To Be Met as a Person

The Dynamics of Attachment in Professional Encounters

Una McCluskey

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367329303
• eBook ISBN:
  9780429923067
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This book presents a theory of interaction in adult life when the dynamics of careseeking and caregiving are elicited. It sets out a framework for thinking about the way adults interact with one another, particularly when they are anxious, under stress or frightened.

Chapter One
The dynamics of careseeking and caregiving

We are born with the expectation of being met as a person

(Sutherland, 1993)

Introduction

Every doctor, therapist, educationalist, social worker, organisational consultant, knows when an interview or session has ‘gone well’. They feel enlivened, energised and physiologically nourished in some way. Their whole system is involved, not just their emotional or intellectual capacities; it feels like a complete, what we call ‘good’, experience. Conversely, we have all experienced the opposite. We have had encounters, either as caregivers ourselves or we have approached someone for help such as a GP or consultant, and have come away dissatisfied and distressed. What are these dynamics about? Is there a correlation between the affect experienced by the person seeking help and the person approached for help? As therapists, educators, consultants or clinicians, how seriously should we take our experience of the encounter as an indicator of how successful the consultation was from the point of view of the person seeking help?

This book presents a way of understanding the interactions between professional caregivers and the people who come to them for help. It is directed at all those who provide therapeutic help to individuals or who have to negotiate and manage interviews with people when they are anxious or under stress, particularly when the nature of the consultation raises issues of threat to livelihood, health and well-being. A key concept presented in the book is that of goal-corrected empathic attunement (GCEA). Goal-corrected empathic attunement implies that when individuals approach others whom they consider have the resources, or access to the resources, to help them, the ensuing interaction is mutually regulated in ways that are experienced by both as either satisfactory or unsatisfactory. Satisfactory interactions are experienced when both parties achieve the goal of their respective, separate but interdependent instinctive biologically based systems of careseeking and caregiving.

The concept of goal-corrected empathic attunement (GCEA), which is described and presented in this book, has been developed within the context of psychotherapy. GCEA is also found in forms of caregiving outwith the context of psychotherapy. Indeed, one of the advantages of the theory of interaction being presented here is that it seeks to ground psychotherapy in psychological theories derived from other fields.

The aim of this book is to help us make sense of the feelings we have both when we are successful and we are unsuccessful in providing help for other people when they are in what one would describe as a ‘state’. It also addresses our own or others’ experiences of feeling frustrated and defeated by attempts to achieve a compassionate and intelligent response when we are frightened and anxious. The idea is to take the reader through some of the early research in psychotherapy which looked at just this issue. Such research provides the base for a close look at attachment theory and what extended attachment theory in particular suggests is going on between adults when they engage in careseeking/caregiving relationships. The central core of the book is a series of experiments that explore the role of empathic attunement in effective caregiving.

Many of us, whether or not we see ourselves in the role of caregiving, actually do perform that function when someone asks us for help. We may be parents, teachers, psychotherapists, counsellors, medical doctors, nurses, occupational therapists, physiotherapists, social workers, clergy, debt managers, organisational consultants, or members of the general public offering a service. When people are anxious and seek help what they need is a non anxious response that understands and acts on the nature of their request accurately, leaving them in a settled and satisfied state. All of us have observed when these encounters go smoothly and have marvelled at the skill of the caregiver involved. Some people seem to be naturally ‘good’ at responding to the various ways in which distress and anxiety manifest themselves; others clearly get involved or respond in ways which make matters worse, either by ignoring the distress, or becoming hostile and defensive.

This book sets out a framework for thinking about the way we interact with one another, particularly when we – or they – are anxious, under stress or frightened. At these times what we need is a response that puts us in touch with our competence to act; with our emotional, physical and intellectual capacity. A response which enables us to identify people we can rely on, as well as our spiritual, financial and aesthetic resources. And if we are severely incapacitated this response must also feel related to us, be sensitive, alert and responsible and above all focused on our well-being.

