Tensions between personal and professional identities

Staff in mental healthcare and penal settings are advised to operate with neutrality, to dress and behave professionally, and not to ‘bring themselves’ to work. Nevertheless, the ‘person’ is the first thing patients notice about their therapists: appearance, general manner, age, gender, disability, weight, height, skin colour, dress and hairstyle are ‘all mutually assessed at some level before any words are spoken’ (Reference Scaife, Walsh and ScaifeScaife 2001a: p. 39).

Professionalism is, of course, essential, but can belie the impact of operating in settings where power and hierarchy are defining features of the organisation, and the working conditions can be traumatic:

What can happen to staff exposed to such pressures? Significant emotional stress can over-flow into their personal lives and can create fears even within their families (Reference Bowers, McFarlane and KiyimbaBowers 2000). Repeated encounters with disturbing material at work can have an impact on choices beyond work: how people dress, conduct themselves, the relationships they form or avoid, and how they raise their children. Collaboration in the workplace flounders where differences between staff members’ responses exist and, crucially, are not safely explored. Some common patterns in the ‘interpersonal dance’ (Reference Duggan, Newrith, Meux and TaylorDuggan 2005) between patients with personality disorder and staff are outlined below.

The pull to punish

People-centred occupations are intrinsically stressful (Reference CoffeyCoffey 1999). Staff working with patients who have been violent are likely to be concerned about being the recipient of attacks and of being identified as aggressors (Reference DoctorDoctor 2008). Some therapeutic practices, such as large community meetings, can be experienced by staff as ‘too risky’ (Reference Moore and FreestoneMoore 2006). Interactions which alter or flatten the balance of power between staff and patients can generate a tendency to overcontrol in staff who are anxious about losing power. Bullying, intimidation and assaults on patients by staff have been associated with circumstances in which there are no safeguards on imbalances of power, and the majority operate in collusion with a custodial regime (Reference Blom-CooperBlom-Cooper 1992; Reference Fallon, Bluglass and EdwardsFallon 1999).

Obviously, a workforce needs to feel confident and skilled in managing high-risk situations effectively. Staff who are well trained in the management of violence describe the experience of feeling physically safe in the presence of patients with personality disorder, yet emotionally vulnerable (Reference Kurtz and TurnerKurtz 2007). Hence, physical security is only part of the task of the service overall: the emotional world of the unit cannot be ignored.

Displacement and ‘acting out’ of distress

‘Acting out’ is an analytic phrase which implies the non-conscious and unplanned behavioural ‘acting out’ of intolerable feelings, impulses and beliefs, without the capacity to contain or manage those in other ways. It should not be confused with the sort of performance that an actor consciously engages in as part of a pre-determined role.

In the ‘culture’ of personality disorder services, it may still covertly be deemed unprofessional to admit to having or expressing personal feelings or emotions about patients’ actions and, perhaps even more so, about the response of colleagues to challenging behaviour. If this is the case, then emotions can be dislocated or transposed and reattached to another idea (Reference VaillantVaillant 1994). Frontline staff in a range of settings who are interviewed about job-related stress more often implicate working conditions and organisational pressures as more problematic for them than contact with patients (Reference KurtzKurtz 2005). It is possible that it is much easier to transfer (displaced) feelings of anxiety and frustration onto concrete external issues than give voice to emotions about patients.

Personal reactions may be masked as professional opinions. The term ‘splitting’ is common parlance within multidisciplinary teams struggling to contain divergent views about how best to respond to challenging behaviour. Mirroring the primitive defence mechanism, through which ‘good’ and ‘bad’ objects are set in opposition, a patient’s behaviour can provoke different members of the team to ally to a greater or lesser extent with one another either in defence of or in opposition to the patient.

If there is a discrepancy between a personal reaction to behaviour (e.g. serious self-harm/shock and anger) and a professional intervention (calm and neutral), how does it get resolved? Reference Norton and DolanNorton & Dolan (1995) have illustrated the process by which ‘many psychiatric hospitals are in effect, like acting out patients, in that they tend to display only a narrow repertoire of relatively inflexible responses’ to distress. Acting out in the context of Cluster B personality disorder is a process through which the direct behavioural expression of an unconscious wish/conflict allows the individual to remain unaware of the idea/emotion that the action accompanies.

