1 comm2 core_theory_2014-2015__narration

Underpinning Theory of People in relationships

Underpinning Theory of People in relationshipsPerson Centred & Attachment TheoriesSarah Patrick: Leeds Met 20131

The BOND FrameworkBaughan & Smith (2013) Compassion, Caring & Communication. Skills for Nursing Practice. 2nd Ed, Harlow. Pearson Education. p155

Being & BecomingBeing a caring presence: ..ready to connect to and be available for patients, families and significant others....includes the opportunities to share with others in their search for meaning and hope. (p156)Being Empathic: seeing things from the other persons perspective.Becoming more emotionally intelligent & competent: ..we need to be more aware of and analytical about ourselves, recognising and learning from our own emotions and their effects. Becoming more emotionally intelligent allows us to become more caring by recognising the positive and negative effects of our emotional responses...[we can learn from our feelings and]..manage these emotions

Cues

Paraphrasing/Summarising

Reflection:ContentReflection:FeelingSkilled use ofQuestions

Doing this will show:Active ListeningInterest

How you do it shows:WarmthCollaborationWhich all demonstrates:EMPATHICUNDERSTANDINGPutting skills into Action

Scenario from PracticeThink about placement an incident, or experience, or something you witnessed with a patient/service user when you felt REALLY FRUSTRATED by something they said or did.Write a brief descriptionWhen was it? Where was it? What were you doing or trying to do? What was getting you all het up? What did they say or do? What did you say? What did you feel (as well as frustrated) and why? What were you thinking? Etc

HINT for your essay: this is where we start with all reflecting; a brief description.This is the WHAT? In Driscolls reflective model!

Part 1Person Centred Theory

Person Centred (Humanist) Perspective.In the view of humanistic psychologists there is in each and every one of us a humanity that is struggling to make itself known Mayhew (1997) Psychological Change. Basingstoke. Palgrave

Patient/Service User is not seen as passive in need of expert helpEmphasises personal choice one size does not fit all! Belief that the patient/service user has inner resources for changeSarah Patrick: Leeds Met 20137

7Everything to do with human nature

Person Centred TheoryActualizing Tendency: the one natural motivational force of all human beings; to expand, extend, be autonomous, mature and develop into adults who can successfully function within the wider world.We are all being the best we can be.Depends on our experiences and what we have learned to this date.Depends on our relationships with those that socialised us as we grew up.Sarah Patrick: Leeds Met 20138

Person Centred TheoryPositive Regard: without this, our actualizing tendency can become thwarted. Need for positive regard is so strong, child will seek it whether it is conditional or unconditional.Any attention is better than no attention at all.Looking for love but we might not find it!Learn to be different to who we really are as a way of trying to get it.....

Person Centred TheoryConditions of worth: operate against actualizing tendency. A child takes in from adults around these messages and develops a conditional positive regard; i.e. They only feel they have value (or will be loved/approved of) if they live up to these conditions. Some examples might be:I must do as Im toldI must make sure other people are happyI must work hard It is wrong to be angryI must put people other people first as I should not be selfishIt is weak to cryGirls are not as important as boys

Person Centred TheorySelf Concept: The subjective view and belief of the person from within themselves which develops over time. Depends on level of PR and conditions of worth. Can be positive or negative; e.g.I am not intelligent enough or academic enoughI am not loveableIn order to be liked I must .....Other people deserve this more than me...It might be different deep down to what it seems on the surface

Application to ScenarioActualising Tendency: what do you experience the person to be like? What has s/he not learned to do in life? What have YOU not learned to do in life?Positive Regard: how might this person have learned to get attention? What are the challenges for you in keeping this person in positive regard? Was there something that you or someone else was fdoing that meant the patient had to up the ante?Conditions of Worth: what beliefs about themselves might they believe?Self Concept: what is your theory about their self concept based on the above? How might that leave them feeling about themselves and in relation to other people?HINT for your essay: this is the start of the So What? part of Driscolls reflective model and is when you start to analyse the situation!

