Category: Mental Health

What is Group Emotion?

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Introduction

Group emotion refers to the moods, emotions and dispositional affects of a group of people. It can be seen as either an emotional entity influencing individual members’ emotional states (top down) or the sum of the individuals’ emotional states (bottom up).

Top Down Approach

This view sees the group’s dynamic processes as responsible for an elusive feeling state which influences the members’ feelings and behaviour. This view, that groups have an existence as entities beyond the characters that comprise them, has several angles.

Effects on Individuals

One angle of this approach was depicted in early works such as Le Bon’s and Freud’s who reasoned that there is a general influence of a crowd or group which makes the members of the group “feel, think and act” differently than they would have as isolated individuals. The reassurance of belonging to a crowd makes people act more extremely. Also, the intense uniformity of feelings is overwhelming and causes people to be emotionally swept to join the group’s atmosphere. Thus, the effect of the group causes emotions to be exaggerated.

Norms

Another aspect of the group as a whole perspective sees the normative forces a group has on its members’ emotional behaviour such as norms for the amount of feelings’ expression and even which emotions it is best to feel. The group’s norms control which emotions would (or at least should) be displayed at a specific situation according to the group’s best interest and goals. The norms help differentiate felt emotions, what the individuals actually feel, from expressed emotions, what they display in the current situation. This perspective has practical implications as shown by researchers. Thus, according to this angle the group causes the emotions to be moderated and controlled.

Binding Force

Another perspective emphasizes the importance of emotional attraction in group settings. It defines group emotion as members’ desire to be together, and finds that emotional ties are a type of glue which holds groups together and influences the group’s cohesiveness and the commitment to the task. This perspective focuses on the positive emotions of liking the other group members and the task at hand.

Indicator

This perspective of the group as a whole approach studies the dynamic development of the group, from its establishment to its disassembly. Along the course the group changes in its interrelationships and interdependence amongst its members. These changes are accompanied by emotional processes which shape the outcome of the group. For instance, the midpoint in a group’s development is characterised by anxiety and anticipation about the capacity of the team to complete its goals, which drives teams to restructure their interaction patterns following the midpoint. Should the group harness these feelings and overcome the crisis stronger, its chances of completing the group’s goals are higher. In other cases, negative emotions towards members of the group or towards the task might jeopardise the group’s existence. This perspective sees the temporal changes of the emotions that govern the group.

Bottom Up

Contrary to the former approach, this approach views group-level emotion as the sum of its individuals’ affective compositions. These affective compositions are actually the emotional features each member brings with them to the group, such as: dispositional affect, mood, acute emotions, emotional intelligence, and sentiments (affective evaluations of the group). The team affective composition approach helps to understand the group emotion and its origins, and how these individual members’ affective predisposition combine to become one common entity. For the purpose of combining these individual characteristics, one can embrace several viewpoints:

Average Mood

Research has shown that by averaging the members’ dispositional affective tone it is possible to predict group-level behaviour such as absenteeism and prosocial behaviour. Also, when the average mood of employees was positive, it was positively related to the team’s performance.

Emotional Variance

Affective-homogenous groups are expected to behave differently from heterogeneous ones. The verdict is yet to be decided as to whether homogeneity is better than heterogeneity. In favour of affective homogeneity stand the notion that familiarity and similarity bring feelings of liking, comfort and positive emotions, and thus presumably better group outcomes and performances. It has long been found that people prefer to be in a group similar to them in many perspectives. A support for the positive effects of homogeneity can be found in a study that examined homogeneity in managers’ positive affectivity (PA) and its influence on several aspects of performance such as satisfaction, cooperation and financial outcome of the organisation. On the other hand, according to the view of opposites being beneficial, affective heterogeneity may lead to more emotional checks and balances which could then lead to better team performance. This was found to be true especially in groups where creativity is needed to complete the task appropriately. Homogeneity might lead to groupthink and hamper performance. It is necessary though for group members in heterogeneous groups to accept and allow one another to enact their different emotional roles.

Emotionally Extreme Members

Even if there is only one member in an otherwise averaged group which is extremely negative (or positive) in effect, that person might influence the affective state of the other members and cause the group to be much more negative (or positive) than would be expected from its mean-level dispositional affect. This mood shift might happen through emotional contagion, in which members are “infected” by others’ emotions, as well as through other processes. Emotional contagion has been observed even in absence of non-verbal cues, for example on online social networks like Facebook and Twitter.

Combining Approaches

The above approaches can be combined in a way that they maintain reciprocal relations. For instance, members bring dispositional affective states and norms for expressing them to the team. These components are then factors determining the creation of group norms, which may in turn alter the moods, feelings and their expression by the members. Thus, the top-down and bottom-up approaches coalesce along the dynamic formation and lifespan of teams.

Empirical Definition

One study compared the reports of team members to reports of outside-observers. It showed that team affect and emotions were observable by and agreed upon by outsiders as well as by members of the team interacting face to face. So, it is possible to identify the group’s affective tone by aggregating self-reports of members of the group, as well as by viewing the group from the outside and looking for emotional gestures, both verbal and nonverbal.

Affecting Group Emotion

Studies show that the leader of the team has an important part in determining the moods of their team’s members. Such that members of a team with a leader in a negative affective state tend to be more negative themselves than members of teams with a leader in a positive mood. However, any member of the group might influence the other members’ emotions. The leader may do so either by way of implicit, automatic, emotional contagion or by explicit, deliberate, emotional influence in order to promote his interests. Other factors that affect the forming of the group’s emotional state are its emotional history, its norms for expressing feelings and the broader organisational norms regarding emotions.

Influence on Performance

The emotional state of the group influences team processes and outcomes. For example, a group in a positive mood displays more coordination between members, yet sometimes the effort they apply is not as high as groups in a negative mood. Another role emotions play in group dynamics and performance is the relation between intra-group task-conflicts and relationship-conflicts. It is assumed that conflicts related to the task can be beneficial for achieving the goal, unless these task-conflicts lead to relationship-conflicts among the team members, in which case the performance is hindered. The traits that decouple task from relationship conflicts are emotional attributes such as emotional intelligence, intragroup relational ties, and norms for reducing or preventing negative emotionality. Hence aspects of group emotion affect the outcome. Other findings are that an increase in positive mood will lead to greater cooperativeness and less group conflict. Also, positive mood results in elevated perceptions of task performance.

Evolutionary-Psychological Perspective

According to the evolutionary psychology approach, group affect has a function of helping communication between members of the group. The emotional state of the group informs its members about factors in the environment. For instance, if everyone is in a bad mood it is necessary to change the conditions, or perhaps work harder to achieve the goal and improve the conditions. Also, shared affect in groups coordinates group activity through fostering group bonds and group loyalty.

Emotional Aperture

Emotional aperture has been defined as the ability or skill to perceive features of group emotions. Examples of features of group emotions include the level of variability of emotions among members (i.e. affective diversity), the proportion of positive or negative emotions, and the modal (i.e. most common) emotion present in a group. The term “emotional aperture” was first defined by the social psychologist, Jeffrey Sanchez-Burks and organisational theorist, Quy Huy. Analogous to adjusting a camera’s aperture setting to increase depth of field, emotional aperture involves adjusting one’s depth of field to bring into focus not solely the emotions of one person but also others scattered across a visual landscape. The difference between perceiving individual-level emotions versus group-level emotions is builds upon the distinction between analytic versus holistic perception.

What is Emotion Work?

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Introduction

Emotion work is understood as the art of trying to change in degree or quality an emotion or feeling.

Emotion work may be defined as the management of one’s own feelings, or work done in an effort to maintain a relationship; there is dispute as to whether emotion work is only work done regulating one’s own emotion, or extends to performing the emotional work for others.

Not to be confused with Emotional Labour and refer to Emotional Self-Regulation.

Hochschild

Arlie Russell Hochschild, who introduced the term in 1979, distinguished emotion work – unpaid emotional work that a person undertakes in private life – from emotional labour: emotional work done in a paid work setting. Emotion work has use value and occurs in situations in which people choose to regulate their emotions for their own non-compensated benefit (e.g., in their interactions with family and friends). By contrast, emotional labour has exchange value because it is traded and performed for a wage.

In a later development, Hochschild distinguished between two broad types of emotion work, and among three techniques of emotion work. The two broad types involve evocation and suppression of emotion, while the three techniques of emotion work that Hochschild describes are cognitive, bodily and expressive.

However, the concept (if not the term) has been traced back as far as Aristotle: as Aristotle saw, the problem is not with emotionality, but with the appropriateness of emotion and its expression.

Examples

Examples of emotion work include showing affection, apologizing after an argument, bringing up problems that need to be addressed in an intimate relationship or any kind of interpersonal relationship, and making sure the household runs smoothly.

Emotion work also involves the orientation of self/others to accord with accepted norms of emotional expression: emotion work is often performed by family members and friends, who put pressure on individuals to conform to emotional norms. Arguably, then, an individual’s ultimate obeisance and/or resistance to aspects of emotion regimes are made visible in their emotion work.

Cultural norms often imply that emotion work is reserved for females. There is certainly evidence to the effect that the emotional management that women and men do is asymmetric; and that in general, women come into a marriage groomed for the role of emotional manager.

Criticism

The social theorist Victor Jeleniewski Seidler argues that women’s emotion work is merely another demonstration of false consciousness under patriarchy, and that emotion work, as a concept, has been adopted, adapted or criticised to such an extent that it is in danger of becoming a “catch-all-cliché”.

More broadly, the concept of emotion work has itself been criticized as a wide over-simplification of mental processes such as repression and denial which continually occur in everyday life.

Literary Analogues

Rousseau in The New Heloise suggests that the attempt to master instrumentally one’s affective life always results in a weakening and eventually the fragmentation of one’s identity, even if the emotion work is performed at the demand of ethical principles.

What is Emotional Labour?