Acting out serves two functions: expressive (communicating intense and urgent need) and defensive (preventing the destruction of integrity) (Reference CamplingCampling 1996). Staff who are experienced in working with people with personality disorder typically recognise the behavioural component of acting out as a surface marker of a concurrent emotional problem, but even so, such actions can impair collaboration.

Those not immediately involved with the patient (but perhaps with responsibilities such as supervisors and managers) can also evidence intense reactions. The more frustration staff experience, the more the patient acts out and stalemate can ensue (Reference Norton and DolanNorton 1995). Regulation of affect, acknowledgement of the need for staff and patients to vent emotion, and adherence to relationship roles, create the security that is essential for therapeutic responses when patients are both distressed and highly distressing in the actions they undertake (Reference AdsheadAdshead 2002).

Complex and damaging repetitions

Individuals who were traumatised within their family environment are vulnerable in terms of the long-term maladaptive effect of their reaction to the trauma, and their reduced resilience in the face of it (Reference Fonagy and TargetFonagy 1997). Lack of resolution of abusive experience, often via inhibition of reflective functioning, reduces the likelihood of forming meaningful and successful adult relationships (Reference McGauley, Rubitel, Newrith, Meux and TaylorMcGauley 2006).

Unresolved distress is communicated via uncomfortable feelings that carers experience and through behavioural re-enactments of past traumatic experiences. Staff actions/interpersonal styles often trigger such conflict re-enactments through the process of ‘projective identification’ (whereby ‘bad’ feelings, impulses and beliefs are projected onto staff, who experience the patient’s emotions as their own). For example, a frightened patient may consider his named nurse to be persecutory and be unusually hostile towards her (due to fear), while the named nurse experiences her patient as frightening. Staff may find themselves subjected to the hatred and rejection that patients were exposed to in earlier circumstances (Reference Neeld, Clark, Aiyegbusi and Clark-MooreNeeld 2009). The challenge of distinguishing which feelings belong to whom, when and possibly why, is essential to the building of psychotherapeutic alliances, especially in forensic settings (Reference Aiyegbusi, Jeffcote and WatsonAiyegbusi 2004).

Boundary violations

The experience of a therapeutic alliance can trigger in patients an ‘aching awareness’ (Reference CamplingCampling 1996) of the extent of former neglect and loss, and frantic demands for staff time can be the consequence. This often materialises (and can become dangerous) at breaks or terminations in therapeutic contact. At such times patients may draw on contact-maintaining activities (e.g. threats to self-harm), and/or further seek ‘concrete evidence’ (e.g. a sign of commitment or a declaration of intimacy) of attachment from staff (Reference CamplingCampling 1996). This does not mean that therapy is necessarily contraindicated, but that attachment-related distress must be anticipated. If the capacity for mentalisation in close relationships (i.e. the understanding of behaviour in terms of the associated mental states in self and others) is not recovered in therapy, change is unlikely. Patients with borderline personality disorder have been shown to be particularly vulnerable to side-effects of individual sessions that activate their attachment systems (Reference Fonagy and BatemanFonagy 2006).

Feeling attraction or love for a therapist can be a normal part of therapy that requires a ‘working through’ by the patient within a healthy alliance (Reference DischDisch 1993). Ideally, the therapist also works through their negative and positive emotions towards the patient. However, difficulties arise if any eroticism of the transference or counter-transference becomes secret and acted upon. Although the most notorious boundary violations are sexual (and may initially be viewed as positive by both the member of staff and the patient), there are other types of boundary violations that are also harmful such as breaches of confidentiality and scapegoating.

An established author in this field, Reference GutheilGutheil (2005) cautions as to the need for ‘non-judgemental clarity’ in the area of boundary problems, given the ‘perils of confusion’. He distinguishes ‘boundary crossing’ (transient, non-exploitative deviations from ‘classical’/general practice that do no harm, and may even facilitate alliance) from ‘boundary violation’ (essentially harmful deviations from the normal parameters of treatment). One essential test of this distinction is whether the events in question can be discussed during therapy or supervision. ‘Explore before action’ is a useful recommendation for staff responses when working with people with personality disorder.

No discipline is immune to perpetrating misuses of professional power; neither gender nor seniority are necessarily protective factors. Any actions that meet the needs of the staff member rather than those of the patient are ethically unjustifiable (Reference Pope and VetterPope 1991; Reference PetersonPeterson 1992; Reference Thomas-Peter and GarrettThomas-Peter 2000). This is because such violations exploit power disparities and imbalance relations in favour of the more powerful (Reference Llewelyn and GardnerLlewelyn 2009).