Core Conditions of Person Centred Theory for NursingCongruenceEmpathyUnconditional Positive Regard (UPR)

Sarah Patrick: Leeds Met 201313

CongruenceSometimes referred to as genuineness, authenticity or transparency.Congruence relates to the ability of the practitioners to be a real person in the helping situation. That is to say that the helper is not wedded to the idea of being the expert and does not assume a superior position in relation to the patient. Freshwater. D, (2003) , Counselling Skills for Nurses, Midwives and health Visitors P21. Berkshire. OU Press.


UPRThe patient is seen as being the best or healthiest they can be at this moment in time (Haugh 2008:41)UPR reflected in empathic understanding and the way we are with patients.Might not always feel accepting danger is when we are NOT AWARE of being judgemental.


EmpathyEmpathy is understanding the patients frame of reference and way of experiencing the world. It is close to 'perspective taking.Empathy is the sensitive ability and willingness to understand another person's thoughts, feelings and struggles; from their point of view. It is the ability to see through the other person's eyes, and to understand their frame of reference,It is COMMUNICATING THIS to the other person.


What Empathy is NOT ?NOT EMPATHY: Ways We Disconnect with Feelings & NeedsSYMPATHY: Bring attention back to yourself. Oh, I am so sorry, I feel terrible for you.ADVICE: We assume the person needs information. Well, what you could do is. . . .EXPLAIN / ANALYZE: We believe we know why someone feels the way we do and think knowing why will change their feeling state. Youre just feel bad because . . . CORRECT: We try to point out someones mistake in interpreting. He didnt do that to hurt you, he was just in a hurry.CONSOLE: It will be okay. Youre okay, everything will work out.TELL A STORY: The same thing happened to me. This one time . . .PUSH AWAY FEELINGS: We might be uncomfortable so we tell others not to feel what they feel. Come on smile, dont be sad. Just calm down and take a deep breathINVESTIGATE / INTEROGATE: Why did you do that? What made you feel that way?EVALUATE: We decide if anothers emotional response is appropriate or not. You are over reacting. This is no big deal.EDUCATE: What I see about the situation is . . . The reason you feel like that is. . . ONE-UP: Thats awful, but something even worse happened to me and I was devastated.DIAGNOSE: Sounds like you had a panic attack. I know some good herbs for anxiety.DEMAND: If you dont get control of your emotions, Im leaving!DENIAL OF CHOICE: Its a hard thing, but we all have to do it.NOD & SMILE: You feel uncomfortable and just want to get out of the situation.Created by LaShelle Charde' Wiseheart Training & Counseling www.wiseheartpdx.org


Interpersonal Theory (Harry Stack-Sullivan)How we interact with others will directly affect how they interact with us.This leads to a self sustaining and reinforcing system. This is done through negotiation of verbal and non-verbal cues. This is described as the Self system (Harry Stack Sullivan), and it protects us from information that would cause you to reevaluate self perception.We do this through the process of selective inattention.

Sarah Patrick: Leeds Met 201318Interpersonal Complimentarity

Part 2

Attachment TheoryThe unconscious dynamicSarah Patrick: Leeds Met 201319

Who are we? And how did we become us?Regardless of theoretical position, the reality is that the only way children can know themselves is through the responses of those near to them. If early responses are primarily positive, consistent, and confirming, or as Winnicott (1960) described, good enough, then children are comforted and can grow in a world without overwhelming anxiety (Gallop & OBrien (2003) p218)Gradually they will feel the world is safe, people are trustworthy and they are ok.Sarah Patrick: Leeds Met 201320We are still exploring the So What?

The UnconsciousBeyond the reach of voluntary recallRepository for socially unacceptable ideas, wishes, desires, traumatic memories or painful emotionsConsciously we can attend to 5-9 items at a time. The unconscious processes the restInfluences our communications and behaviours & can therefore only be recognised by its effectsCannot be altered by argument, negation or contradictionDoesnt respond to conscious logic


EvidenceSomething creates the dreams we experience in sleepMemory is unconscious remembering something means it has moved into consciousnessInstincts; defence and sexual arise at unconscious levelSubliminal perception tuning out of every impulseHypnosis and tranceCause of emotionsLanguage and speech


Things that happen in the Unconscious in relationships..There are 4 critical components to this:Relational style Repeating patternsReliving in the present Defence mechanisms


