“Them two are around when I need their help” The importance of good relationships in supporting people with learning disabilities to be “in a good space”

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Introduction
A relatively small but enduring number of people with learning disabilities are detained in locked or secure inpatient units in the England despite a succession of policy initiatives, and what Hatton (2020) refers to as a 'major push' in 2019 to reduce these numbers. Successive reviews of National Health Service (NHS) data (cf. Hatton 2015;2020) demonstrate that the number of inpatients has gradually reduced from the estimated 3,400 people in 2012 (Department of Health, 2012) to a recent figure of 2,250 people with learning disabilities and/or autism living as inpatients in mental health hospitals and other specialist settings -often referred to as forensic or locked settings and hereafter referred to as 'secure settings' (Department of Health and Social Care, 2019). The majority of people are detained under the Mental Health Act 1983 1 or under the Deprivation of Liberty Safeguards (DoLs) although there are some voluntary admissions.
During their stay in secure settings, people with learning disabilities are distanced, geographically and emotionally, from their family and friends (Fish, 2016). Residents 2 tend to experience long total lengths of stay. According to data analysed by Hatton (2020), average length of stays in current placements have reduced slightly to 2 years 6 months, and overall length of stay in secure settings have maintained a similar length at an average of 5 years 5 months in the period 2015-2018, with 36% of residents having been in continuous inpatient services for 5 years or longer. People are removed from their community and natural networks of relationships, visits are limited and restricted, and the 1 Under the Mental Health Act 1983 people with learning disabilities or autism can be detained in hospital under Section 3 of the act if they are deemed to be 'abnormally aggressive or seriously irresponsible'. There is no requirement that have a mental health diagnosis for this detention. However, it is argued that being detained under the Mental Health Act 1983 provides greater safeguards than the deprivation of liberty under the Mental Capacity Act 2005, and there is an ongoing debate about whether people with learning disabilities should be removed from the scope of the Mental Health Act 1983 (or its successors) see Series, L. (2021). 2 We acknowledge the challenges of appropriate language to describe people with learning disabilities who are detained in locked wards. We decided to use residents as a factual description of their status. settings are often a significant geographic distance from their home and the local community (Brown et al., 2017). They reside in gender-segregated settings with varying levels of restriction.
Day to day relationships are thus with other residents and staff. Drawing on our previous research, and that by Head et al, it is clear that relationships are an important factor in the wellbeing of residents including their ability to move through the services and be discharged successfully into the community (Fish, 2017;Fish and Duperouzel, 2008;Fish and Morgan, 2019;Head et al., 2018)). However, there are multiple challenges to the building of relationships related to the requirement for boundaries and professionalism on behalf of staff, and self-sufficiency on behalf of residents (Fish, 2016;Fish, 2018;Parkes and Freshwater, 2012).
In this article we consider the role of relationships with staff members -particularly 'good' or 'positive' relationships -in the lives of people with learning disabilities who are resident in secure settings. In a previous article (Fish and Morgan, 2019) we explored what it meant to progress or 'move on' through these settings. It was clear there was a divergence between how staff and residents conceptualized progression, although both groups saw the outcome as being to move to less restrictive settings and ultimately to live in the community. Navigating successful relationships was viewed as a critical pre-requisite to moving through (and out of) services, and supportive relationships with staff were crucial to successful transition.