A person who is frightened will to some extent regress to an earlier stage of development; they will not be in touch with their full capacity in the here and now. They will also behave towards the person they are seeking help from in ways that are familiar and habitual to them and which may or may not work. This book will present ideas based on attachment theory, on research into infant and child development and on extended attachment theory that provide pointers for how adults will seek help when in crisis, frightened or in distress. The book will also present some preliminary research that provides some evidence for these views and provide pointers for future research.

From the viewpoint being presented in this book, adults who seek help when frightened, in pain or facing threat to their lives will adopt one of four typical stances: (i) they will have confidence in their strategies for getting help and be clear and direct in their communication; (ii) they will have no confidence that their needs will be addressed and attended to and so will only seek help in extremis and then in a way that minimises the extent of their problem, thereby giving inadequate information to the potential caregiver; (iii) they will be uncertain, half hopeful, half sceptical, and therefore communicate in contradictory and ambiguous ways; or (iv) they will be bewildered, unclear, uncertain and disorganised about the state they are in and what would relieve it, fearing any response could potentially make things worse, thus avoiding seeking help in the first place and being frightened/angry when in a caregiving context.

As caregivers, responding to these different strategies for getting help and the different forms of relating through which such strategies are mediated, is a challenge. Training offered to those involved in the medical, social, pastoral or psychotherapy professions rarely addresses the complexities of the form in which careseeking is expressed. Most professional training courses have counselling or skills-based laboratories or observed fieldwork practice as standard. However, this type of training mainly operates without a theory of interaction and without seeing the relevance of research into early careseeking and caregiving as laying down habitual, context-specific patterns of behaviour, and therefore relevant for understanding styles of careseeking and caregiving in adult life.

Typically taught to young professionals in training are the skills of listening, observing, clarifying, negotiating, empathy and goal-setting. However, these skills, divorced from an understanding of personality development and organisation and the dynamics aroused in the intimate act of helping another human being, fail to get to the heart of what one needs to learn: that the dynamics of caregiving and careseeking are highly complex, have their roots in early infancy and require an understanding in their own right. This is what this book addresses.

When I was in my early twenties, I accompanied my mother to see a consultant cardiologist in Fitzwilliam Square in Dublin, about the possibility of her having an operation to replace three malfunctioning valves. She came out from the consultation in considerable distress. From what I could gather she was told she was not ill enough to warrant the risk of the operation. She was very frustrated, depressed and in despair. I do not know whether she conveyed any of this to the cardiologist or whether he had any clue that she saw the operation as her only hope of survival and wanted to have it whatever her chances. From what I know of her she would have been polite, deferential and would have accepted his advice with good grace and a smile, would have thanked him for his time and paid his exorbitant fee. I had come from Scotland where I was working, and my mother had travelled at some inconvenience and distress from the south of Ireland to Dublin for this consultation. It lasted about twenty minutes. Neither of us thought to seek a further word on the subject, to go back into the building and discuss the choices and the risks of having the operation more fully. She died six months later aged fifty-five.

This is an account of a desperate attempt to get help in the light of an extremely dangerous medical condition. It is an example of both failed careseeking and failed caregiving. A more skilled careseeker may have negotiated that consultation better; a more skilled caregiver may have looked behind my mother’s elegant, well-dressed appearance and gentle manner and seen the desperation of a woman who felt she was losing control of her life. Part of my mother’s careseeking style was to support the other’s claim to know what was best; an effective caregiver in this instance would have had to have the skills necessary to deflect such flattery, to override the fragility of her physical appearance and tackle her directly about the risks she was willing to take.

Should caregivers fail to meet the needs of careseekers, the latter cannot reach the goal of careseeking, and commonly become frustrated and then depressed. What happens when each partner is failing to reach their goals, and what is happening to their careseeking and caregiving systems is increasingly being researched and understood in both non-human primates and in human beings.

(Heard and Lake, 1997, p.5)

It is with this arena of interaction, that between careseeker and caregiver that is the concern of this book.