Relational Style: John Bowlbys Attachment Theory..human beings of all ages are happiest and able to deploy their talents to best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties arise. The person trusted, also known as an attachment figure, can be considered as providing his (or her) companion with a secure base from which to operate (Bowlby 1979 The Making and Breaking of Affectional Bonds Routledge. London. P 103)Sarah Patrick: Leeds Met 201324

Attachment Theory

Young infants instinctively seek proximity to their primary caregiver due to the evolutionary advantage that this safety providesIf older infants feel secure they will be willing to explore their environment and begin to separate from the motherAs infants mature they develop cognitive models of their relationships with their primary caregivers and these then guide behavior throughout lifeAttachment styles can be passed down through generations due to parenting behaviors that are guided by the attachment styleSarah Patrick: Leeds Met 201325

25 note the emotional component to this - security includes positive emotion. Facing a threat and not being protected by caregiver induces anxiety. Reliability of caregiver matters - if you cant count on them then its not a secure base

Attachment Styles

What do we mean by security?The Secure Base:Literal our care-givers and our experience of being cared forRepresentational our models of attachment and relationship with people i.e. how weve learned to be in relationshipsLeads to us feeling the world is safe, people will be there for us if we need them, they are reliable, caring and understanding and can cope with our hurt, distress and upset as well as out happiness and joy.We can therefore feel warm toward others and allow ourselves to feel close, soothed and safe in the knowledge all will be well.Sarah Patrick: Leeds Met 201327

Difficulties in early attachment will influence later attachmentsAttachments are stable over time can be seen in our Internal Working Models (IWM)Early parental responsiveness and accessibility is critical to how we learn to organise and regulate our emotional experiencesOur attachment figures are how we learn to be with people and be in the world and how we deal with stress in life (including illness and disease).


Emotional regulationIn times of stress/distress the infant displays behaviour to elicit proximity of AFAF needs to do 2 things:Deal with the cause of distressDeal with the experience of emotionThe sensitive AF tunes in to the child's affect (physical feeling, psychological feeling and facial expression) in order to soothe.Infants signals are recognised, read and responded to appropriately.Soothing leads to reduction of cortisolAlso about positive experiences: play, singing together etc. all help the infant think about and deal with stress.Enjoyment leads to release of endorphins.Sarah Patrick: Leeds Met 201329

Attachment figure responsesResponsiveness to distress leads to;An ability to regulate distressAdopt strategies and behaviours to help us do this (i.e. seek out comfort and support)The development of a secure attachment styleInsensitive or inconstant response to distress will lead to;Association of distress with aversive consequences (e.g. rejection, denial or violence)Belief that seeking comfort and support is dangerous and causes painThe development of insecure attachment styles.Sarah Patrick: Leeds Met 201330

Attachment StylesAvoidant (or Dismissive):Suppression of attachment needs in order not to risk rejection/painAmbivalent (or Anxious):Cling to attachment figure for fear they would otherwise reject/cause painSecure:Recognition of attachment needs and confidence these can be met.


We are still exploring the So What?

Avoidant / dismissingAFs reject overtures of need:Experienced as rejectingChilds distress leads to AF feeling annoyance, anger, upset.Displays of attachment therefore lead to rebuke, dismissal, denial or worse.Child learns to OVER-REGULATE FEELINGSNot to demand & contain feelingsNot to communicate distress or show vulnerabilityNeed to experience extremely high arousal before seeking attachmentIWM:Self is unloved/unlovable though need to be self reliantOthers are rejecting, unloving, intrusive and predictably unavailable (consistently unresponsive)Sarah Patrick: Leeds Met 201332

Avoidant / dismissing:In relationships.....Fear rejectionNeed to achieve in order to feel acceptedFeel uncomfortable around emotionLack close supportive relationshipsBottle things up, outwardly composedTry to control emotion => anger, obsessive, compulsive naturesExperience a range of somatic symptoms and sleep problemsDont cope well and will deny feelings re loss: grieving may not get startedSarah Patrick: Leeds Met 201333