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Introduction

Emotional labour is the process of managing feelings and expressions to fulfil the emotional requirements of a job. More specifically, workers are expected to regulate their emotions during interactions with customers, co-workers and managers.

Not to be confused with Emotion Work and refer to Affective Labour.

Roles that have been identified as requiring emotional labour include those involved in public administration, espionage, law, caring for children, medical care, social work; roles in hospitality, and jobs in the media. As particular economies move from a manufacturing to a service-based economy, more workers in a variety of occupational fields are expected to manage their emotions according to employer demands when compared to sixty years ago.

Usage of the term has also been extended to refer to unpaid work that is expected interpersonally, such as taking care of organising holiday events or helping a friend solve their problems.

Definition

The sociologist Arlie Hochschild provides the first definition of emotional labour, which is displaying certain emotions to meet the requirements of a job. The related term emotion work (also called “emotion management”) refers to displaying certain emotions for personal purposes, such as within the private sphere of one’s home or interactions with family and friends. Hochschild identified three emotion regulation strategies:

StrategyDescription
CognitiveWithin cognitive emotion work, one attempts to change images, ideas, or thoughts in hopes of changing the feelings associated with them. For example, one may associate a family picture with feeling happy and think about said picture whenever attempting to feel happy.
BodilyWithin bodily emotion work, one attempts to change physical symptoms in order to create a desired emotion. For example, one may attempt deep breathing in order to reduce anger.
ExpressiveWithin expressive emotion work, one attempts to change expressive gestures to change inner feelings, such as smiling when trying to feel happy.

While emotion work happens within the private sphere, emotional labour is emotion management within the workplace according to employer expectations. Jobs involving emotional labour are defined as those that:

  • Require face-to-face or voice-to-voice contact with the public.
  • Require the worker to produce an emotional state in another person.
  • Allow the employer, through training and supervision, to exercise a degree of control over the emotional activities of employees.

Hochschild (1983) argues that within this commodification process, service workers are estranged from their own feelings in the workplace.

Alternative Usage

The term has been applied in modern contexts to refer to household tasks, specifically unpaid labour that is often expected of women, e.g. planning celebrations or having to remind their partner of chores. The term can also refer to informal counselling, such as providing advice to a friend or helping someone through a breakup. When Hochschild was interviewed about this shifting usage, she expressed that it made the concept blurrier and was sometimes being applied to things that were simply just labour, although how carrying out this labour made a person feel could make it emotional labour as well.

This modern use of the term had originally been introduced by non-professionals of the field and has therefore received criticism by medical and psychological professionals.

Determinants

DeterminantDescription
Societal, Occupational, and Organisational NormsFor example, empirical evidence indicates that in typically “busy” stores there is more legitimacy to express negative emotions than there is in typically “slow” stores, in which employees are expected to behave in accordance with the display rules. Hence, the emotional culture to which one belongs influences the employee’s commitment to those rules.
Dispositional Traits and Inner Feeling on the JobSuch as employees’ emotional expressiveness, which refers to the capability to use facial expressions, voice, gestures, and body movements to transmit emotions; or employees’ level of career identity (the importance of the career role to self-identity), which allows them to express the organisationally-desired emotions more easily (because there is less discrepancy between expressed behaviour and emotional experience when engaged in their work).
Supervisory Regulation of Display RulesSupervisors are likely to be important definers of display rules at the job level, given their direct influence on workers’ beliefs about high-performance expectations. Moreover, supervisors’ impressions of the need to suppress negative emotions on the job influence the employees’ impressions of that display rule.


Surface and deep acting foundational text divided emotional labour into two components:

  • Surface acting: Occurs when employees display the emotions required for a job without changing how they actually feel.
  • Deep acting: Is an effortful process through which employees change their internal feelings to align with organisational expectations, producing more natural and genuine emotional displays.

Although the underlying processes differ, the objective of both is typically to show positive emotions, which are presumed to impact the feelings of customers and bottom-line outcomes (e.g. sales, positive recommendations, and repeat business). However, research generally has shown surface acting is more harmful to employee health. Without a consideration of ethical values, the consequences of emotional work on employees can easily become negative. Business ethics can be used as a guide for employees on how to present feelings that are consistent with ethical values, and can show them how to regulate their feelings more easily and comfortably while working.

Careers

In the past, emotional labour demands and display rules were viewed as a characteristic of particular occupations, such as restaurant workers, cashiers, hospital workers, bill collectors, counsellors, secretaries, and nurses. However, display rules have been conceptualised not only as role requirements of particular occupational groups, but also as interpersonal job demands, which are shared by many kinds of occupations.

Bill Collectors

In 1991, Sutton did an in-depth qualitative study into bill collectors at a collection agency. He found that unlike the other jobs described here where employees need to act cheerful and concerned, bill collectors are selected and socialised to show irritation to most debtors. Specifically, the collection agency hired agents who seemed to be easily aroused. The newly hired agents were then trained on when and how to show varying emotions to different types of debtors. As they worked at the collection agency, they were closely monitored by their supervisors to make sure that they frequently conveyed urgency to debtors.

Bill collectors’ emotional labour consists of not letting angry and hostile debtors make them angry and to not feel guilty about pressuring friendly debtors for money. They coped with angry debtors by publicly showing their anger or making jokes when they got off the phone. They minimised the guilt they felt by staying emotionally detached from the debtors.

Childcare Workers

The skills involved in childcare are often viewed as innate to women, making the components of childcare invisible. However, a number of scholars have not only studied the difficulty and skill required for childcare, but also suggested that the emotional labour of childcare is unique and needs to be studied differently. Performing emotional labour requires the development of emotional capital, and that can only be developed through experience and reflection. Through semi-structured interviews, Edwards (2016) found that there were two components of emotional labour in childcare in addition to Hochschild’s original two: emotional consonance and suppression. Edwards (2016) defined suppression as hiding emotion and emotional consonance as naturally experiencing the same emotion that one is expected to feel for the job.

Food-Industry Workers

Wait Staff

In her 1991 study of waitresses in Philadelphia, Paules examines how these workers assert control and protect their self identity during interactions with customers. In restaurant work, Paules argues, workers’ subordination to customers is reinforced through “cultural symbols that originate from deeply rooted assumptions about service work.” Because the waitresses were not strictly regulated by their employers, waitresses’ interactions with customers were controlled by the waitresses themselves. Although they are stigmatised by the stereotypes and assumptions of servitude surrounding restaurant work, the waitresses studied were not negatively affected by their interactions with customers. To the contrary, they viewed their ability to manage their emotions as a valuable skill that could be used to gain control over customers. Thus, the Philadelphia waitresses took advantage of the lack of employer-regulated emotional labour in order to avoid the potentially negative consequences of emotional labour.

Though Paules highlights the positive consequences of emotional labour for a specific population of waitresses, other scholars have also found negative consequences of emotional labour within the waitressing industry. Through eighteen months of participant observation research, Bayard De Volo (2003) found that casino waitresses are highly monitored and monetarily bribed to perform emotional labour in the workplace. Specifically, Bayard De Volo (2003) argues that through a sexualized environment and a generous tipping system, both casino owners and customers control waitresses’ behaviour and appearance for their own benefit and pleasure. Even though the waitresses have their own forms of individual and collective resistance mechanisms, intense and consistent monitoring of their actions by casino management makes it difficult to change the power dynamics of the casino workplace.

Fast-Food Employees

By using participant observation and interviews, Leidner (1993) examines how employers in fast food restaurants regulate workers’ interactions with customers. According to Leidner (1993), employers attempt to regulate workers’ interactions with customers only under certain conditions. Specifically, when employers attempt to regulate worker-customer interactions, employers believe that “the quality of the interaction is important to the success of the enterprise”, that workers are “unable or unwilling to conduct the interactions appropriately on their own”, and that the “tasks themselves are not too complex or context-dependent.” According to Leidner (1993), regulating employee interactions with customers involves standardizing workers’ personal interactions with customers. At the McDonald’s fast food restaurants in Leidner’s (1993) study, these interactions are strictly scripted, and workers’ compliance with the scripts and regulations are closely monitored.

Along with examining employers’ attempts to regulate employee-customer interactions, Leidner (1993) examines how fast-food workers’ respond to these regulations. According to Leidner (1993), meeting employers’ expectations requires workers to engage in some form of emotional labour. For example, McDonald’s workers are expected to greet customers with a smile and friendly attitude independent of their own mood or temperament at the time. Leidner (1993) suggests that rigid compliance with these expectations is at least potentially damaging to workers’ sense of self and identity. However, Leidner (1993) did not see the negative consequences of emotional labour in the workers she studied. Instead, McDonald’s workers attempted to individualise their responses to customers in small ways. Specifically, they used humour or exaggeration to demonstrate their rebellion against the strict regulation of their employee-customer interactions.

Physicians

According to Larson and Yao (2005), empathy should characterize physicians’ interactions with their patients because, despite advancement in medical technology, the interpersonal relationship between physicians and patients remains essential to quality healthcare. Larson and Yao (2005) argue that physicians consider empathy a form of emotional labour. Specifically, according to Larson and Yao (2005), physicians engage in emotional labour through deep acting by feeling sincere empathy before, during, and after interactions with patients. On the other hand, Larson and Yao (2005) argue that physicians engage in surface acting when they fake empathic behaviours toward the patient. Although Larson and Yao (2005) argue that deep acting is preferred, physicians may rely on surface acting when sincere empathy for patients is impossible. Overall, Larson and Yao (2005) argue that physicians are more effective and enjoy more professional satisfaction when they engage in empathy through deep acting due to emotional labour.

Police Work

According to Martin (1999), police work involves substantial amounts of emotional labour by officers, who must control their own facial and bodily displays of emotion in the presence of other officers and citizens. Although policing is often viewed as stereotypically masculine work that focuses on fighting crime, policing also requires officers to maintain order and provide a variety of interpersonal services. For example, police must have a commanding presence that allows them to act decisively and maintain control in unpredictable situations while having the ability to actively listen and talk to citizens. According to Martin (1999), a police officer who displays too much anger, sympathy, or other emotion while dealing with danger on the job will be viewed by other officers as someone unable to withstand the pressures of police work, due to the sexist views of many police officers. While being able to balance this self-management of emotions in front of other officers, police must also assertively restore order and use effective interpersonal skills to gain citizen trust and compliance. Ultimately, the ability of police officers to effectively engage in emotional labour affects how other officers and citizens view them.

