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Lorentz. A, 2023, Adapting the boundary seesaw model (Hamilton, 2010), to supervise Clinical Nurse Specialists (CNS’s) in a physical health setting, Reformulation 56, p.8-10
I first came across the boundary seesaw model (Hamilton, 2010) during my CAT Practitioner training. The model was developed within a Forensic in-patient mental health setting, where Hamilton spoke about using a relational framework, to help achieve a balance between providing care (treatment) and control (security). In these environments staff are often ‘pushed’ and ‘pulled’ (by themselves, other staff or patients) to become either a “security guard” or a “super-carer.” Hamilton wrote about how neither of these positions are ideal because they often resulted in a “slippery slope” towards boundary crossing, boundary violation and ultimately, unless this is addressed, to abuse of the people the health professional is attempting to help. Hamilton felt that a balanced position between the two positions of “negotiator” allowed health professionals to provide flexible care, but within explicit limits. In this way they were able to keep an eye on their boundaries, without being too rigid and also notice when they were starting to slip into other roles.
Having worked within these settings previously, the roles and procedures described really resonated with my experience of the roles that I and other staff had been ‘invited‘ to play. I really liked the way the model named our responses in a relational way. I also liked that it described a range of responses and how we as health professionals could be ‘pushed’ or ‘pulled’ to enact these roles and the seesaw can then ‘tip’ from one way to another. As the model was being described, I could see that the same parallels were occurring with the patients (throughout this article I will use the term patient, rather than client/ service user, as this is the most commonly used term within acute medical settings) that would be described to me as ‘challenging’ when I was supervising CNS’s within a Community Palliative Care team. This staff group were all very experienced, compassionate and competent nurses who regularly went ‘over and above’ to meet the palliative care needs of their patients and their families. This went well most of the time, the patients and their families experienced helpful, compassionate and empathic support at a time when they most needed it and were grateful. In return, the CNS’s felt a lot of satisfaction to be able to provide this care and support.
However, at other times, this tried and tested formula seemed to fail. The CNS’s would go over and above as usual, but rather than the gratefulness that they were usually met with, they faced anger, criticism and rejection. In response, they would try even harder to meet the patients and their family’s needs and again would often be told that they had failed to meet the expectations of the patient and their families. Another member of the team would normally step in to ‘save’ the situation. This would go well for a bit and then they too would face the disappointment of the patient and their family. This would be the point that they would present the patient in supervision with me, in an attempt to find out what they had “done wrong” and how they could “fix it.” At other times the patient and/or their family would be labelled as “challenging.” Once this label had arisen the CNS’s tended to withdraw and hold the patient and/or family at arm’s length. This often increased the anger and criticism from the patient and/or family and they would hear “why aren’t you doing this for us anymore? You used to!” Often this would lead to conflict within the team and a split between those who wanted to offer “more” and those who felt that “holding back” was the more helpful strategy.
In order to supervise and help the CNS’s manage these dynamics between the patient, their family and themselves, I adapted the boundary see saw model (see figure 1) to help the CNS’s think about their role in these enactments. I wanted to normalise and acknowledge that we are invited to play roles (these or others) within all our relationships. However, in professional caring relationships, (e.g., nurse to patient), they are important to be aware of and attend to. I was hoping that the model could help us to think about emotional boundaries together, so as to inform how they could most helpfully interact with their patients and be able to think about times when this felt less helpful. 
At the centre or ‘balance’ point of this adapted model are the ‘helpful’ roles. The Health Professional is caring, empowering, validating, containing and listens. In return the patient feels cared for, empowered, validated, held and heard. The ‘see saw’ can start to ‘tip’ when the health professional moves towards (pushed by themselves/ the wider system or pulled by the patient) attempting to ‘rescue’ or ‘fix’ the patient, hoping that in return the patient will feel ‘rescued’ or ‘fixed.’ The ‘see saw’ can also start to ‘tip’ the other way when the health professional moves towards (again, pushed by themselves or pulled by the patient) dismissing, rejecting or withholding care and in return the patient is left feeling dismissed, rejected or unattended to. When I shared this model with the CNS’s they could recognise these roles and felt there was some validity in the model. They were able to recognise times when they had been pulled towards or pushed themselves towards ‘rescuing’ or ‘fixing.’
At some of these times, moving towards this had still felt helpful, but there always seemed to come a point, where, if this continued, the enactment became unhelpful. Even on the occasions when this had “worked” in some sense (they were able to feel good that they had ‘gone the extra mile’), they also often experienced a range of “side effects.” For example, they often found it hard to discharge the patient, because they had come to rely on the nurse(s) and therefore often expressed disappointment or frustration at discharge. At other times the nurse/team would experience a sense of ‘compassion fatigue’ or reflect that in meeting one patient/ family’s needs they had inadvertently neglected other patients, etc. This would then leave them feeling exhausted or sad that they had let others down.
These “working” times were the exception and most of the time when they had been pushed or pulled towards ‘rescuing’ or ‘fixing,’ and despite their best efforts, they weren’t able to ‘rescue’ or ‘fix,’ the patient would become disappointed, frustrated and feel helpless. The CNS’s would find themselves feeling disappointment, frustration and helplessness in response to their efforts “not working” and the seesaw would start to ‘tip’ back the other way. This shift seemed to happen at speed, and as such the seesaw would ‘tip’ from one side to the other and they would ‘slide’ past the balance point and further towards dismissing, rejecting or withholding in response to the patients disappointment, frustration or hopelessness. They were not intending to do this, but this was the pattern that often played out.
As I started to use this model with different groups of nurses and health professionals, someone would inevitably say “what’s wrong with trying to fix things for people?” Or “shouldn’t we be trying to fix things for people? That’s our job!” I find that this is where the idea of emotional boundaries as a seesaw, is the most helpful. It allows me and others to notice and reflect that, although the intention behind this is good, the outcome, as described above, has unintended consequences. I then also started to think about what this might mean for the patient in the longer term and the potential benefits and downsides of being in different places on the seesaw. I suggested that having had the experience of feeling cared for, etc, in the balanced position, also allowed the patient to feel empowered, to be able to cope, able to think, use their own resources and connect with social resources. Whereas, if they had felt ‘rescued’ or ‘fixed’ by an ‘other,’ this was likely to be temporary, potentially left them disempowered, with potentially unrealistic expectations of what others could do for them moving forwards. It was also possible that they could be left feeling infantilised or controlled. Also, if the rescuing or fixing didn’t ‘work out’ and the health professional became dismissing, withholding and rejecting, then the potential longer term consequences were that the patient could be left feeling abandoned, humiliated, lost or excluded.
Before using this model, it was often easy for the CNS’s to recognise that this end of the seesaw was not a desired outcome, but it was harder for them to see that trying to ‘rescue’ or ‘fix’ could be the thing that could lead to this being acted out. I have since used this model with a variety of staff groups and shared it with other Psychologists who have found it useful in helping them to facilitate boundary conversations with different staff groups within physical health settings (E.g., as described by Lalayiannis, 2019).
References:
Hamilton, L. (2010). The Boundary Seesaw Model: Good Fences Make for Good Neighbours. In Tennant, A. and Howells, K. (eds.). Using Time, Not Doing Time: Practitioner Perspectives on Personality Disorder and Risk. Chichester, UK: John Wiley & Sons, pp. 181-194.
Lalayiannis, L. (2019). Reflecting on working with palliative cancer patients through a CAT ‘lens’ with a focus on reciprocal roles. Reformulation, Summer, pp.17-22.
Dr Ian Lorentz is a principal clinical psychologist working in Leeds. For correspondence: ianlorentz@live.co.uk