Anxious / ambivalentAFs are insensitive, unreliable and inconsistently responsiveExperienced as unknown: sometimes OK sometimes notDistress sometimes recognised and responded to but sometimes notChild learns to UNDER-REGULATE FEELINGS Maximise and exaggerate in the hope of eliciting AF responseOverplay the need for attachmentIWMSelf is of little worth, ineffective and dependentOthers are insensitive, depriving, neglecting, unpredictable and unreliable


Anxious / ambivalent:In relationships....Poor ability to regulate feelingsAbility to reflect on self is diminishedFeelings therefore acted out and not managed.Rumination and anxiety commonChronic low self esteem and passivity: prone to feeling helpless, depressed and ineffectiveFear disapproval and abandonmentSarah Patrick: Leeds Met 201335

Three Category Measure of Attachment:

A. I am somewhat uncomfortable being close to others; I find it difficult to trust them completely, difficult to allow myself to depend on them. I am nervous when anyone gets too close, and often, others want me to be more intimate than I feel comfortable being.

B. I find it relatively easy to get close to others and am comfortable depending on them and having them depend on me. I don't worry about being abandoned or about someone getting too close to me.

C. I find that others are reluctant to get as close as I would like. I often worry that my partner doesn't really love me or won't want to stay with me. I want to get very close to my partner, and this sometimes scares people away. Hazan and Shaver (1987)


Repeating PatternsAre seen when an individual repeats relationship patterns e.g.; here I am again, I dont know why I keep doing this people always do this to me etcCan ..cause dismay when we see it in our friends and despair when we see it in ourselves (Kahn 2001 p25)Understood as an unconscious attempt to get it right this time undo what was done before.Unwillingly people seek out significant people, familiar behavioursSarah Patrick: Leeds Met 201337

Because of our maps of the world

And our attachment styles

Repeating PatternsA way of understanding how past hurts, including early environments that interfered with or failed to support healthy development, can be manifested as problems in the presentThe problematic relational patterns can often be re-experienced and acted out when a person is in distress or pain

Sarah Patrick: Leeds Met 201338If its happening with you....It will be happening with others....Because its based on relationships in the PAST

Transference

Sarah Patrick: Leeds Met 201339TransferenceCountertransference

Transferencetransference is not the development of new feelings, rather it is a rerun of what already exists for the individual unconsciously (Schroder 1985 p21)Principles laid down in childhood influence subsequent responses in adulthood and the presentTriggered by a specific characteristic of another person, their role or the setting in which the interaction occursSarah Patrick: Leeds Met 201340

Defense MechanismsHabitual, unconscious and sometimes pathological mental processes, used to prevent the re-emergence of unacceptable material into the conscious they defend against pain and hurt.They can also be healthy mechanisms!!!Unconscious defenses.. operate ..like circuit breakers. When the current gets too great, the increase in amperage trips the circuit breaker which breaks the circuit, and the lights go off. (Blackman 2004 pxiv)


Common Defense Mechanisms Projection = attribute to another your own affect, impulse or wish. This distorts how you see the other. Denial = your mind does not pay attention to reality as the affect is too painful or full of conflictDisplacement = you have a feeling toward one person but actually experience it toward another.Splitting = unacceptable aspects of self are split off and not acknowledged- world seen as good or badSublimation = you channel unacceptable feelings into socially acceptable activities.Rationalisation = you make socially acceptable explanations that justify behaviour but which are based on unacceptable motives.


Application to ScenarioWhat is your theory about this persons attachment style?What do you think their internal working model (or map of the world) is like?How did you feel in relation to them? Does this give you a clue to how they might be in relationships generally?Might there have been some transference going on either towards you from them, or from you towards them (counter-transference)?HINT for your essay: this is the start of the So What? part of Driscolls reflective model and is when you start to analyse the situation!

Reflection on LearningHow have you found the process of taking the theory and applying it to your scenario?What key things have you learned about the scenario as a result of this?Why are these so significant?What conclusions have you drawn?What actions would you take in a similar situation in the future?HINT for your essay: this is the start of the NOW What? part of Driscolls reflective model and is when you start to identify learning and what action you would take in the future.

Health & Medicine

1 comm2 core_theory_2014-2015__narration