Literature Review
Caring relationships with paid staff in inpatient services are often referred to as 'therapeutic relationships', and principles originate within the traditions of nursing (Peplau, 1952) and therapy (Rogers, 1951). Combined, these principles consist of acceptance, unconditional positive regard, empathy, genuineness and collaboration (see Norcross, 2002) -and as a way of forming an 'ongoing constructive partnership' (Ryan and Morgan, 2004:141).
Literature applying these principles acknowledges the importance of family and peer support when working towards transition, however, the therapeutic relationship is seen to be crucial as an agent of change in supporting a person to progress (Forchuk et al., 1998).
The relationship becomes therapeutic when people come to 'know and respect each other as persons who are alike, and yet, different, as persons who share in the solutions of problems' (Peplau, 1952:166). Therapeutic relationships can therefore 'confirm self-worth, provide a sense of connectedness with others, and support self-esteem' (Peplau, 1997:166).
Some literature describes the particular aspects of the therapeutic relationship when working within secure settings, including the need to balance care with containment. Lovell and Skellern (2020:248) describe this as particularly difficult: The establishment of the therapeutic relationship cannot be detached from the secure context, and the way it is developed in conjunction with its primary characteristics is coloured by the level of security.
Because of these aspects of risk and security, residing in a secure setting can have a profound effect on how people with learning disabilities see themselves. Moving on from these settings can develop a person's sense of identity from something narrow or problemfocussed, to a 'wider array of meaning-making' about who they are (Head et al., 2018:69).
Head et al's study with 11 people who had moved on from inpatient units in the UK found that successful transition depended on supportive relationships with staff, family members and friends. Participants highlighted the importance of trusting relationships with staff who knew them well, and the need for continuity when moving into the community.
The development of supportive relationships between staff and residents is therefore extremely important, indeed service-users have reported that relationships with staff are more important to them than therapeutic interventions per se. (Clarkson et al., 2009;Gilburt et al., 2008;Molvaer et al., 1992). According to the residents in Forchuk's (1998) study, trust, availability and consistency of staff facilitated the progression of the staff/resident relationship when moving through services and into the community. In other studies, residents highlighted staff's honesty/authenticity, respect, understanding, and taking time to get to know a person in order to bring about change (Hostick and McClelland, 2002;Shattell et al., 2007). This article considers the potential for supportive relationships as helping people to move out of secure settings, using data from a synthesis of two research studies set in a secure inpatient unit in the North of England. We explore characteristics of positive relationships in secure settings, and how these are developed and nurtured in services to support a successful transition into the community. In the discussion section we highlight the ways in which power imbalances hinder the potential of mutual support invisible in relationships and identify the importance of empathy and trust. We conclude by offering some ideas for future research.

Methodology
The data from two studies are used for analysis in this article. Both studies were performed in the same secure setting in the north of England. Table 1 shows details about each study:  (Fish, 2015) and a report for funders (Fish and Morgan, 2017) for Study 2 3 .
Both studies received ethical approval from the NHS IRAS committee in the North of England, as well as from the FASS and LUMS ethical committee at Lancaster University. All participants had the capacity to consent to participate in the research. The research questions for the studies were based around improvement of services rather than supportive relationships, however it became clear during analysis that supportive relationships formed a significant emergent theme within the fieldnotes and interview transcriptions. Original analysis in each study was inductive, and themes were determined by the areas of discussion formed during the in-depth interviews and fieldnotes.
For the present article, we worked together to revisit the data from both studies to elicit quotes and fieldnotes that focussed on supportive relationships, and their functions in terms of helping people move on to be in a 'good space' as described by our participants.
We recognise that the findings from the 2012 study are dated, however our purpose was to explore enduring notions of positive relationships, outside of the temporal context of service policy or practice. We arranged our findings into the inductive sub themes: characteristics of positive relationships, challenges to positive relationships, encouraging positive relationships, and how positive relationships can support people to move on.

Findings
The central message from the two studies was that during their separation from family and friends the residents' relationships with members of staff in the secure setting became central 4 to supporting a person to achieve the required steps to progress.

Characteristics of positive relationships
A key determinator of moving on through the locked ward system is behavioural stability, i.e. enduring lack of aggression and/or self-harm (Ryan et al., 2018;Travers, 2013 This caring interaction, which is an example of comforting touch, demonstrates the effort that staff put into the therapeutic relationship. Of course, Candice's reassurance to Lorna was dependent on staffing levels being sufficient enough for Candice to be able to bring Lorna back to the ward.
All of the staff discussed how they maintained positive relationships with residents, with some describing themselves as 'friends': John: Really, it's to be a friend. A lot of it is to be a friend to them, and be there if they need to talk, reassure them sometimes, and again if they have a bad day, they have a bad day. Everybody has a bad day, you know, it's how you react and recover. (Women's ward Interview, staff) It is interesting that a male staff member used the word 'friend' to describe the relationship and talked about 'reassuring' and 'being there'. This emphasises the opportunities for a caring relationship to emerge, as described in the feminist literature on caring (Walmsley, 1993), based on reciprocity and interdependence (Kittay, 2001;Williams and Robinson, 2001). There was evidence of many positive relationships between male staff and female residents.
Karen, a ward manager outlined the attributes of importance for staff members, in terms of empathy whilst maintaining boundaries: Karen mentioned the balance between fairness and empathy. However, Karen's comment highlights the power differential by acknowledging that staff make decisions on behalf of residents. Julie described how it is possible to be caring whilst maintaining boundaries: Marion picked out the two key aspects that residents discuss when talking about their relationships with staff, practical help and emotional support. These two key roles were highlighted as important by residents in Clarkson's (2009)  The themes running throughout these responses are that staff are offering much emotional support, but also they are being asked to do things for the residents, because the residents are not allowed to do these things for themselves. Residents valued these gestures of assistance, but an issue with this was that staff had other demands on their time and may be seen to 'put off' the residents by saying they would do something later.
3.2 What are the challenges for positive relationships? We found that people with learning disabilities were perceived as inherently incompetent at navigating relationships, and this was attributed as one of the reasons why they had been detained within the unit. Some of the social and structural reasons for this were acknowledged by staff, however this perceived incompetence was generally regarded as a feature of a person's learning disability rather than their experiences and circumstances, for example:

Adele: Somebody with a learning disability for example, one of their features may be impulsive behaviour and not understanding social norms of keeping a polite space from people, and invading people's space and stuff like that, because that applies to a lot of people with learning disability. (Women's ward interview, staff)
Communication difficulties were also blamed as a reason for holding people back. However, staff knowing the person well was described as mitigating problems here:

Julie: He won't say [he's distressed], you have to have a conversation with him to work around to -what's the issue? And it does tend to be around some specific things. So once you know him, it's not too difficult. (Men's ward interview, staff)
This suggests that consistency of staff is important for understanding people's likes and dislikes, as well as their body language when they become distressed.
The power disparity between staff and residents was highlighted as a stress point in the therapeutic relationship -bringing about the potential for feeling manipulated, as staff member Iona explained here: Iona was commenting on the aspect of the staff role which often involves containing and controlling the residents. Many of the staff mentioned this as a difficult part of their job, balancing the two aspects of their role, therapy and containment. It seemed in the secure setting that the requirements of the service and residents were necessarily conflicting, as services have a duty to control and contain residents. The idea of being manipulated related to being able to balance the tensions between care and control:

Irene: It's difficult as a nurse in a secure unit. You don't want to be manipulated but you want them to know you give a shit. Sometimes it was tough love. But they knew I cared. I really don't think I disliked many clients even when they were threatening my life. I just understood where they were coming from. A lot didn't really have a loving/caring start in life. When you care -you care, you can't help it. A hug, a smile, or just taking time to listen -goes a long way with all of us. (Men's ward interview, staff)
When residents discussed the challenges to positive relationships, these generally involved the use of restrictive practices, such as the use of incentive systems, continual observation, physical intervention, and/or seclusion. These were generally seen as aversive or as punishments. The potential for highlighting the imbalance of power and subsequent damage to relationships due to the use of restrictive interventions is well-documented (Fish and Hatton, 2017;Quinn, 2018) and there is a growing body of resources that offer ways to avoid their use (McDonnell and Ridout, 2019;McKeown et al., 2020).

Encouraging positive relationships
Services are able to make positive steps to support the therapeutic relationship as a way to ensure everyone is working towards residents' transition back to the community. Here, Elaine describes how changes in self-harm policy worked to enable more collaborative relationships: Jackie's ideas about collaborative planning and asking women how they would prefer to be treated in times of anger and distress, are about sharing the power and control, bringing to mind the disability activists' mantra 'nothing about us without us'. We argue that attention from staff is a legitimate requirement in such units, and if this was freely given, behaviour which is interpreted as 'attention seeking' and 'manipulative' (see Bowers, 2003) would be considered as an indication that extra support is needed, and the power struggles would be re-evaluated.
3.4 How can relationships help people to move on? Fish (2018) found that incidents of aggression or self-harm can work to keep a person longer in a unit. However, a staff member here describes how good relationships can work to reduce incidents of aggression, therefore bringing about stability:

Iona: My attitude towards her was very upbeat and very OK. I was never negative towards her, if she couldn't do something, I didn't say it in a negative way. And the relationship was very different between them two [staff members] and her because
they'd had all the aggression and I'd never had aggression. We'd have a laugh to be honest, we'd laugh and joke and I think there was an element of -what's the difference? (Women's ward interview, staff) This comment shows that aggression often arises in a relational context, and importantly, that a positive staff/resident relationship can work to reduce or eliminate anger and aggression.
Staff adopt different strategies in response to aggression or the risk of aggression. Some staff proactively seek to manage the risk, by using humour and offering 'face saving' alternatives (see Duperouzel, 2008). As Iona pointed out, at certain times humour and patience in the face of anger, could enable relationships: Mutual trust was discussed as a way to facilitate relationships, in ways that allowed discussion and safety. Here, Bella talked about becoming trusted more now that she has stopped self-harming: here and work with them. They'll start visiting the house, the flat, buy in things and eventually our staff will take a back seat and their staff will take sort of over more of the lead. (Men's ward interview, staff) The examples of successful progression and moving on in both studies were accompanied by examples of good staff/resident relationships, that included utilising trust and patience to foster gradual transition.