Public Administration

Many scholars argue that the amount of emotional work required between all levels of government is greatest on the local level. It is at the level of cities and counties that the responsibility lies for day to day emergency preparedness, firefighters, law enforcement, public education, public health, and family and children’s services. Citizens in a community expect the same level of satisfaction from their government, as they receive in a customer service-oriented job. This takes a considerate amount of work for both employees and employers in the field of public administration. There are two comparisons that represent emotional labour within public administration, “Rational Work versus Emotion Work”, and “Emotional Labour versus Emotional Intelligence.”

Performance

Many scholars argue that when public administrators perform emotional labour, they are dealing with significantly more sensitive situations than employees in the service industry. The reason for this is because they are on the front lines of the government, and are expected by citizens to serve them quickly and efficiently. When confronted by a citizen or a co-worker, public administrators use emotional sensing to size up the emotional state of the citizen in need. Workers then take stock of their own emotional state in order to make sure that the emotion they are expressing is appropriate to their roles. Simultaneously, they have to determine how to act in order to elicit the desired response from the citizen as well as from co-workers. Public Administrators perform emotional labour through five different strategies: Psychological First Aid, Compartments and Closets, Crazy Calm, Humour, and Common Sense.

Definition: Rational Work vs. Emotion Work

According to Mary Guy, Public administration does not only focus on the business side of administration but on the personal side as well. It is not just about collecting the water bill or land ordinances to construct a new property, it is also about the quality of life and sense of community that is allotted to individuals by their city officials. Rational work is the ability to think cognitively and analytically, while emotional work means to think more practically and with more reason.

Definition: Intelligence vs. Emotional Intelligence

Knowing how to suppress and manage one’s own feelings is known as emotional intelligence. The ability to control one’s emotions and to be able to do this at a high level guarantees one’s own ability to serve those in need. Emotional intelligence is performed while performing emotional labour, and without one the other can not be there.

Gender

Macdonald and Sirianni (1996) use the term “emotional proletariat” to describe service jobs in which “workers exercise emotional labour wherein they are required to display friendliness and deference to customers.” Because of deference, these occupations tend to be stereotyped as female jobs, independent of the actual number of women working the job. According to Macdonald and Sirianni (1996), because deference is a characteristic demanded of all those in disadvantaged structural positions, especially women, when deference is made a job requirement, women are likely to be overrepresented in these jobs. Macdonald and Sirianni (1996) claim that “[i]n no other area of wage labour are the personal characteristics of the workers so strongly associated with the nature of the work.” Thus, according to Macdonald and Sirianna (1996), although all workers employed within the service economy may have a difficult time maintaining their dignity and self-identity due to the demands of emotional labour, such an issue may be especially problematic for women workers.

Emotional labour also affects women by perpetuating occupational segregation and the gender wage gap. Job segregation, which is the systematic tendency for men and women to work in different occupations, is often cited as the reason why women lack equal pay when compared to men. According to Guy and Newman (2004), occupational segregation and ultimately the gender wage gap can at least be partially attributed to emotional labour. Specifically, work-related tasks that require emotional work thought to be natural for women, such as caring and empathizing are requirements of many female-dominated occupations. However, according to Guy and Newman (2004), these feminized work tasks are not a part of formal job descriptions and performance evaluations: “Excluded from job descriptions and performance evaluations, the work is invisible and uncompensated. Public service relies heavily on such skills, yet civil service systems, which are designed on the assumptions of a bygone era, fail to acknowledge and compensate emotional labour.” According to Guy and Newman (2004), women working in positions that require emotional labour in addition to regular work are not compensated for this additional labour because of the sexist notion that the additional labour is to be expected of them by the fact of being a woman.

Implications

Positive affective display in service interactions, such as smiling and conveying friendliness, are positively associated with customer positive feelings, and important outcomes, such as intention to return, intention to recommend a store to others, and perception of overall service quality. There is evidence that emotional labour may lead to employees’ emotional exhaustion and burnout over time, and may also reduce employees’ job satisfaction. That is, higher degree of using emotion regulation on the job is related to higher levels of employees’ emotional exhaustion, and lower levels of employees’ job satisfaction.

There is empirical evidence that higher levels of emotional labour demands are not uniformly rewarded with higher wages. Rather, the reward is dependent on the level of general cognitive demands required by the job. That is, occupations with high cognitive demands evidence wage returns with increasing emotional labour demands; whereas occupations low in cognitive demands evidence a wage “penalty” with increasing emotional labour demands. Additionally, innovations that increase employee empowerment – such as conversion into worker cooperatives, co-managing schemes, or flattened workplace structures – have been found to increase workers’ levels of emotional labour as they take on more workplace responsibilities.

Coping Skills

Coping occurs in response to psychological stress – usually triggered by changes – in an effort to maintain mental health and emotional well-being. Life stressors are often described as negative events (loss of a job). However, positive changes in life (a new job) can also constitute life stressors, thus requiring the use of coping skills to adapt. Coping strategies are the behaviours, thoughts, and emotions that you use to adjust to the changes that occur in your life. The use of coping skills will help a person better themselves in the work place and perform to the best of their ability to achieve success. There are many ways to cope and adapt to changes. Some ways include: sharing emotions with peers, having a healthy social life outside of work, being humorous, and adjusting expectations of self and work. These coping skills will help turn negative emotion to positive and allow for more focus on the public in contrast to oneself.

What is Emotional Self-Regulation?

Published on by Andrew Marshall6 Comments

Introduction

Emotional self-regulation or emotion regulation is the ability to respond to the ongoing demands of experience with the range of emotions in a manner that is socially tolerable and sufficiently flexible to permit spontaneous reactions as well as the ability to delay spontaneous reactions as needed.

Refer to Emotional Dysregulation.

Plutchik Wheel
Plutchik Dyads

It can also be defined as extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions. Emotional self-regulation belongs to the broader set of emotion regulation processes, which includes both the regulation of one’s own feelings and the regulation of other people’s feelings.

Emotion regulation is a complex process that involves initiating, inhibiting, or modulating one’s state or behaviour in a given situation – for example, the subjective experience (feelings), cognitive responses (thoughts), emotion-related physiological responses (for example heart rate or hormonal activity), and emotion-related behaviour (bodily actions or expressions). Functionally, emotion regulation can also refer to processes such as the tendency to focus one’s attention to a task and the ability to suppress inappropriate behaviour under instruction. Emotion regulation is a highly significant function in human life.

Every day, people are continually exposed to a wide variety of potentially arousing stimuli. Inappropriate, extreme or unchecked emotional reactions to such stimuli could impede functional fit within society; therefore, people must engage in some form of emotion regulation almost all of the time. Generally speaking, emotion dysregulation has been defined as difficulties in controlling the influence of emotional arousal on the organisation and quality of thoughts, actions, and interactions. Individuals who are emotionally dysregulated exhibit patterns of responding in which there is a mismatch between their goals, responses, and/or modes of expression, and the demands of the social environment. For example, there is a significant association between emotion dysregulation and symptoms of depression, anxiety, eating pathology, and substance abuse. Higher levels of emotion regulation are likely to be related to both high levels of social competence and the expression of socially appropriate emotions.

Theory

Process Model

The process model of emotion regulation is based upon the modal model of emotion. The modal model of emotion suggests that the emotion generation process occurs in a particular sequence over time. This sequence occurs as follows:

  1. Situation: the sequence begins with a situation (real or imagined) that is emotionally relevant.
  2. Attention: attention is directed towards the emotional situation.
  3. Appraisal: the emotional situation is evaluated and interpreted.
  4. Response: an emotional response is generated, giving rise to loosely coordinated changes in experiential, behavioural, and physiological response systems.

Because an emotional response (4.) can cause changes to a situation (1.), this model involves a feedback loop from (4.) Response to (1.) Situation. This feedback loop suggests that the emotion generation process can occur recursively, is ongoing, and dynamic.

The process model contends that each of these four points in the emotion generation process can be subjected to regulation. From this conceptualisation, the process model posits five different families of emotion regulation that correspond to the regulation of a particular point in the emotion generation process. They occur in the following order:

  1. Situation selection.
  2. Situation modification.
  3. Attentional deployment.
  4. Cognitive change.
  5. Response modulation.

The process model also divides these emotion regulation strategies into two categories:

  • Antecedent-focused strategies (i.e. situation selection, situation modification, attentional deployment, and cognitive change) occur before an emotional response is fully generated.
  • Response-focused strategies (i.e. response modulation) occur after an emotional response is fully generated.

Strategies

Situation Selection

Situation selection involves choosing to avoid or approach an emotionally relevant situation. If a person selects to avoid or disengage from an emotionally relevant situation, he or she is decreasing the likelihood of experiencing an emotion. Alternatively, if a person selects to approach or engage with an emotionally relevant situation, he or she is increasing the likelihood of experiencing an emotion.

Typical examples of situation selection may be seen interpersonally, such as when a parent removes his or her child from an emotionally unpleasant situation. Use of situation selection may also be seen in psychopathology. For example, avoidance of social situations to regulate emotions is particularly pronounced for those with social anxiety disorder and avoidant personality disorder.

Effective situation selection is not always an easy task. For instance, humans display difficulties predicting their emotional responses to future events. Therefore, they may have trouble making accurate and appropriate decisions about which emotionally relevant situations to approach or to avoid.

Situation Modification

Situation modification involves efforts to modify a situation so as to change its emotional impact. Situation modification refers specifically to altering one’s external, physical environment. Altering one’s “internal” environment to regulate emotion is called cognitive change.