The damage to patients of breaches in the professional duty of care is phenomenal, exacerbating loss of trust in carers, and extensive distress and isolation that may endure for many years (Reference DischDisch 1993; Reference Thomas-Peter and GarrettThomas-Peter 2000). Equally, the damage caused by boundary violations has an impact on the wider institution, undermining its capacity for effective treatment (Reference Gutheil and GabbardGutheil 2003).

Specific impacts on staff range from the experience of constant anxiety in the workplace to suspension and dismissal (with concomitant loss of job, status and income). Those who are witness to colleagues ‘crossing the line’ are likely to experience feelings of uncertainty about previous evaluations of their colleagues’ work, divided loyalties and moral distress (Reference Peternelj-TaylorPeternelj-Taylor 2003), such that the directive always to place the patient’s welfare above all other considerations can become difficult to follow (Reference Thomas-Peter and GarrettThomas-Peter 2000). All involved know that boundary violations are harmful, but they still occur.

Early detection of warning signs (‘red flag’ systems) is perhaps the best form of prevention: violations rarely happen ‘out of the blue’ (Reference GutheilGutheil 2005). Self-assessment checklists are available that promote self-monitoring for ‘blind spots’ in relational security (e.g. Reference LoveLove 2001). Slippages (behaviour that falls into the grey area between staying within or crossing boundaries) preceding violation are known to include overfamiliarity, inappropriate favouritism and the exchange of promises/gifts (Reference WebbWebb 1997; Reference Walker and ClarkWalker 1999). A lack of consequence for seemingly minor breaches decreases the likelihood of arresting toxicity in alliances before enduring harm has occurred (Box 4). The boundary seesaw model (Reference Hamilton, Tennant and HowellsHamilton 2010) supports a collective conceptualisation of boundaries in practice and generates clear guidelines for staff on how to relate in a balanced and professional way.

In summary, defensive attitudes and practices are known to obstruct therapeutic opportunities at every level of the institution (Reference Menzies LythMenzies Lyth 1960; Reference Norton and DolanNorton 1995). Conflict in professional relationships is inevitable, but the risk is higher in personality disorder services because, by definition, people with personality disorder have a compromised set of skills to enable them to handle distress safely. The context for the management of Cluster B personality disorder is often controlling and hierarchical, which gives rise to another layer of manipulation (and iatrogenic outcomes; Reference Fonagy and BatemanFonagy 2006; Reference JonesJones 2007). When patients and staff rely on (maladaptive) survival skills, this maintains potentially unhealthy relationships in systems that have the power to detain (Box 3). Policies on conduct (and what will happen in the event of misconduct) should be accessible to all.

Choosing staff who can ‘contain’

Who might be best suited to working with people with personality disorder? Such a question is of interest to anyone seeking to recruit motivated, secure and reliable colleagues. People may be attracted to such posts for a whole range of reasons, most of which, it has been suggested, pale into insignificance in the face of the dynamic processes that they will encounter in the workplace. Reference Scanlon, Adlam, Aiyegbusi and Clark-MooreScanlon & Adlam (2009) refer to the notion of ‘psychic survival’ as a key competence: conferring the ability to retain a clear sense of separateness, to be able to think your own thoughts while remaining functional and effective.

Similarly, Reference MadenMaden (2006) notes that different skills are required of staff working in personality disorder services than other mental healthcare services, and that the ability of staff to resolve conflict assertively might be a useful predictor of a future resilience in the role. Reference Thomas-Peter and GarrettThomas-Peter & Garratt (2000) recommend that staff who appear vulnerable to establishing unethical relations should not be selected for roles in forensic environments. This can be difficult to identify during a selection process, and may also change over the duration of a career. Relationship tensions outside the workplace can put staff at risk of emotional strain and potentially unhelpful self-disclosure, communicating mutuality rather than collaboration for treatment purposes (Reference Walker and ClarkWalker 1999). Procedures such as personal health checks, certainly pre-employment and regularly (annually) post-employment, have been proposed for staff in regular contact with patients with personality disorder (Reference LordLord 2003; Sainsbury Centre for Mental Health 2009).

