{"id":1254,"date":"2026-08-25T07:00:41","date_gmt":"2026-08-25T07:00:41","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjleader\/?p=1254"},"modified":"2026-08-14T14:33:24","modified_gmt":"2026-08-14T14:33:24","slug":"what-the-team-feels-psychodynamics-risk-and-reflection-in-forensic-psychiatry-by-angela-misra-and-farheen-ebrahim","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjleader\/2026\/08\/25\/what-the-team-feels-psychodynamics-risk-and-reflection-in-forensic-psychiatry-by-angela-misra-and-farheen-ebrahim\/","title":{"rendered":"What the Team Feels: Psychodynamics, Risk and Reflection in Forensic Psychiatry. By Angela Misra and Farheen Ebrahim"},"content":{"rendered":"

Teams function best when they can reflect on their emotional responses. This blog will explore how reflection can be used in stressful team situations to improve decision-making using examples from forensic psychiatry.\u00a0<\/span><\/p>\n

Team dynamics are particularly intensified in forensic psychiatry when treating service users who evoke strong and differing emotional responses. Leadership in this context is critical to determine whether emotion becomes shared clinical information that sharpens judgement or an unexamined influence that could facilitate restrictive practice, minimise risk or fragment a team.<\/span><\/p>\n

This was particularly evident during a multidisciplinary team meeting regarding a service-user after several members of the nursing team had sustained serious injuries during episodes of aggression. The atmosphere in the team was characterised by heightened vigilance, anxiety and emotional exhaustion. The service user, alongside the aggression, also appeared extremely frightened and confused.\u00a0<\/span><\/p>\n

Although the meeting was understandably focused on maintaining safety and preventing further harm, it highlighted a common paradox within forensic psychiatry. At moments of greatest risk, clinical attention is often narrowed towards risk stratification, rather than considering the emotional processes in the service user and multidisciplinary team.\u00a0<\/span><\/p>\n

However, as the service-user became tearful, the emotional atmosphere shifted. For a moment, the attention shifted beyond the recent violence, and the team was able to see not only the risk being posed, but also the distress being experienced by the service user. The service-user had not become less risky but, had become more understandable.<\/span><\/p>\n

In that moment, the concepts of transference (the repetition of earlier relational patterns) and countertransference (the emotional responses evoked in teams) were brought to life. Colleagues had a range of internal responses; some with a strong urge to rescue, others more controlling and some to withdraw from engagement altogether.\u00a0<\/span><\/p>\n

By reflecting on this dynamic, aspects of service-users\u2019 unconscious communication and <\/span>structure of Kleinian defences<\/span><\/a>1<\/sup><\/span> was highlighted. It prompted reflection on the role of leadership in containing anxiety, and the importance of creating reflective spaces where both staff experiences and service-user distress can be held in mind simultaneously.\u00a0<\/span><\/p>\n

From a psychodynamic perspective, anxiety rarely resides solely within the individual service-user. Rather, it is distributed across relationships. <\/span>Bion described how intense emotional states can overwhelm a group’s capacity to think<\/span><\/a> 2<\/sup><\/span>, leading to defensive responses that prioritise action over reflection.\u00a0<\/span><\/p>\n

We reflected that when teams are repeatedly exposed to violence, these relational dynamics become interwoven into the service-user\u2019s narrative. The injuries sustained by nursing staff in this case were real, and their fear was entirely understandable. This is where the concept of moral injury becomes relevant.\u00a0<\/span><\/p>\n

Staff may experience profound psychological conflict when their professional identity grounded in compassion and trauma-focused approaches is repeatedly challenged by exposure to aggression and the necessity of restricting another person’s liberty. Naturally, this can erode empathy and lead to emotional withdrawal, thereby increasing the risk of burnout and defensive practice.\u00a0<\/span><\/p>\n

Here lies the challenge: how to manage risk and preserve a clinicians’ capacity to continue caring in these environments, where caring itself can take its psychological toll? Teams may notice tendencies towards overprotection, excessive control, avoidance or inconsistency. Naming these patterns is not about attributing blame. Such discussions can prompt teams to revisit whether their approach remains proportionate to the available evidence and treatment goals.<\/span><\/p>\n

Group reflection using Balint theory<\/span><\/a>3<\/sup> <\/span>has often helped us to understand how reflection can influence decision-making. In one example, a service-user\u2019s presentation generated markedly different reactions within the team. Some colleagues experienced the service-user as manipulative, while others emphasised repeated experiences of trauma and service failure. Psychodynamic thinking did not replace structured professional judgement or risk assessment tools. Instead, it added another layer of understanding that enriched decision-making. Extensive background histories for service-users are attachment maps that can help explain what individuals expect from others. When teams can think psychologically together, they are often better able to remain cohesive under pressure and avoid defaulting to extremes of control or disengagement.<\/span><\/p>\n