Examples of situation modification may include injecting humour into a speech to elicit laughter or extending the physical distance between oneself and another person.

Attentional Deployment

Attentional deployment involves directing one’s attention towards or away from an emotional situation.

Distraction

Distraction, an example of attentional deployment, is an early selection strategy, which involves diverting one’s attention away from an emotional stimulus and towards other content. Distraction has been shown to reduce the intensity of painful and emotional experiences, to decrease facial responding and neural activation in the amygdala associated with emotion, as well as to alleviate emotional distress. As opposed to reappraisal, individuals show a relative preference to engage in distraction when facing stimuli of high negative emotional intensity. This is because distraction easily filters out high-intensity emotional content, which would otherwise be relatively difficult to appraise and process.

Rumination

Rumination, an example of attentional deployment, is defined as the passive and repetitive focusing of one’s attention on one’s symptoms of distress and the causes and consequences of these symptoms. Rumination is generally considered a maladaptive emotion regulation strategy, as it tends to exacerbate emotional distress. It has also been implicated in a host of disorders including major depression.

Worry

Worry, an example of attentional deployment, involves directing attention to thoughts and images concerned with potentially negative events in the future. By focusing on these events, worrying serves to aid in the down-regulation of intense negative emotion and physiological activity. While worry may sometimes involve problem solving, incessant worry is generally considered maladaptive, being a common feature of anxiety disorders, particularly generalised anxiety disorder.

Thought Suppression

Thought suppression, an example of attentional deployment, involves efforts to redirect one’s attention from specific thoughts and mental images to other content so as to modify one’s emotional state. Although thought suppression may provide temporary relief from undesirable thoughts, it may ironically end up spurring the production of even more unwanted thoughts. This strategy is generally considered maladaptive, being most associated with obsessive-compulsive disorder.

Cognitive Change

Cognitive change involves changing how one appraises a situation so as to alter its emotional meaning.

Reappraisal

Reappraisal, an example of cognitive change, is a late selection strategy, which involves a change of the meaning of an event that alters its emotional impact. It encompasses different substrategies, such as positive reappraisal (creating and focusing on a positive aspect of the stimulus), decentring (reinterpreting an event by broadening one’s perspective to see “the bigger picture”), or fictional reappraisal (adopting or emphasizing the belief that event is not real, that it is for instance “just a movie” or “just my imagination”). Reappraisal has been shown to effectively reduce physiological, subjective, and neural emotional responding. As opposed to distraction, individuals show a relative preference to engage in reappraisal when facing stimuli of low negative emotional intensity because these stimuli are relatively easy to appraise and process.

Reappraisal is generally considered to be an adaptive emotion regulation strategy. Compared to suppression (including both thought suppression and expressive suppression), which is positively correlated with many psychological disorders, reappraisal can be associated with better interpersonal outcomes, and can be positively related to well-being. However, some researchers argue that context is important when evaluating the adaptiveness of a strategy, suggesting that in some contexts reappraisal may be maladaptive. Furthermore, some research has shown reappraisal does not influence affect or physiological responses to recurrent stress.

Distancing

Distancing, an example of cognitive change, involves taking on an independent, third-person perspective when evaluating an emotional event. Distancing has been shown to be an adaptive form of self-reflection, facilitating the emotional processing of negatively valenced stimuli, reducing emotional and cardiovascular reactivity to negative stimuli, and increasing problem-solving behaviour.

Humour

Humour, an example of cognitive change, has been shown to be an effective emotion regulation strategy. Specifically, positive, good-natured humour has been shown to effectively up-regulate positive emotion and down-regulate negative emotion. On the other hand, negative, mean-spirited humour is less effective in this regard.

Response Modulation

Response modulation involves attempts to directly influence experiential, behavioural, and physiological response systems.

Expressive Suppression

Expressive suppression, an example of response modulation, involves inhibiting emotional expressions. It has been shown to effectively reduce facial expressivity, subjective feelings of positive emotion, heart rate, and sympathetic activation. However, the research findings are mixed regarding whether this strategy is effective for down-regulating negative emotion. Research has also shown that expressive suppression may have negative social consequences, correlating with reduced personal connections and greater difficulties forming relationships.

Expressive suppression is generally considered to be a maladaptive emotion regulation strategy. Compared to reappraisal, it is positively correlated with many psychological disorders, associated with worse interpersonal outcomes, is negatively related to well-being, and requires the mobilization of a relatively substantial amount of cognitive resources. However, some researchers argue that context is important when evaluating the adaptiveness of a strategy, suggesting that in some contexts suppression may be adaptive.

Drug Use

Drug use, an example of response modulation, can be used to alter emotion-associated physiological responses. For example, alcohol can produce sedative and anxiolytic effects and beta blockers can affect sympathetic activation.

Exercise

Exercise, an example of response modulation, can be used to down-regulate the physiological and experiential effects of negative emotions. Regular physical activity has also been shown to reduce emotional distress and improve emotional control.

Sleep

Sleep plays a role in emotion regulation, although stress and worry can also interfere with sleep. Studies have shown that sleep, specifically REM (rapid eye movement) sleep, down-regulates reactivity of the amygdala, a brain structure known to be involved in the processing of emotions, in response to previous emotional experiences. On the flip side, sleep deprivation is associated with greater emotional reactivity or overreaction to negative and stressful stimuli. This is a result of both increased amygdala activity and a disconnect between the amygdala and the prefrontal cortex, which regulates the amygdala through inhibition, together resulting in an overactive emotional brain. Due to the subsequent lack of emotional control, sleep deprivation may be associated with depression, impulsivity, and mood swings. Additionally, there is some evidence that sleep deprivation may reduce emotional reactivity to positive stimuli and events and impair emotion recognition in others.

In Psychotherapy

Emotion regulation strategies are taught, and emotion regulation problems are treated, in a variety of counselling and psychotherapy approaches, including Cognitive Behavioural Therapy (CBT), Dialectical Behaviour Therapy (DBT), Emotion-Focused Therapy (EFT), and Mindfulness-Based Cognitive Therapy (MBCT).

For example, a relevant mnemonic formulated in DBT is “ABC PLEASE”:

  • Accumulate positive experiences.
  • Build mastery by being active in activities that make one feel competent and effective to combat helplessness.
  • Cope ahead, preparing an action plan, researching, and rehearsing (with a skilled helper if necessary).
  • Physical illness treatment and prevention through checkups.
  • Low vulnerability to diseases, managed with health care professionals.
  • Eating healthy.
  • Avoiding (non-prescribed) mood-altering drugs.
  • Sleep healthy.
  • Exercise regularly.

Developmental Process

Infancy

Intrinsic emotion regulation efforts during infancy are believed to be guided primarily by innate physiological response systems. These systems usually manifest as an approach towards and an avoidance of pleasant or unpleasant stimuli. At three months, infants can engage in self-soothing behaviours like sucking and can reflexively respond to and signal feelings of distress. For instance, infants have been observed attempting to suppress anger or sadness by knitting their brow or compressing their lips. Between three and six months, basic motor functioning and attentional mechanisms begin to play a role in emotion regulation, allowing infants to more effectively approach or avoid emotionally relevant situations. Infants may also engage in self-distraction and help-seeking behaviours for regulatory purposes. At one year, infants are able to navigate their surroundings more actively and respond to emotional stimuli with greater flexibility due to improved motor skills. They also begin to appreciate their caregivers’ abilities to provide them regulatory support. For instance, infants generally have difficulties regulating fear. As a result, they often find ways to express fear in ways that attract the comfort and attention of caregivers.

Extrinsic emotion regulation efforts by caregivers, including situation selection, modification, and distraction, are particularly important for infants. The emotion regulation strategies employed by caregivers to attenuate distress or to up-regulate positive affect in infants can impact the infants’ emotional and behavioural development, teaching them particular strategies and methods of regulation. The type of attachment style between caregiver and infant can therefore play a meaningful role in the regulatory strategies infants may learn to use.

Recent evidence supports the idea that maternal singing has a positive effect on affect regulation in infants. Singing play-songs, such as “The Wheels on the Bus” or “She’ll Be Comin’ Round the Mountain” have a visible affect-regulatory consequence of prolonged positive affect and even alleviation of distress. In addition to proven facilitation of social bonding, when combined with movement and/or rhythmic touch, maternal singing for affect regulation has possible applications for infants in the NICU (neo-natal intensive care unit) and for adult caregivers with serious personality or adjustment difficulties.

Toddler-Hood

By the end of the first year, toddlers begin to adopt new strategies to decrease negative arousal. These strategies can include rocking themselves, chewing on objects, or moving away from things that upset them. At two years, toddlers become more capable of actively employing emotion regulation strategies. They can apply certain emotion regulation tactics to influence various emotional states. Additionally, maturation of brain functioning and language and motor skills permits toddlers to manage their emotional responses and levels of arousal more effectively.

Extrinsic emotion regulation remains important to emotional development in toddlerhood. Toddlers can learn ways from their caregivers to control their emotions and behaviours. For example, caregivers help teach self-regulation methods by distracting children from unpleasant events (like a vaccination shot) or helping them understand frightening events.

Childhood

Emotion regulation knowledge becomes more substantial during childhood. For example, children aged six to ten begin to understand display rules. They come to appreciate the contexts in which certain emotional expressions are socially most appropriate and therefore ought to be regulated. For example, children may understand that upon receiving a gift they should display a smile, irrespective of their actual feelings about the gift. During childhood, there is also a trend towards the use of more cognitive emotion regulation strategies, taking the place of more basic distraction, approach, and avoidance tactics.

Regarding the development of emotion dysregulation in children, one robust finding suggests that children who are frequently exposed to negative emotion at home will be more likely to display, and have difficulties regulating, high levels of negative emotion.

Adolescence

Adolescents show a marked increase in their capacities to regulate their emotions, and emotion regulation decision making becomes more complex, depending on multiple factors. In particular, the significance of interpersonal outcomes increases for adolescents. When regulating their emotions, adolescents are therefore likely to take into account their social context. For instance, adolescents show a tendency to display more emotion if they expect a sympathetic response from their peers.