4.Discussion
There are many enduring challenges to supportive relationships in secure settings. Lovett (1996:161) refers to the 'general devaluation of people with disabilities, the role of professionals as powerful authorities in the lives of people with disabilities, the monolithic culture of institutional practices' as well as 'the unquestioned cultural superiority of these professionals and their values over people with disabilities'. This echoes the structural disablism identified by James (2021) as inherent in wider learning disability policy interventions over the last 50 years. This 'endemic low expectation and a lack of ambition for people's future' has become engrained in health and social care systems (James et al., :1651. It is through these institutional and policy related discourses that power disparities become rooted and entrenched. We have shown how positive therapeutic relationships are able to address and rebalance this situation. We found that consistent with the literature on therapeutic relationships: respect, acceptance, trust and openness are important, and these are demonstrated through providing practical help, emotional support and enjoyment. These aspects are consistent with a rights-based approach to care and feature in the literature as crucial to therapeutic progression (Doyle et al., 2017;Parry-Crooke and Stafford, 2009;Sarkar and di Lustro, 2011). Staff used words such as 'empathy' and 'support', even 'friendship', which we would suggest reflects the nature of the relationship and the type of work.
We have shown just some ways in which positive relationships can encourage successful progression through, and ultimately out of, secure settings. If effective transitions rely on behavioural stability as demonstrated in the literature (Travers, 2013), we argue that engaged relationships with staff can help to fulfil this aim. It is important that there is recognition of the value of supportive relationships at an organisational level, and a twoway process of communication, where behavioural responses are considered in terms of the contexts and preceding events.
A significant theme here, as well as one which runs through the literature that discusses staff/resident relationships, is trust. Trust works both ways and is described as central to the therapeutic relationship. According to Langley and Klopper (2005), essential conditions for the development of trust in a staff member are availability, honesty and confidentiality, being able to listen and try to understand, and helping the resident to feel safe emotionally and physically. Residents felt that the need to be trusted was as important as being able to trust. Our findings agree with Hermsen et al, (2014) who note the following as contributing to positive relationships: trust, creativity and flexibility, humour and intuition, as well as having an open and respectful staff team.
These elements of relationships are manifested using 'soft skills'. Often undervalued and difficult to measure, soft skills form an essential part of enabling people, and should be nurtured and valued within services, as recommended by Sara Ryan: Love is a central feature of family life and yet remains invisible in health and social care services, practice and research. Where is the love? And why is this word erased in the professional arena? Not scientific enough perhaps, or too messy to engage with. (Ryan, 2020:26) Opportunities for building the staff/resident relationship into one of mutual support may be missed due to the power imbalance between staff and residents. This is recognised by staff as part of the contradictory requirements of care and control. This imbalance of power is exacerbated by the use of restrictive interventions (Gilburt et al., 2008), in particular the use of physical intervention and seclusion, as also pointed out by Quinn (2018): They hold all the power and they own you. They can restrain you when they like and fill you with chemicals when they like. (2018:54) Power imbalance was further entrenched by the use of concepts of 'manipulation' to describe residents. Yates's critique of the government's Valuing People white paper (Department of Health, 2001) points out that 'The discourse of valuing does not permit an analysis of 'manipulation' as a form of resistance' (Yates, 2005:234). Yates points out that employees of service agencies are encouraged to think constantly about values but 'rarely about power relations between residents and support workers -except where residents are deemed to behave in a 'manipulative' fashion, in which case they are seen to attempt power play over us' (Yates, 2005:234, emphasis in original).
We argue that power differentials are brought into play by perceived hierarchies in services: 'We cannot expect to work positively with people as equals in hierarchical services that systematically define them as "less than"' (Lovett, 1996). In order to encourage supportive relationships, we therefore suggest that services should work towards initiating a 'flat hierarchy' (as advocated by Quinn, 2019), and supporting 'more equal relationships based on equality and respect for people's subjective experiences' (Wilde, 2014:210). This model would mean staff and residents being supported to embrace the therapeutic alliance and work together, towards the same goal of successful and smooth transition back to their community as soon as possible.

Conclusion
Key to our argument is the therapeutic potential of staff/resident relationships. Positive relationships can be beneficial for both groups, enabling residents to 'practice' relationshipbuilding soft skills, and can also work to reduce staff burnout (Mersin et al., 2020). We recognise the limitations of our research, in that the theme of supportive relationships from our data arose incidentally: each project we have reported on was not originally centred on relationships. We also acknowledge that we have combined data from two studies that are dissimilar in date and participants -the 2017 study did not include observations or interviews with residents. However, we maintain that enduring and important insights have arisen from our revisiting the data, and we hope that these are helpful to staff members when supporting people to navigate transitions from secure settings. We recommend future research that is centred on the role of positive and supportive relationships for successful rehabilitation and transition, including those that elicit retrospective narratives about what has helped.