In the early seventies, after qualifying in social work at Edinburgh University, I worked for five years in an innovative department of child and family psychiatry in Fife (Haldane et al, 1980). Staff in this department were either trained in psychodynamically oriented therapeutic work or were interested in such work. This meant that there was an emphasis on the meaning of the interactions taking place between therapists and clients. There was an interest in how clients were responding to the therapeutic interventions by the therapists and the impact of such interventions on the clients’ lives. The relationship formed between therapist and client was seen as a very important aspect of the work and probably a key factor in any meaningful change.

The relationship was understood to have meaning particularly for the client who was seeking help, and the therapist saw it as an integral part of their job to try and be as aware as possible of this aspect of the working relationship. Within a psychodynamic framework for working, attention was paid to the feelings that were aroused in therapists by their clients and thought was given to the possibility that these feelings may be unconsciously projected by the clients into the therapists as a way of communicating aspects of their experience too painful to know about, assimilate or put into words.

The work of the psychodynamically trained therapist is to be tuned into these affects and processes and to try to conceptualise their meaning. The psychodynamically trained therapist understands the process of ongoing therapeutic work to be the unravelling and working through of this material with the client in ways that make sense to the client and feel helpful. I was very interested in this work and both received and took part in providing psychodynamic supervision for staff, much helped by the writings of Michael Balint (Balint and Balint, 1961), Janet Mattinson (Mattinson, 1975) and Donald Winnicott (Winnicott, 1958a; Winnicott, 1971a; Winnicott, 1971; Winnicott, 1967; Winnicott, 1958b; Winnicott, 1971b). The clients we were working with were families where the children or adolescents were providing cause for concern either to their parents, school, GPs, or from other agencies, professionals such as probation officers or educational psychologists.

Even though the work was stressful and demanding, the department was a very satisfying place to work. The culture was thoughtful and reflective and the work was subject to constant study and research, much of which was written up. It was in this working context that I came across and worked with other social work colleagues dealing with the same client group. The point of contact was often over a referral of one of the families they were working with. It was striking how seemingly unaware they were of the emotional dynamics of the family and how little support there was for such understanding within the organisation that they worked for. It was equally noticeable that this lack of awareness seemed to affect their capacity to consider engaging the family in resolving their problems in the here and now.

My colleagues often seemed to respond by considering one of two alternatives: refer the family on to another department (such as ours) or place one or more of the children in residential or foster care. The emphasis on separating children from parents often coincided with a lack of awareness that the child and family needed to know what this separation was about, why it was happening, how long it would be for and whether and how they would all come together after the period of separation was over. The idea of the referral to another department, or the separation being part of a planned process that the social worker was overseeing, that had a beginning, a middle and an end that anticipated the post intervention period, was generally absent. Just as these social workers seemed blind to the meaning of relationships within families and the impact of separation on family members, so they seemed equally blind to the impact of their own behaviour on the families who came to social services for help.

They seemed to react to the pain and distress being presented to them by going into flight, a flight that put distance between themselves and the person seeking help rather than coming closer to the person or family to work at whatever needed to be done. It seemed hard for them to think that they or their behaviour might mean something to the families, or that they might have something to offer in the way of help with the family relationships.

This happened in the early to mid nineteen seventies. It highlights the difference between organisational structures which support the task of caregiving and which strive to understand the dynamics of careseeking and caregiving, and organisational structures that do not, and the effect of this on individual members of staff in terms of their response to complex emotions and behaviour. There have been several studies since which support this observation that organisational structures impact on professional functioning and well-being, and on the capacity of professional carers to collaborate effectively with colleagues and provide a relevant and thoughtful service for their clients. Examples are the work of Janet Mattinson and Ian Sinclair, (Mattinson and Sinclair, 1979; and others (Agass, 2000; Brearley, 2000; Woodhouse and Pengelly, 1986). These and other studies demonstrate the crucial importance of understanding the impact of emotionally difficult and disturbing work on the thought processes and behaviour of the professional carers involved.