Additionally, spontaneous use of cognitive emotion regulation strategies increases during adolescence, which is evidenced both by self-report data and neural markers.

Adulthood

Social losses increase and health tends to decrease as people age. As people get older their motivation to seek emotional meaning in life through social ties tends to increase. Autonomic responsiveness decreases with age, and emotion regulation skill tends to increase.

Emotional regulation in adulthood can also be examined in terms of positive and negative affectivity. Positive and negative affectivity refers to the types of emotions felt by an individual as well as the way those emotions are expressed. With adulthood comes an increased ability to maintain both high positive affectivity and low negative affectivity “more rapidly than adolescents.” This response to life’s challenges seems to become “automatised” as people progress throughout adulthood. Thus, as individuals age, their capability of self-regulating emotions and responding to their emotions in healthy ways improves.

Additionally, emotional regulation may vary between young adults and older adults. Younger adults have been found to be more successful than older adults in practicing “cognitive reappraisal” to decrease negative internal emotions. On the other hand, older adults have been found to be more successful in the following emotional regulation areas:

  • Predicting the level of “emotional arousal” in possible situations.
  • Having a higher focus on positive information rather than negative.
  • Maintaining healthy levels of “hedonic well-being” (subjective well-being based on increased pleasure and decreased pain).

Overview of Perspectives

Neuropsychological Perspective

Affective

As people age, their affect – the way they react to emotions – changes, either positively or negatively. Studies show that positive affect increases as a person grows from adolescence to their mid 70s. Negative affect, on the other hand, decreases until the mid 70s. Studies also show that emotions differ in adulthood, particularly affect (positive or negative). Although some studies found that individuals experience less affect as they grow older, other studies have concluded that adults in their middle age experience more positive affect and less negative affect than younger adults. Positive affect was also higher for men than women while the negative affect was higher for women than it was for men and also for single people. A reason that older people – middle adulthood – might have less negative affect is because they have overcome, “the trials and vicissitudes of youth, they may increasingly experience a more pleasant balance of affect, at least up until their mid-70s”. Positive affect might rise during middle age but towards the later years of life – the 70s – it begins to decline while negative affect also does the same. This might be due to failing health, reaching the end of their lives and the death of friends and relatives.

In addition to baseline levels of positive and negative affect, studies have found individual differences in the time-course of emotional responses to stimuli. The temporal dynamics of emotion regulation, also known as affective chronometry, include two key variables in the emotional response process: rise time to peak emotional response, and recovery time to baseline levels of emotion. Studies of affective chronometry typically separate positive and negative affect into distinct categories, as previous research has shown (despite some correlation) the ability of humans to experience changes in these categories independently of one another. Affective chronometry research has been conducted on clinical populations with anxiety, mood, and personality disorders, but is also utilised as a measurement to test the effectiveness of different therapeutic techniques (including mindfulness training) on emotional dysregulation.

Neurological

The development of functional magnetic resonance imaging has allowed for the study of emotion regulation on a biological level. Specifically, research over the last decade strongly suggests that there is a neural basis. Sufficient evidence has correlated emotion regulation to particular patterns of prefrontal activation. These regions include the orbital prefrontal cortex, the ventromedial prefrontal cortex, and the dorsolateral prefrontal cortex. Two additional brain structures that have been found to contribute are the amygdala and the anterior cingulate cortex. Each of these structures are involved in various facets of emotion regulation and irregularities in one or more regions and/or interconnections among them are affiliated with failures of emotion regulation. An implication to these findings is that individual differences in prefrontal activation predict the ability to perform various tasks in aspects of emotion regulation.

Sociological

People intuitively mimic facial expressions; it is a fundamental part of healthy functioning. Similarities across cultures in regards to nonverbal communication has prompted the debate that it is in fact a universal language. It can be argued that emotion regulation plays a key role in the ability to generate the correct responses in social situations. Humans have control over facial expressions both consciously and unconsciously: an intrinsic emotion programme is generated as the result of a transaction with the world, which immediately results in an emotional response and usually a facial reaction. It is a well documented phenomenon that emotions have an effect on facial expression, but recent research has provided evidence that the opposite may also be true.

This notion would give rise to the belief that a person may not only control his emotion but in fact influence them as well. Emotion regulation focuses on providing the appropriate emotion in the appropriate circumstances. Some theories allude to the thought that each emotion serves a specific purpose in coordinating organismic needs with environmental demands. This skill, although apparent throughout all nationalities, has been shown to vary in successful application at different age groups. In experiments done comparing younger and older adults to the same unpleasant stimuli, older adults were able to regulate their emotional reactions in a way that seemed to avoid negative confrontation. These findings support the theory that with time people develop a better ability to regulate their emotions. This ability found in adults seems to better allow individuals to react in what would be considered a more appropriate manner in some social situations, permitting them to avoid adverse situations that could be seen as detrimental.

Expressive Regulation (In Solitary Conditions)

In solitary conditions, emotion regulation can include a minimisation-miniaturisation effect, in which common outward expressive patterns are replaced with toned down versions of expression. Unlike other situations, in which physical expression (and its regulation) serve a social purpose (i.e. conforming to display rules or revealing emotion to outsiders), solitary conditions require no reason for emotions to be outwardly expressed (although intense levels of emotion can bring out noticeable expression anyway). The idea behind this is that as people get older, they learn that the purpose of outward expression (to appeal to other people), is not necessary in situations in which there is no one to appeal to. As a result, the level of emotional expression can be lower in these solitary situations.

Stress

The way an individual reacts to stress can directly overlap with their ability to regulate emotion. Although the two concepts differ in a multitude of ways, “both coping [with stress] and emotion regulation involve affect modulation and appraisal processes” that are necessary for healthy relationships and self-identity.

According to Yu. V. Shcherbatykh, emotional stress in situations like school examinations can be reduced by engaging in self-regulating activities prior to the task being performed. To study the influence of self-regulation on mental and physiological processes under exam stress, Shcherbatykh conducted a test with an experimental group of 28 students (of both sexes) and a control group of 102 students (also of both sexes).

In the moments before the examination, situational stress levels were raised in both groups from what they were in quiet states. In the experimental group, participants engaged in three self-regulating techniques (concentration on respiration, general body relaxation, and the creation of a mental image of successfully passing the examination). During the examination, the anxiety levels of the experimental group were lower than that of the control group. Also, the percent of unsatisfactory marks in the experimental group was 1.7 times less than in the control group. From this data, Shcherbatykh concluded that the application of self-regulating actions before examinations helps to significantly reduce levels of emotional strain, which can help lead to better performance results.

Decision Making

Identification of our emotional self-regulating process can facilitate in the decision making process. Current literature on emotion regulation identifies that humans characteristically make efforts in controlling emotion experiences. There is then a possibility that our present state emotions can be altered by emotion regulation strategies resulting in the possibility that different regulation strategies could have different decision implications.

Effects of Low Self-Regulation

With a failure in emotion regulation, there is a rise in psychosocial and emotional dysfunctions caused by traumatic experiences due to an inability to regulate emotions. These traumatic experiences typically happen in grade school and are sometimes associated with bullying. Children who can not properly self-regulate express their volatile emotions in a variety of ways, including screaming if they don’t have their way, lashing out with their fists, throwing objects (such as chairs), or bullying other children. Such behaviours often elicit negative reactions from the social environment, which, in turn, can exacerbate or maintain the original regulation problems over time, a process termed cumulative continuity.

These children are more likely to have conflict-based relationships with their teachers and other children. This can lead to more severe problems such as an impaired ability to adjust to school and predicts school dropout many years later. Children who fail to properly self-regulate grow as teenagers with more emerging problems. Their peers begin to notice this “immaturity”, and these children are often excluded from social groups and teased and harassed by their peers. This “immaturity” certainly causes some teenagers to become social outcasts in their respective social groups, causing them to lash out in angry and potentially violent ways. Being teased or being an outcast in childhood is especially damaging because it could lead to psychological symptoms such as depression and anxiety (in which dysregulated emotions play a central role), which, in turn, could lead to more peer victimisation. This is why it is recommended to foster emotional self-regulation in children as early as possible.

What is the Dialogical Self?

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Introduction

The dialogical self is a psychological concept which describes the mind’s ability to imagine the different positions of participants in an internal dialogue, in close connection with external dialogue.

The “dialogical self” is the central concept in the dialogical self theory (DST), as created and developed by the Dutch psychologist Hubert Hermans since the 1990s.

Overview

Dialogical Self Theory (DST) weaves two concepts, self and dialogue, together in such a way that a more profound understanding of the interconnection of self and society is achieved. Usually, the concept of self refers to something “internal,” something that takes place within the mind of the individual person, while dialogue is typically associated with something “external,” that is, processes that take place between people involved in communication.

The composite concept “dialogical self” goes beyond the self-other dichotomy by infusing the external to the internal and, in reverse, to introduce the internal into the external. As functioning as a “society of mind”, the self is populated by a multiplicity of “self-positions” that have the possibility to entertain dialogical relationships with each other.

In Dialogical Self Theory (DST) the self is considered as “extended,” that is, individuals and groups in the society at large are incorporated as positions in the mini-society of the self. As a result of this extension, the self does not only include internal positions (e.g. I as the son of my mother, I as a teacher, I as a lover of jazz), but also external positions (e.g. my father, my pupils, the groups to which I belong).

Given the basic assumption of the extended self, the other is not simply outside the self but rather an intrinsic part of it. There is not only the actual other outside the self, but also the imagined other who is entrenched as the other-in-the-self. An important theoretical implication is that basic processes, like self-conflicts, self-criticism, self-agreements, and self-consultancy, are taking place in different domains in the self:

  • Within the internal domain (e.g. “As an enjoyer of life I disagree with myself as an ambitious worker”);
  • Between the internal and external (extended) domain (e.g. “I want to do this but the voice of my mother in myself criticises me”); and
  • Within the external domain (e.g. “The way my colleagues interact with each other has led me to decide for another job”).