A genuine interest in the work is likely to be a helpful starting place. The capacity to form secure attachments with others is also important, and has been associated with higher alliance ratings in psychotherapy services (Reference Eames and RothEames 2000).

Staff motivations and interests

Staff attitudes to their role as agents of help can make a difference to the nature and quality of the care patients receive. There is evidence that critical views about patients with enduring and complex disorders can change with psychoeducational training input (Reference Finnema, Louwerens and SlooffFinnema 1996; Reference Willetts and LeffWilletts 1997; Reference Hazelton, Rossiter and MilnerHazelton 2006). Specifically, attributions about the causes of behavioural problems are important in determining the emotional and behavioural responses of staff.

Experience is another factor, with less-trained staff being more critical and emotionally cold, with higher levels of expressed emotion (Reference Van Humbeeck and van AudenhoveVan Humbeeck 2003). Reference Dennis and LeachDennis & Leach (2007) report high expressed emotion in male healthcare support staff who endorsed elements of burnout including depersonalisation and low personal accomplishment. High expressed emotion is linked to less favourable outcomes for patients in forensic services with complex needs, including personality disorder (Reference Moore, Yates and MallindineMoore 2002). Views can shift considerably following experiences of assault: staff victims are more likely to express criticism and to reject patients in the immediate aftermath (Reference Cottle, Kuipers and MurphyCottle 1995).

Reference MothersoleMothersole (2000) highlights voyeuristic motivations, particularly in forensic units, whereby staff may gain a vicarious excitement/notoriety from their connection to certain offender patients.

Opportunities to learn about core competencies

‘Relational security’ is dependent on a multi-disciplinary workforce that can enhance and develop therapeutic programmes (Reference Exworthy and GunnExworthy 2003). Working as a newcomer in a personality disorder service is likely to be highly anxiety-provoking: the process of induction and the behaviour and attitudes of key mentors make an important contribution. From the outset, the tensions between security and care will be evident to inexperienced staff (who may find themselves swinging between inclinations to care v. reject, or seek to protect v. punish, operate with too much confidence v. hesitation) as they make sense of how to amalgamate complex information about the clinical task.

Longer-serving/senior staff are role models (Reference CrichtonCrichton 1998), and much therefore depends on the psychological health of the unit. Whole teams and organisations can become dysfunctional, so that the external world reflects grave and disabling splits in the patients’ internal world, in a ‘some staff good, most staff bad’ caricature (Reference Tuck, Aiyegbusi and Clark-MooreTuck 2009). Learning to operate with self-awareness might be considered a fundamental skill, a prerequisite for working with people with personality disorder.

What should the contents of a training package for staff on personality disorder units include?

Health, safety, violence and risk training are typically mandatory. Service users with personality disorder have recommended that training staff to develop empathy and understanding of personality disorder would also be a good start (Reference HaighHaigh 2002). Skills in treating others respectfully while under pressure to do otherwise should probably be a fundamental training goal: understanding personality pathology and the nature of change provides an essential foundation (Reference LivesleyLivesley 2005).

A formal introduction as to what constitutes inappropriate interaction (Reference Thomas-Peter and GarrettThomas-Peter 2000) and how to set and maintain boundaries are also core competencies. More complex interpersonal therapeutic skills including orientation to emotional availability for patients in distress (Reference ZeddiesZeddies 1999) typically demands longer post-qualification training. Knowledge of the service content is also important: what range of services is available to the patients? What is the contribution of (other) disciplines? What are the politics of the setting? (Reference ScaifeScaife 2001b: p. 249).

Training for staff must be well timed. For staff who appear ‘burnt out’ (‘I’ve seen all this before, they’ll never change, I’m basically here to pay the mortgage’), training may actually intensify such beliefs if mistimed. Extended contact with very slow-to-change populations can lead staff to identify with the hopelessness that patients encounter, and the ‘no-win’ position of offender patients in relation to the society that has excluded them (Reference Lowdell, Adshead, Aiyegbusi and Clark-MooreLowdell 2009). Conversely, a risk for well-intentioned staff might be that they are seen as overattentive, perhaps too ready to do things for patients, rather than helping them to accomplish their own goals.

