An excerpt from Lauren Naismith and Marion O'Shea's practitioner article on Malignant Alienation, what it is, and how to overcome it.
The purpose of this article is to make practitioners more aware of malignant alienation, why it occurs, how it affects our work, and the best way to manage it. Given that the focus of much of our work is on building and strengthening the therapeutic relationship, this phenomenon is of critical importance.
Malignant alienation can have a significant impact on the way we perceive individuals and consequently the level of care we provide them with. Therefore, it is vital that we try to prevent this process from occurring in the first place. The theoretical framework for this article comes from the Low Arousal Approach, which is a “person-centred, non-confrontational method of managing behaviour” (McDonnell, 2019; p.114). A key element to this approach is reflective practice. By becoming reflective practitioners, we can learn to more effectively identify and manage the strong negative emotions we may feel towards certain clients, rather than ignore them and allow them to build momentum.
What is Malignant Alienation?
Malignant alienation is a term that was coined by Morgan in 1979 (Watts & Morgan, 1994). It refers to the progressive deterioration of the therapeutic relationship, when a practitioner effectively starts to dislike the individual they are supporting. It is often accompanied by a reduction in the sympathy and level of support provided. As Pembroke (2009) says, it is the “worst possible place a relationship can reach.” This phenomenon is characterised by “powerful negative feelings” that are felt towards a patient, but that are often ignored and avoided (Watts, 2004; p. 459). When working with an individual who provokes these strong negative feelings in us, it can be difficult to remain objective and can cause difficulties to arise as we continue trying to support them. Watts and Morgan (1994) identified different elements that contribute towards the alienation process, including staff-specific factors, patient-specific factors, their interaction and the care environment in general. These different components can trigger intense emotions that can be emotionally draining and significantly affect our work.
Despite the severe impact malignant alienation can have, in some cases resulting in fatal outcomes, it is a construct that is still largely excluded from the literature and from clinical practice (Watts, 2004; Pembroke, 2009). The unconscious feelings of aversion that we have towards our client may play out in our behaviour, for example serious neglect of our client’s needs (Watts & Morgan, 1994). Practitioners may feel disillusioned by their efforts to help the client, and consequently label them as hopeless or undeserving of their care. These responses can be spread to other staff members through the process of emotional contagion (Elvén, 2010), and can increase the likelihood of behaviours of concern occurring more frequently (McDonnell, 2019; Petitta et al., 2021). To look at a real-life example of this, we can consider BBC panorama’s coverage of Winterbourne view (Cafe, 2012). This case-study highlights how staff members’ dislike towards their clients resulted in malignant alienation and emotional contagion amongst staff. These in turn can be seen as contributory factors for the institutional neglect and abuse that took place. As practitioners, we are all vulnerable to malignant alienation but if we can become more aware of the process of malignant alienation and the significant effect it can have on our work, we can take proactive steps to avoid it altogether, and to manage it when it arises. This in turn will improve our own emotional well-being at work, and also have a positive impact upon the well-being of those we support.
Why Does Malignant Alienation Occur?
A number of factors have been identified in the literature that can contribute towards the process of malignant alienation. Some of these are universal factors that explain why people dislike others in their everyday lives, such as resenting an individual due to differences in their attitudes, beliefs or values, an apparent lack of cultural competency or personal habits that you find difficult to tolerate (Natwick, 2017). However, some factors that contribute to the process are more work-specific and are related specifically to the job. This may involve individuals overstepping boundaries or questioning your professional competence. In this article, the focus will be on some of the key factors that may contribute towards malignant alienation specifically from our field of work, which involves working with individuals with autism, intellectual disabilities and other neurodevelopmental conditions.