As these examples show, there is not always a sharp separation between the inside of the self and the outside world, but rather a gradual transition. DST assumes that the self as a society of mind is populated by internal and external self-positions. When some positions in the self silence or suppress other positions, monological relationships prevail. When, in contrast, positions are recognized and accepted in their differences and alterity (both within and between the internal and external domains of the self), dialogical relationships emerge with the possibility to further develop and renew the self and the other as central parts of the society at large.

Historical Background

DST is inspired by two thinkers in particular, William James and Mikhail Bakhtin, who worked in different countries (US and Russia, respectively), in different disciplines (psychology and literary sciences), and in different theoretical traditions (pragmatism and dialogism). As the composite term dialogical self suggests, the present theory finds itself not exclusively in one of these traditions but explicitly at their intersection. As a theory about the self it is inspired by William James, as a theory about dialogue it elaborates on some insights of Mikhail Bakhtin. The purpose of the present theory is to profit from the insights of founding fathers like William James, George Herbert Mead and Mikhail Bakhtin and, at the same time, to go beyond them.

William James (1890) proposed a distinction between the I and the Me, which, according to Morris Rosenberg, is a classic distinction in the psychology of the self. According to James the I is equated with the self-as-knower and has three features: continuity, distinctness, and volition. The continuity of the self-as-knower is expressed in a sense of personal identity, that is, a sense of sameness through time. A feeling of distinctness from others, or individuality, is also characteristic of the self-as-knower. Finally, a sense of personal volition is reflected in the continuous appropriation and rejection of thoughts by which the self-as-knower manifests itself as an active processor of experience.

Of particular relevance to DST is James’s view that the Me, equated with the self-as-known, is composed of the empirical elements considered as belonging to oneself. James was aware that there is a gradual transition between Me and mine and concluded that the empirical self is composed of all that the person can call his or her own, “not only his body and his psychic powers, but his clothes and his house, his wife and children, his ancestors and friends, his reputation and works, his lands and horses, and yacht and bank-account”. According to this view, people and things in the environment belong to the self, as far as they are felt as “mine”. This means that not only “my mother” belongs to the self but even “my enemy”. In this way, James proposed a view in which the self is ‘extended’ to the environment. This proposal contrasts with a Cartesian view of the self which is based on a dualistic conception, not only between self and body but also between self and other. With his conception of the extended self, that defined as going beyond the skin, James has paved the way for later theoretical developments in which other people and groups, defined as “mine” are part of a dynamic multi-voiced self.

In the above quotation from William James, we see a constellation of characters (or self-positions) which he sees as belonging to the Me/mine: my wife and children, my ancestors and friends. Such characters are more explicitly elaborated in Mikhail Bakhtin’s metaphor of the polyphonic novel, which became a source of inspiration for later dialogical approaches to the self. In proposing this metaphor, he draws on the idea that in Dostoevsky’s works there is not a single author at work – Dostoevsky himself – but several authors or thinkers, portrayed as characters such as Ivan Karamazov, Myshkin, Raskolnikov, Stavrogin, and the Grand Inquisitor.

These characters are not presented as obedient slaves in the service of one author-thinker, Dostoevsky, but treated as independent thinkers, each with their own view of the world. Each hero is put forward as the author of his own ideology, and not as the object of Dostoevsky’s finalizing artistic vision. Rather than a multiplicity of characters within a unified world, there is a plurality of consciousnesses located in different worlds. As in a polyphonic musical composition, multiple voices accompany and oppose one another in dialogical ways. In bringing together different characters in a polyphonic construction, Dostoevsky creates a multiplicity of perspectives, portraying characters conversing with the Devil (Ivan and the Devil), with their alter egos (Ivan and Smerdyakov), and even with caricatures of themselves (Raskolnikov and Svidrigailov).

Inspired by the original ideas of William James and Mikhail Bakhtin, Hubert Hermans, Harry Kempen and Rens van Loon wrote the first psychological publication on the “dialogical self” in which they conceptualised the self in terms of a dynamic multiplicity of relatively autonomous I-positions in the (extended) landscape of the mind. In this conception, the I has the possibility to move from one spatial position to another in accordance with changes in situation and time. The I fluctuates among different and even opposed positions, and has the capacity to imaginatively endow each position with a voice so that dialogical relations between positions can be established. The voices function like interacting characters in a story, involved in processes of question and answer, agreement and disagreement. Each of them have a story to tell about their own experiences from their own stance. As different voices, these characters exchange information about their respective Me’s and mines, resulting in a complex, narratively structured self.

Construction of Assessment and Research Procedures

The theory has led to the construction of different assessment and research procedures for investigating central aspects of the dialogical self. Hubert Hermans has constructed the Personal Position Repertoire (PPR) method, an idiographic procedure for assessing the internal and external domains of the self in terms of an organised position repertoire.

This is done by offering the participant a list of internal and external self-positions. The participants mark those positions that they feel as relevant in their lives. They are allowed to add extra internal and external positions to the list and phrase them in their own terms. The relationship between internal and external positions is then established by inviting the participants to fill out a matrix with the rows representing the internal positions and the columns the external positions. In the entries of the matrix, the participant fills in, on a scale from 0 to 5 the extent to which an internal position is prominent in the relation to an external position. The scores in the matrix allow for the calculation of a number of indices, such as sum scores representing the overall prominence of particular internal or external positions and correlations showing the extent to which internal (or external) positions have similar profiles. On the basis of the results of the quantitative analysis, some positions can be selected, by the client or assessor, for closer examination.

From the selected positions the client can tell a story that reflects the specific experiences associated with that position and, moreover, assessor and client can explore which positions can be considered as a dialogical response to one or more other positions. In this way, the method combines both qualitative and quantitative analyses.

Psychometric Aspects of the PPR Method

The psychometric aspects of the PPR method was refined a procedure proposed by A. Kluger, Nir, & Y. Kluger. The authors analyse clients’ Personal Position Repertoires by creating a bi-plot of the factors underlying their internal and external positions. A bi-plot provides a clear and comprehensible visual map of the relations between all the meaningful internal and external positions within the self in such a way that both types of positions are simultaneously visible. Through this procedure clusters of internal and external positions and dominant patterns can be easily observed and analysed.

The method allows researchers or practitioners to study the general deep structures of the self. There are multiple bi-plots technologies available today. The simplest approach, however, is to perform a standard principal component analysis (PCA). To obtain a bi-plot, a PCA is once performed on the external positions and once on the internal positions, with the number of components in both PCA’s restricted to two. Next, a scatter of the two PCAs is plotted on the same plane, where results of the first components are projected to the X-axis and of the second components to Y-axis. In this way, an overview of the organisation of the internal and external positions together is realised.

The Personality Web Assessment Method

Another assessment method, the Personality Web, is devised by Raggatt. This semi-structured method starts from the assumption that the self is populated by a number of opposing narrative voices, with each voice having its own life story. Each voice competes with other voices for dominance in thought and action and each is constituted by a different set of affectively-charged attachments, to people, events, objects and one’s own body.

The assessment comprises two phases:

  • In the first phase, 24 attachments are elicited in four categories: people, events, places and objects, and orientations to body parts. In an interview, the history and meaning of each attachment is explored.
  • In the second phase, participants are invited to group their attachments by strength of association into cluster analysis and multidimensional scaling is used to map the individual’s web of attachments.

This method represents a combination of qualitative and quantitative procedures that provide insight in the content and organisation of a multi-voiced self.

Self-Confrontation Method

Dialogical relationships are also studied with an adapted version of the Self-Confrontation Method (SCM).

Take the following example. A client, Mary, reported that she sometimes experienced herself as a witch, eager to murder her husband, particularly when he was drunk. She did a self-investigation in two parts, one from her ordinary position as Mary and another from the position of the witch. Then, she told from each of the positions a story about her past, present, and future. These stories were summarized in the form of a number of sentences. It appeared that Mary formulated sentences that were much more acceptable from a societal point of view than those from the witch. Mary formulated sentences like “I want to try to see what my mother gives me: there’s only one of me” or “For the first time in my life, I’m engaged in making a home (“home” is also coming at home, entering into myself)”, whereas the witch produced statements like “With my bland, pussycat qualities I have vulnerable things in hand, from which I derive power at a later moment (somebody tells me things that I can use so that I get what I want)” or “I enjoy when I have broken him [husband]: from a power position entering the battlefield.”

It was found that the sentences of the two positions were very different in content, style, and affective meaning. Moreover, the relationship between Mary and the witch seemed to be more monological than dialogical, that is, either the one or the other was in control of the self and the situation and there was not no exchange between them. After the investigation, Mary received a therapeutic supervision during which she started to keep a diary in which she learned to make fine discriminations between her own experiences as Mary and those of the witch. She became not only aware of the needs of the witch but learned also to give an adequate response as soon as she noticed that the energy of the witch was upcoming. In a second investigation, one year later, the intensely conflicting relationship between Mary and the witch was significantly reduced and, as a result, there was less tension and stress in the self. She reported that in some situations, she even could make good use of the energy of the witch (e.g. when applying for a job). Whereas in some situations she was in control of the witch, in other situations she could even cooperate with her. The changes that took place between investigation 1 and investigation 2 suggested that the initial monological relationship between the two positions changed clearly into a more dialogical direction.

The Initial Questionnaire Method

Under the supervision of the Polish psychologist Piotr Oleś, a group of researchers constructed a questionnaire method, called the Initial Questionnaire, for the measurement of three types of “internal activity”:

  1. Change of perspective;
  2. Internal monologue; and
  3. Internal dialogue.

The purpose of this questionnaire is to induce the subject’s self-reflection and determine which I-positions are reflected by the participant’s interlocutors and which of them give new and different points of view to the person.