Creating a context for boundaried practice: the clinical importance of supervision

No one can entirely process emotional reactions at the time of their occurrence, and people will vary in their preparedness and ability to acknowledge or express uncomfortable feelings. Sometimes services claim to promote safe expression of feeling, while in reality they stigmatise and discriminate against those who give voice to any struggles. The term supervision is often misused in this way: staff thought to be ‘at risk’ who are directed to attend ‘more supervision’ might see this as a form of discipline rather than as a resource for safe exploration and learning.

Clear therapeutic objectives and clinical supervision provide the framework within which alliances for change can be generated with patients. Supervisory relationships should either preclude the simultaneous existence of relationships or, where dual relationships pertain (e.g., with a line manager and a clinical supervisor), this should be acknowledged and the implications addressed (Reference ScaifeScaife 2001b: p. 45).

In essence, supervision refers to a range of key ideas (Reference ScaifeScaife 2001b) about how to provide support, reflective space and function, regulation of the supervisee and the establishment of the ‘limit[s] that promote integrity’ (Reference KatherineKatherine 1991). Empowerment of the supervisee is a key function of the supervisory alliance but is often poorly implemented in secure environments (Reference Storey and MintoStorey 2000). To managers less exposed to clinical challenges, supervision might be viewed as irrelevant to the task, ineffective, expensive and ultimately unavailable due to lack of good supervisors. Problems such as this must be addressed in any therapeutic service for patients with personality disorder. There are two primary aspects to supervision: (1) establishing and maintaining appropriate boundaries for professionals and services; and (2) attending to the needs (for safety, personal development, etc.) of the staff member.

Boundary setting and maintenance is therefore a key supervisory task often highlighted as lacking in the wake of enquiries (Reference Exworthy and GunnExworthy 2003). Boundaries must be regarded as flexible standards of good practice, the application of professional judgements, and not as rigidly adhered to lists of ‘generically forbidden behaviour’ (Reference HermanssonHermansson 1997; Reference Gutheil and GabbardGutheil 2003). Boundaries define relationships and roles. A good definition of the nature of ‘boundary’ in clinical practice is ‘the edge of appropriate professional contact’ (Reference GutheilGutheil 2005). Accepting boundaries implies that we acknowledge that ‘there are limits to what we can do, with whom and when, central to which are a commitment to non-exploitation of the other, and trust’ (Reference Llewelyn and GardnerLlewelyn 2009).

Boundaries are maintained, and limits set, by staff working in multidisciplinary teams via the communication of clear expectations about behaviour. Since exchanges between patients with personality disorder and staff can be ‘covert’ (Reference Duggan, Newrith, Meux and TaylorDuggan 2005), it is very important that staff have a safe place to describe and discuss how best to respond to such challenges. Certain useful strategies for maintaining boundaries are co-working, allocation of roles, and sharing the burden in demanding work (Reference Melia, Moran and MasonMelia 1999).

The role of supervision in maintaining ‘optimal’ working alliances

Supervision has a number of functions that are formative (lifelong learning and professional development), restorative (a space for support, shared understanding and acknowledgement of impacts), and normative (concerned with good practice standards). The supervisor’s role is to attend both to the actions and reactions of the staff member and team, and to the knowledge, feelings and qualities that influence the alliance with the patient. The aim of the process is to ensure the best possible practice whatever the context, and to enhance the staff members’ range and depth of clinical skills. Clinical supervision has been defined by Reference MothersoleMothersole (2000) as a ‘scheduled regular meeting in which a clinician meets with a fellow professional with the express purpose of examining their work’.

In the past, transfer to a colleague, team or service who could ‘stand’ the patient (Reference GrovesGroves 1978) was considered a solution to patients who engendered difficult feelings in professionals. Nowadays, treatment alliances in personality disorder services ideally involve a level of compassionate neutrality on the part of the professional. It is helpful (with the assistance of supervision) to process challenging events without excessive aggression, outrage, withdrawal or compliance. An understanding of the unconscious message of challenging behaviour has the potential to arrest vicious cycles of rejecting re-enactments.

Some patients with personality disorder will be unaware of their impact on others, but are nevertheless held accountable for it, as if they could/should do something about this. Rather, it must be the staff who provide the routes to repair ruptures in professional alliances as they develop. Staff should not expect to like or be liked by all patients (Reference Moran and MasonMoran 1996). Nevertheless, they must always treat all services users with respect (Sainsbury Centre for Mental Health 2009).

