are often in the acute phase of their illness, but the team cannot work with them in the management of risk unless both parties agree to work together therapeutically.
We know that a therapeutic relationship encourages collaboration, which shifts the power dynamic paradigm so it swings back and forth between the service user and the clinician.
The service user has to be in a therapeutic alliance with the team, believing that the clinician can help them in managing their risk and expectations. They need to trust the clinician as much as the clinician needs to trust them. Again, this echoes the swing of power and the trust that is required in this relationship.
The therapeutic relationship is not lost in a crisis. It manifests in this team working with a service user, which is the closest thing we have to a ‘real-world relationship’.
Being aware of the power shift between them helps to clarify the expectations of both sides. If this can be achieved, we are completely engaged in a relationship with clients that is equal and collaborative, and this ultimately helps to contain risk.
- Gersh E, Hulbert C, McKechnie B et al (2016) Alliance rupture and repair processes and therapeutic change in youth with borderline personality disorder. Psychology and Psychotherapy: Theory, Research and Practice. 90, 1, 1-21
- Safran J, Crocker P, McMain S et al (1990) Therapeutic alliance rupture as a therapy event for empirical investigation. Psychotherapy: Theory, Research, Practice, Training. 27, 2, 154-165
About the author
Hannah Brown is a mental health trainer at ²gether NHS Foundation Trust, Gloucester