The method includes a list of potential positions. The participants are invited to choose some of them and can add their own to the list. The selected positions, both internal and external ones, are then assessed as belonging to the dialogue, monologue of perspective categories. Such a questionnaire is well-suited for the investigation of correlations with other questionnaires.

For example, correlating the Initial Questionnaire with the Revised NEO Personality Inventory (NEO PI-R), the researchers found that persons having inner dialogues scored significantly lower on Assertiveness and higher on Self-Consciousness, Fantasy, Aesthetics, Feelings and Openness than people having internal monologues. They concluded that “people entering into imaginary dialogues in comparison with ones having mainly monologues are characterised by:

  • A more vivid and creative imagination (Fantasy).
  • A deep appreciation of art and beauty (Aesthetics) and receptivity to inner feelings and emotions (Feelings).
  • They are curious about both inner and outer worlds and their lives are experientially richer.
  • They are willing to entertain novel ideas and unconventional values and they experience positive as well as negative emotions more keenly (Openness).
  • At the same time these persons are more disturbed by awkward social situations, uncomfortable around others, sensitive to ridicule, and prone to feelings of inferiority (Self-Consciousness).
  • They prefer to stay in the background and let others do the talking (Assertiveness)”.

Other Methods

Other methods are developed in fields related to DST. Based on Stiles’ assimilation model, “Osatuke et al.”, describes a method that enables the researcher to compare what is said by a client (verbal content) and how it is said (speech sounds). With this method the authors are able to assess to what extent the vocal manifestations (how it is said) of different internal voices of the same client parallel, contradict or complement their written manifestations (what is said). This method can be used to study the non-verbal characteristics of different voices in the self in connection with verbal content.

Dialogical Sequence Analysis

On the basis of Mikhail Bakhtin’s theory of utterances, Leiman devised a dialogical sequence analysis. This method starts from the assumption that every utterance has an addressee. The central question is: To whom is the person speaking?

Usually, we think of one listener as the immediately observable addressee. However, the addressee is rather a multiplicity of others, a complex web of invisible others, whose presence can be traced in the content, flow and expressive elements of the utterance (e.g. I’m directly addressing you but while speaking I’m protesting to a third person who is invisibly present in the conversation). When there are more than one addressees present in the conversation, the utterance positions the author/speaker into more (metaphorical) locations. Usually, these locations form sequences, that can be examined and made explicit when one listens carefully not only to the content but also the expressive elements in the conversation. Leiman’s method, which analyses a conversation in terms of “chains of dialogical patterns”, is theory-guided, qualitative and sensitive to the verbal and the non-verbal aspects of utterances.

Fields of Application

It is not the main purpose of the presented theory to formulate testable hypotheses, but to generate new ideas. It is certainly possible to perform theory-guided research on the basis of the theory, as exemplified by a special issue on dialogical self research in the Journal of Constructivist Psychology (2008) and in other publications (further on in the present section). Yet, the primary purpose is the generation of new ideas that lead to continued theory, research, and practice on the basis of links between the central concepts of the theory.

Theoretical advances, empirical research, and practical applications are discussed in the International Journal for Dialogical Science and at the biennial International Conferences on the Dialogical Self as they are held in different countries and continents: Nijmegen, Netherlands (2000), Ghent, Belgium (2002), Warsaw, Poland (2004), Braga, Portugal (2006), Cambridge, United Kingdom (2008), Athens, Greece (2010), Athens, Georgia, United States (2012), and The Hague, Netherlands (2014).The aim of the journal and the conferences is to transcend the boundaries of (sub)disciplines, countries, and continents and create fertile interfaces where theorists, researchers and practitioners meet in order to engage in innovative dialogue.

After initial publication on DST, the theory has been applied in a variety of fields: cultural psychology psychotherapy; personality psychology; psychopathology; developmental psychology; experimental social psychology; autobiography; social work; educational psychology; brain science; Jungian psychoanalysis; history; cultural anthropology; constructivism; social constructionism; philosophy; the psychology of globalisation; cyberpsychology; media psychology; vocational psychology; and literary sciences.

Fields of applications are also reflected by several special issues that appeared in psychological journals. In Culture & Psychology (2001), DST, as a theory of personal and cultural positioning, was exposed and commented on by researchers from different cultures. In Theory & Psychology (2002) the potential contribution of the theory for a variety of fields was discussed: developmental psychology, personality psychology, psychotherapy, psychopathology, brain sciences, cultural psychology, Jungian psychoanalysis, and semiotic dialogism. A second issue of this journal published in 2010 was also devoted to DST. In the Journal of Constructivist Psychology (2003) researchers and practitioners focused on the implications of the dialogical self for personal construct psychology, on the philosophy of Martin Buber, on the rewriting of narratives in psychotherapy, and on a psycho-dramatic approach in psychotherapy. The topic of mediated dialogue in a global and digital age was at the heart of a special issue in Identity: An International Journal of Theory and Research (2004). In Counselling Psychology Quarterly (2006), the dialogical self was applied to a variety of topics, such as, the relationship between adult attachment and working models of emotion, paranoid personality disorder, narrative impoverishment in schizophrenia, and the significance of social power in psychotherapy. In the Journal of Constructivist Psychology (2008) and in Studia Psychologica, groups of researchers addressed the question of how empirical research can be performed on the basis of DST. The relevance of the dialogical self to developmental psychology was discussed in a special issue of New Directions for Child and Adolescent Development (2012). The application of the dialogical self in educational settings was presented in a special issue of the Journal of Constructivist Psychology (2013).

Evaluation

Since its first inception in 1992, DST is discussed and evaluated, particularly at the biennial International Conferences on the Dialogical Self and in the International Journal for Dialogical Science. Some of the main positive evaluations and main criticisms are summarised here. On the positive side, many researchers appreciate the breadth and the integrative character of the theory. As the above review of applications demonstrates, there is a broad range of fields in psychology and other disciplines in which the theory has received interests from thinkers, researchers and practitioners. The breadth of interest is also reflected by the range of scientific journals that have devoted special issues to the theory and its implications.

The theory has the potential to bring together scientists and practitioners from a variety of countries, continents and cultures. The Fifth International Conference on the Dialogical Self in Cambridge, United Kingdom attracted 300 participants from 43 countries. The conference focused primarily on DST, and dialogism as a related field. However, by focusing on dialogue, dialogical self goes beyond the post-modernism idea of the decentralisation of the self and the notion of fragmentation. Recent work by John Rowan has resulted in the publication of a book by him entitled – ‘Personification: Using the Dialogical Self in Psychotherapy and Counselling’ published by Routledge. The book shows how to apply the concepts by those working in the therapeutic field.

Criticism

The theory and its applications have also received several criticism. Many researchers have noted a discrepancy between theory and research. Certainly, more than most post-modernist approaches, the theory has instigated a variety of empirical studies and some of its main tenets are confirmed in experimental social-psychological research. Yet, the gap between theory and research still exists.

Closely related to this gap, there is the lack of connection between dialogical self research and mainstream psychology. Although the theory and its applications have been published in mainstream journals like Psychological Bulletin and the American Psychologist, it has not yet led to the adoption of the theory as a significant development in mainstream (American) psychology. Apart from the theory-research gap, one of the additional reasons for the lacking connection with mainstream research may be the fact that interest in the notion of dialogue, central in the history of philosophy since Plato, is largely neglected in psychology and other social sciences. Another disadvantage of the theory is that it lacks a research procedure that is sufficiently common to allow for the exchange of research data among investigators. Although different research tools have been developed (see the above review of assessment and research methods), none of them are used by a majority of researchers in the field.

Investigators often use different research tools which lead to a considerable richness of information but, at the same time, create a stumbling block for the comparison of research data. It seems that the breadth of the theory and the richness of its applications have a shadowy side in the relative isolation of research in the DST subfields. Other researchers find the scientific work done thus far to be of a too verbal nature. While the theory explicitly acknowledges the importance of pre-linguistic, non-linguistic forms of dialogue, the actual research is typically taking place on the verbal level with the simultaneous neglect of the non-verbal level (for a notable exception cultural-anthropological research on shape-shifting). Finally, some researchers would like to see more emphasis on the bodily aspects of dialogue. Up till now the theory has focused almost exclusively on the transcendence of the self-other dualism, as typical of the modern model of the self. More work should be done on the embodied nature of the dialogical self (for the role of the body in connection with emotions).

What is a Caregiver?

Published on by Andrew Marshall3 Comments

Introduction

A caregiver is a paid or unpaid member of a person’s social network who helps them with activities of daily living.

Refer to Caregiver Stress and Dignity of Risk.

Since they have no specific professional training, they are often described as informal caregivers. Caregivers most commonly assist with impairments related to old age, disability, a disease, or a mental disorder.

Typical duties of a caregiver might include taking care of someone who has a chronic illness or disease; managing medications or talking to doctors and nurses on someone’s behalf; helping to bathe or dress someone who is frail or disabled; or taking care of household chores, meals, or processes both formal and informal documentation related to health for someone who cannot do these things alone.

With an aging population in all developed societies, the role of caregiver has been increasingly recognised as an important one, both functionally and economically. Many organisations that provide support for persons with disabilities have developed various forms of support for carers as well.

Uses

A primary caregiver is the person who takes primary responsibility for someone who cannot care fully for themselves. The primary caregiver may be a family member, a trained professional or another individual. Depending on culture there may be various members of the family engaged in care. The concept can be important in attachment theory as well as in family law, for example in guardianship and child custody.

A person may need care due to loss of health, loss of memory, the onset of illness, an incident (or risk) of falling, anxiety or depression, grief, or a disabling condition.

Technique

Basic Principles

A fundamental part of giving care is being a good communicator with the person getting care. Care is given with respect for the dignity of the person receiving care. The carer remains in contact with the primary health care provider, often a doctor or nurse, and helps the person receiving care make decisions about their health and matters affecting their daily life.

