‘Everything contradicts in your mind’: A qualitative study of experiences of forensic mental health staff in two contrasting services

BACKGROUND: In the theoretical literature, there is growing recognition of the psychological impact on staff of working in challenging healthcare settings. In forensic mental health (FMH) services, powerful transference and counter-transference reactions in staff-patient relationships may emerge and may even play a role in contributing to incidents of malpractice, but there is little empirical research here. AIM: The exploration of the experiences of FMH staff in two contrasting services. METHOD: Thirteen in-depth interviews were carried out with staff from a range of clinical disciplines in a mainstream National Health Service (NHS) medium secure unit (MSU), and 12 interviews were undertaken with such staff from a Personality Disorder Unit (PDU) in an MSU. All interview data were analysed independently using the grounded theory method. To synthesise the two separate analyses, a thematic analysis of both data sets was carried out, in which 'thematic units' were defined as significant points of comparison between the analyses of the two sets of interviews. RESULTS: The combined analysis yielded six main themes under two main headings. Themes under the first heading Experience of the Clinical Task were: 'difficulty in achieving task integration'; 'motivation to build relationships, work through difficulty and bring about change'; and 'minimal sense of risk and anxiety at the centre'. Themes under the second heading Experience of the Organisation were: 'a distant and difficult relationship with outside'; 'preoccupation with staff relationships'; and 'feeling unsafe'. The overarching concept of the combined analysis was encapsulated in the quotation: 'Everything contradicts in your mind'. CONCLUSIONS AND IMPLICATIONS: Clinical and organisational aspects of work seemed separate in the minds of staff, with the latter reported to be more stressful; staff support came in the form of close relationships with colleagues, who saw themselves as isolated in the context of the wider environment. Promotion of the well-being and effectiveness of FMH staff should therefore take account of clinical, organisational and societal aspects of their situation.