The Law of the land applies to both Patient and keyworker.

Professional rules and regulations (laid down by professional bodies for nurses, therapists, doctors, etc), regarding ethics, probity, and professional conduct apply to the therapist/keyworker.

There is information about Consent to Treatment here.

It is in the nature of working with adolescents in crisis that boundaries are often challenged and tested by our patients. In outreach situations it is necessary to be additionally clear and explicit about boundaries, and to maintain appropriate vigilance (see Work on the Self) so that any small infringements of boundaries are noticed and discussed in supervision (see SupervisoryStructures) at the earliest opportunity. Evidence from inquiries often demonstrates that significant untoward incidents involving boundary infringements very often occur after a succession of much smaller (and, individually, almost unremarkable) infringements.

Boundaries as "Bearings"

See KeepingYourBearings for the T.A.R.T.S. boundaries that can usefully be applied at any point in time to whatever we are engaged in, so that they help to orientate the worker.

Boundaries of Touch

An obvious boundary that needs to be rehearsed and repeatedly clarified in the keyworker's mind and in the team's protocols (notwithstanding the professional boundaries referred to above, which remain valid at all times) is that of touch between patient and therapist.

Ideally, the Keyworker will work with a mitigated 'no-touch' policy in mind.

It is recognised that there are many times when not touching a young person is either impossible or entirely inappropriate; for instance if the worker is checking a patient's blood pressure, or playing a game of football, some incidental physical contact would be quite ordinary. Likewise, a patient who is extremely distressed may actively seek out physical comfort, by putting a head on the worker's shoulder, or a young person who is excited and happy to see a worker to whom they feel securely attached may offer, and expect, a physical welcoming hug, pat, etc. Recoiling in such a situation could be interpreted as highly rejecting and be detrimental to therapeutic Engagement, so as a Keyworker you have to maintain a flexible stance, all the while KeepingYourBearings.

We work from a premise that distress is ideally managed through equipping the young person with the emotional and mental equipment to cope and contain themselves, rather than via physical methods of containment. So, resorting to physical contact as a primary means of dealing with distress may be the most immediately effective and essentially human response - if it is, say, the asking for and receiving of an empathising hug. However, there is a risk that remaining only in the realm of the physical as a means of resolving distress could be an example of Teleological thinking, and this would not be helpful.

We also recognise that young people who have histories of physical or sexual abuse may either;

• Communicate their needs or wishes inaccurately around physical contact, or
• Interpret physical contact in ways that are very different from the way these were originally intended to be received.

Hence, if touch does occur it must only occur:

1. With the explicit consent/at the request of the young person.
2. For the miminimum appropriate duration of time.
3. In the way that is least liable to be misinterpreted (for instance light touch to non-erogenous zones such as the forearms, or the giving of a brief hug in a 'side to side' position, rather than face-to-face, etc)
4. In a way that is obviously and exclusively for the benefit of the young person, rather than addressing any of the needs or wishes of the adult.

Team SupervisoryStructures and touch.

The Keyworker would be expected to raise incidents where 'more than incidental' physical contact had occurred with a young person for discussion in supervison, as a part of KeepingYourBearings. Part of the the team culture of Mentalization should be to allow and encourage an open curious exploration of these sometimes anxiety-provoking experiences between team members.

A KeyWorker who displays avoidance of, or refuses to try to mentalize these experiences may need additional support and reassurance via SupervisoryStructures, but AMBIT's focus on good Clinical Governance would be clear that this is not an acceptable position to maintain. Our capacity to share experiences amongst team members, and to mentalize openly between each other, is a major guarantor of safety for all individuals concerned.