It is essential for patients with personality disorder to experience clinicians as personal, human and authentic (Reference SafranSafran 1993). As Reference Kraus and ReynoldsKraus & Reynolds (2001) put it, ‘the person in the clinician must meet the person in the patient’. The adoption of an inquisitive (not expert) stance enables staff to retrace steps in the interaction/series of encounters that have ‘gone wrong’, and to take the initiative in building and rebuilding bridges (Reference Fonagy and BatemanFonagy 2006).

Drawing on research involving others with serious and long-term mental health problems, Reference Repper, Ford and CrookeRepper et al (1994) describe how successful staff realise the need to balance ‘realism’ (taking a long-term perspective) with optimistic hope of change and growth, appreciating that, given the nature of the patients’ problems, recovery will be a fluctuating process.

Group approaches to supervision

Learning from incidents

During the early 1990s, the introduction of the serious incident review had the adverse effect of fostering a ‘blame culture’ in some quarters of the healthcare service (Reference Blumenthal and LavenderBlumenthal 2001; Reference RoseRose 2008). Analysis of errors (e.g. root cause analysis) generates knowledge, but sometimes at a cost: over the past decade, there has been an expansion in the formal management procedures for dealing with bad outcomes. If an incident has occurred, the inclusion of a range of staff, and the use of external facilitators, promotes the production of reports to operational boards, whose task is then to analyse the failure of the system as a whole.

Reference RoseRose (2008) has argued that good patient care is best served by the use of an inclusive review process that combines peer group front-line expertise with management inquiry skills. Untoward incidents in large organisations often have complex interrelationships and need to be reviewed in this light (Reference Vincent, Stanhope and Taylor-AdamsVincent 2000). Recent work on the dissemination of learning points from service incident reviews has highlighted how critical the process of communicating the findings is (Reference ThinnThinn 2010). Frequently, the learning cycle is incomplete because key points are not accessibly and specifically communicated to front-line staff.

Key events can have a profound impact on individual clinicians and their inclination or suitability to remain in post. The impacts of the work (ranging from reading forensic case- note material, being subject to verbal abuse or complaint, and/or suffering/witnessing a violent attack) and management handling of these occurrences, have all been articulated by staff working with people with personality disorder as areas of concern (Reference Bowers, McFarlane and KiyimbaBowers 2000). When incidents of crisis/acute distress in the clinical work occur early in the person’s career and are survived, this can enhance resilience. Senior managers have a responsibility to understand and anticipate the potential for these events, and to operate to minimise any ‘casualties’ of the process. All staff involved in any complaints or investigatory process should have access to (external) support (Reference Bowers, McFarlane and KiyimbaBowers 2000) (Box 5).

Evidence of the benefits of supervision: enhancing morale

As Reference ScaifeScaife (2001b) observes, supervision is not the ‘panacea for dealing with [all] work-related issues’. The aims and purposes of supervision may not be realised, and typically especially not for those most at risk of defaulting from the professional task. Equally, many of the functions of supervision can be achieved in other ways via less ‘formal’ relationships (over a cup of coffee) in the workplace. However, in support of its role, vital in modern, effective healthcare systems, there is evidence that supervision is associated with positive outcomes (Reference MilneMilne 2007).

The benefits of participation in clinical supervision can be highly significant: enhancing a sense of coherence and creativity, reducing job-related strain and increasing satisfaction (Reference Berg and HallbergBerg 1999). A number of factors contribute to rewarding, ‘happy’ work environments in mental healthcare (Reference Bowers, Allan and SimpsonBowers 2009): services that are well organised, that have clearly defined and consistently implemented policies (e.g. relating to abuse directed at staff), that educate and rotate their staff, and that see retaining a sense of humour as valued and essential (Reference Moran and MasonMoran 1996).

The positive impacts of working with individuals with personality disorder are rarely explicitly articulated. Even the work of the best-intentioned staff in a personality disorder service is likely to be replete with failures to retain impartiality. Being a therapist of a patient with borderline personality disorder is ‘to be acutely reminded that one is a human being’ (Reference Layden, Newman and FreemanLayden 1993). If staff feel secure in the support of colleagues, with a sense of purpose in their encounters, they stand some chance of accepting distress, sometimes responding with creativity, and structuring the relational environment such that those in their company might begin to do the same.

What could be more rewarding than that?