For early-career leaders, one practical step is to make emotional responses discussable<\/span>. One useful framework considers four perspectives<\/span><\/a>4<\/sup>:<\/span> how the service-user experiences others; how the service-user experiences themselves with others; how staff experience the service-user; and how staff experience themselves in response to the service-user. This shifts discussion from asking \u201cWhat is wrong with this service-user?\u201d to asking \u201cWhat might be happening in the interactions between the service-user and the team?\u201d Using these perspectives often reveals translational patterns.<\/span><\/p>\n

For senior leaders, the challenge is to protect time and space for reflection. Brief interpersonal dynamics reviews and Balint-style discussions should be recognised as important components of compassion-focused practice. Leaders can also support teams by considering the emotional climate and relational risks alongside structured assessment within governance frameworks. High-quality supervision and post-incident debriefs will help the teams transform emotional experience into clinical understanding.<\/span><\/p>\n

When leadership provides containment for staff, staff are better able to provide containment for patients. In this way, leadership becomes not simply an organisational function but a therapeutic intervention, protecting both staff wellbeing and the quality of patient care.\u00a0<\/span><\/p>\n

References<\/strong><\/p>\n

    \n
  1. https:\/\/melaniekleintrust.org.uk\/the-writings-of-melanie-klein\/<\/span><\/a>\u00a0<\/span><\/li>\n
  2. https:\/\/www.routledge.com\/Experiences-in-Groups-and-Other-Papers\/Bion\/p\/book\/9780415040205<\/span><\/a>\u00a0<\/span><\/li>\n
  3. https:\/\/www.routledge.com\/The-Doctor-His-Patient-and-the-Illness\/Balint\/p\/book\/9780415042322<\/span><\/a>\u00a0<\/span><\/li>\n
  4. https:\/\/www.routledge.com\/Formulation-in-Psychology-and-Psychotherapy-Making-Sense-of-Peoples-Problems\/Johnstone-Dallos\/p\/book\/9780415682313<\/span><\/a><\/li>\n<\/ol>\n

    Authors<\/strong><\/p>\n

    Dr Angela Misra<\/b><\/p>\n

    \"\"<\/p>\n

    Dr Angela Misra’s clinical and academic interests focus on quality improvement, patient safety, medical education, co-production, and healthcare leadership, with an emphasis on developing resilient, sustainable mental health systems that promote equitable access to high-quality care nationally and internationally. She has co-led psychiatric rehabilitation service transformation, developed and scaled psychological interventions across the UK, and co-founded a national mentoring service. Dr Misra also developed Islamic Behavioural Therapy and has advised national and international organisations on Countering Violent Extremism (CVE) strategy. She serves on the executive committee of the RCPsych Volunteering and International Psychiatry Special Interest Group (VIPSIG), is a member of the RCPsych Coaching and Mentoring Delivery Unit and is the World Psychiatric Association Early Career Psychiatrists Section Appointed Position (ESAP) Committee Member for Mentoring.<\/span><\/em><\/p>\n

    Dr Farheen Ebrahim <\/b><\/p>\n

    \"\"<\/p>\n

    Dr Farheen Ebrahim has specialist interests in the mental health of asylum-seekers and refugees and accompanying medicolegal issues, trauma-informed care, neurodivergence and the intersection of mental health with human rights and public policy. She holds national leadership roles within the Royal College of Psychiatrists, including representation on the Psychiatric Residents Committee, the Special Committee on Human Rights and is an executive member of the Volunteering International Psychiatry Special Interest Group, where she contributes to work on mental health legislation, ethical practice, and international psychiatry. She has extensive experience in medical education, curriculum development, and quality improvement with experience in approaches with education, and leadership, particularly with work around conflict-affected and resource-limited settings.<\/span><\/em><\/p>\n

    Declarations of Interest<\/strong>
    \nNo interests to declare.<\/p>\n

    Aspiring Leaders in Healthcare<\/strong>
    \n    Aspiring Leaders in Healthcare Network<\/span><\/a> aims to foster a multiprofessional community of practice, united by the common goal of nurturing future healthcare leaders across the globe. Our regular online meetings, social media communities and conference huddles connect members to a wider network passionate about leading positive change and improvement in healthcare. <\/span><\/p>\n","protected":false},"excerpt":{"rendered":"

    Teams function best when they can reflect on their emotional responses. This blog will explore how reflection can be used in stressful team situations to improve decision-making using examples from forensic psychiatry.\u00a0 Team dynamics are particularly intensified in forensic psychiatry when treating service users who evoke strong and differing emotional responses. Leadership in this context […]<\/p>\n

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