At the level of policy, the importance of professional collaboration, interagency functioning and collaborative interdisciplinary training at pre- and post- professional qualification has been emphasised over the years in a number of government inquiries. The current green paper Every Child Matters (2003) aims to bring together health and social services staff in schools and local children’s centres. Government plans to set up children’s trusts by 2006 designed to amalgamate social care, health, education and other services are precisely in order to address the failures in communication between services that numerous inquiries, and more particularly that into Victoria Climbie’s death, have made so tragically clear. What all policies need to be watchful of, however, is that any attempt to improve interprofessional collaboration must be grounded in an understanding of the dynamics of communication between careseekers and caregivers in the first place; in a knowledge of the way emotions are communicated, registered and understood, and of the different ways in which professionals and others so quickly become defensive in the context of any form of communication which is infiltrated by anxiety.

Starting towards the end of the seventies and continuing through the eighties up to the present day, there has been a movement away from the idea that professional caregivers need certain conditions which support their work towards the idea that what is needed is more effective monitoring and clearer procedures. It has become as if good practice can be encapsulated in good procedures and the able practitioner need only follow them. The concept and practice of purchaser and provider in health and social services exemplifies this assumption, where the professional caregiver is bought to provide a tightly defined service within strictly defined time limits.

On a visit to a social services office in my capacity as consultant to a family therapy team I found the social workers completely demoralised; they were low in numbers in terms both of referrals to their service and in new recruits of staff to their team. Even their own regular members were attending their fortnightly meetings in haphazard fashion. Their description of their most recent reorganisation was that the teams were now so structured that they rarely met their colleagues from other teams; the office was dead at 5 p.m. in the evening, where previously they would have stayed on and chatted with their colleagues – they now do their work and go home.

The work was so compartmentalised, they told me, that before they saw a client they had to establish a contract for service with them by post and then wait for them to make the appointment at the office – home visits are a rarity. It could take three weeks or longer to actually make face-to-face contact with someone who has presented to the duty team in an emergency. Most self-referrals fall by the wayside – they did not show up for appointments and the view of the social work staff was that they were not responding quickly enough.

The sense of alienation from the core of their work, from direct contact with people wanting help was palpable. And of course what is obvious to the reader from the way this service is organised and delivered is that there is a complete absence of the idea (in the minds of the managers) that the dynamics aroused by careseeking might be worth taking into account and paying some attention to when organising a service, and that if careseekers are met by an impersonal response from potential caregivers it might well influence how they feel about pursuing their request for help. The experience that we had in the department of child and family psychiatry in Fife referred to earlier confirmed that clients sought help reluctantly, rarely followed through on first request for help and needed highly responsive staff who could effect home visits – otherwise these usually desperate people dropped from the sight of social workers, GPs and others. From what we now know of attachment behaviour, i...

Table of contents

• Cover
• Half Title
• Title
• Dedication
• Copyright
• Contents
• Acknowledgments
• Foreword
• Preface
• 1 The dynamics of careseeking and caregiving
• 2 Research on the process of interaction in adult psychotherapy
• 3 Infant/caregiver interactions: the process of affect identification, communication, and regulation
• 4 Patterns of careseeking/caregiving relationships: research into attachment behaviour in infants and young children
• 5 Presenting the concept of goal-corrected empathic attunement: effective caregiving within psychotherapy
• 6 First experiment: the identification of affect attunement in adult psychotherapy
• 7 Second experiment: is empathic attunement interactive?
• 8 Third experiment: an experiment designed to test whether secure attachment style correlates with empathic attunement and whether empathic attunement can be improved with training
• 9 The process of obtaining a reliable measure for goal-corrected empathic attunement
• 10 Results of the Third Experiment
• 11 Patterns of functional and dysfunctional careseeking-caregiving partnerships
• 12 Interactions between therapists and patients and their roots in infancy
• Appendix 1 Role play scenarios for day one
• Appendix 2 Measure of student attunement to be completed by the student after each interview
• Appendix 3 Measure of student attunement to be completed by the actor after each interview
• Appendix 4 Role play scenarios for day two
• References
• Index