In the course of giving care, the caregiver is responsible for managing hygiene of themselves, the person receiving care, and the living environment. Hand washing for both caregivers and persons receiving care happen often. If the person receiving care is producing sharps waste from regular injections, then the caregiver should manage that. Surfaces of the living area should be regularly cleaned and wiped and laundry managed.

The caregiver manages organisation of the person’s agenda. Of special importance is helping the person meet medical appointments. Also routine daily living functions are scheduled, like managing hygiene tasks and keeping health care products available.

Monitoring

The caregiver is in close contact with the person receiving care and should monitor their health in a reasonable way.

Some people receiving care require that someone take notice of their breathing. It is expected that a caregiver would notice changes in breathing, and that if a doctor advised a caregiver to watch for something, then the caregiver should be able to follow the doctor’s instructions in monitoring the person.

Some people receiving care require that the caregiver monitor their body temperature. If this needs to be done, a doctor will advise the caregiver on how to use a thermometer. For people who need blood pressure monitoring, blood glucose monitoring, or other specific health monitoring, then a doctor will advise the care giver on how to do this. The caregiver should watch for changes in a person’s mental condition, including becoming unhappy, withdrawn, less interested, confused, or otherwise not as healthy as they have been. In all monitoring, the caregiver’s duty is to take notes of anything unusual and share it with the doctor.

Keeping the Person Mentally Alert

There is a link between mental health and physical health and mind–body interventions may increase physical health by improving mental health. These practices seek to improve a person’s quality of life by helping them socialise with others, keep friendships, do hobbies, and enjoy whatever physical exercise is appropriate.

Caregivers encourage people to leave their homes for the health benefits of the resulting physical and mental activity. Depending on a person’s situation, a walk through their own neighbourhood or a visit to a park may require planning or have risks, but it is good to do when possible.

Depending on a person’s situation, it may be useful for them to meet others also getting similar care services. Many places offer exercise groups to join. Social clubs may host hobby groups for art classes, social outings, or to play games. For elderly people there may be senior clubs which organise day trips.

Eating Assistance

Caregivers help people have a healthy diet. This help might include giving nutrition suggestions based on the recommendations of dietitians, monitoring body weight, addressing difficulty swallowing or eating, complying with dietary restrictions, assisting with the use of any dietary supplements, and arranging for pleasant mealtimes.

A healthy diet includes everything to meet a person’s food energy and nutritional needs. People become at risk for not having a healthy diet when they are inactive or bedbound; living alone; sick; having difficulty eating; affected by medication; depressed; having difficulty hearing, seeing, or tasting; unable to get food they enjoy; or are having communication problems. A poor diet contributes to many health problems, including increased risk of infection, poor recovery time from surgery or wound healing, skin problems, difficulty in activities of daily living, fatigue, and irritability. Older people are less likely to recognize thirst and may benefit from being offered water.

Difficulty eating is most often caused by difficulty swallowing. This symptom is common in people after a stroke, people with Parkinson’s disease or who have multiple sclerosis, and people with dementia. The most common way to help people with trouble swallowing is to change the texture of their food to be softer. Another way is to use special eating equipment to make it easier for the person to eat. In some situations, caregivers can be supportive by providing assisted feeding in which the person’s independence is respected while the caregiver helps them take food in their mouth by placing it there and being patient with them.

Support with Managing Medications

Caregivers have a vital role in supporting people with managing their medications at home. A person living with chronic illness may have a complex medication regimen with multiple medications and doses at different times of the day. Caregivers may assist in managing medications in many ways. This may range from going to the pharmacy to collect medications, helping with devices such as a Webster-pak or a dosette box, or actually administering the medications at home. These medications might include tablets, but also cremes, injections or liquid medications. It is important that the healthcare providers in the clinic help educate caregivers since those caregivers will often be the ones that manage medications over the long term for an individual living with a chronic condition at home.

Changes to the Home

Living Arrangements

To have a caregiver, a person may have to decide on changes on where they live and with whom they live. When someone needs a caregiver, the two must meet, and this typically happens either in the person’s own home or the caregiver’s home. Consequently, this could mean that a person moves to live with the caregiver, or the caregiver moves to live with the person. It is also possible that the caregiver only visits occasionally or is able to provide support remotely, or that the person who needs care is able to travel to the caregiver to get it.

A common example of this is when a parent gets older and has previously lived alone. If the parent’s children are to be caregivers, then they may move in with the parent or have the parent move in with them.

Safety in the Home

Persons who need care are also frequently people who need homes that are accessible in a way that matches their needs. If the caregiving plan calls for a check on the home, then typically this includes checking that the floor is free from hazards which could cause a falling, has temperature control which suits the person getting care, and has faucets and knobs which suit the users. To reduce risk of any major problem, smoke detectors should be put in place and appropriate physical security measures taken for home safety.

Complications

Discontinuing Unnecessary Treatment

For some diseases, such as advanced cancer, there may be no treatment of the disease which can prolong the life of the patient or improve the patient’s quality of life. In such cases, standard medical advice would be for the caregiver and patient to have conversations with the doctor about the risks and benefits of treatment and to seek options for palliative care or hospice.

During end-of-life care the caregiver can assist in discussions about screening which is no longer necessary. Screenings which would be indicated at other times of life, like colonoscopy, breast cancer screening, prostate cancer screening, bone density screening, and other tests may not be reasonable to have for a person at the end of life who would not take treatment for these conditions and who would only be disturbed to learn they had them. It can be the caregivers place to have conversations about the potential benefits for screenings and to participate in discussions about their usefulness. An example of a need for caregiver intervention is to talk with people on dialysis who cannot have cancer treatment and can have no benefit from cancer screening, but who consider getting the screening.

People with diabetes who use caregiving services, like those in a nursing home, frequently have problems using sliding-scale insulin therapy, which is the use of varying amounts of insulin depending on the person’s blood sugar. For people receiving caregiving services, long-acting insulin doses are indicated with varying doses of insulin being less preferable treatment. If exceptions must be made, then use the long-acting insulin and correct with small doses of sliding scale insulin before the biggest meal of the day.

Advance care planning should note if a patient is using an implantable cardioverter-defibrillator (ICD) and give instructions about the circumstances in which leaving it activated would be contrary to the patient’s goals. An ICD is a device designed to prevent cardiac arrhythmia in heart patients. This is a life saving device for people who have a goal to live for a long time, but at the end of life it is recommended that the caregiver discuss deactivating this device with the patient and health care provider. For patients at the end of life, the device rarely prevents death as intended. Using the device at the end of life can cause pain to the patient and distress to anyone who sees the patient experience this. Likewise, ICDs should not be implanted in anyone who is unlikely to live for more than a year.

Responding to Dementia

People with dementia need support from their caregivers, yet caregivers do no always have sufficient guidance for using multiple patient interventions. Findings from a 2021 systematic review of the literature found caregivers of patients in nursing homes with dementia do not have sufficient tools or clinical guidance for behavioural and psychological symptoms of dementia (BPSD) along with medication use.

People with dementia can become restless or aggressive but treating these behaviour changes with antipsychotic drugs is not a preferable option unless the person seems likely to harm themselves or others. Antipsychotic drugs have undesirable side effects, including increasing risk of diabetes, pneumonia, stroke, disruption of cognitive skill, and confusion, and consequently are better avoided when possible. Alternatives to using these drugs is trying to identify and treat underlying causing of irritability and anger, perhaps by arranging for the person to spend more time socializing or exercising. Antidepressants may also help. A caregiver who can try other options can improve the patient’s quality of life.

People with dementia are likely to lose memories and cognitive skill. Drugs such as donepezil and memantine can slow the loss of function but the benefits to the patient’s quality of life are few and in some cases there may not be any. Such drugs also have many undesirable side effects. Before using these drugs, the caregiver should discuss and consider treatment goals for the patient. If the drugs are used, then after twelve weeks, if the caregiver finds that goals are not being met, then use of the drugs should be discontinued.

People with dementia are likely to have difficulty eating and swallowing. Sometimes feeding tubes are used to give food to people with dementia, especially when they are in the hospital or a nursing home. While feeding tubes can help people gain weight, they carry risks including bleeding, infection, pressure ulcers, and nausea. Whenever possible, use assisted feeding in preference. Besides being a safer alternative to the feeding tube, it creates an opportunity for social interaction which can also be comforting to the person being fed.

Behaviour Changes

Caregivers can help people understand and respond to changes in their behaviour.

Caregivers are recommended to help people find alternatives to using sleep medication when possible. Sleeping medications do not provide a lot of benefit to most people and have side effects including causing memory problems and confusion, increasing risk of blood clots, and bringing weight gain. Caregivers can help people improve their sleep hygiene in other ways, such as getting regular exercise, keeping to a sleep schedule, and arranging for a quiet place to sleep.

Caregivers are recommended to help people find alternatives to using appetite stimulants or food supplements high in food energy. These treatments are not proven to provide benefit over alternatives but they do increase the risk of various health problems. One alternative to using appetite stimulants is to provide social support, as many people are more comfortable eating when sharing a meal with others. People who have trouble eating may appreciate assisted feeding from their caregiver. Depending on the situation, a caregiver, patient, and physician may decide to forgo any dietary restrictions such as a low sodium diet and feed the person what they enjoy eating despite the health consequences if that seems preferable to avoiding appetite stimulants

Promoting Self-Care

Self-care has been defined as “a process of maintaining health through health promoting practices and managing illness”. Self-care may be performed for several reasons, whether in response to disease or injury, to manage chronic conditions, to maintain health, or for the preservation of self. There are many different factors that may influence self-care, including knowledge and educational background, physical limitations, economic status, culture, and social support, to name a few. Additionally, the process of self-care can be performed individually or with the assistance of a caregiver.

Caregiver-patient interactions form dynamic relationships that vary based on multiple factors, including disease, comorbid conditions, dependence level, and personal relationship, among others. The term “caregiver” can refer to people who take care of someone with a chronic illness or a supporter who influences the self-care behaviours of another person. Couples often form an interdependent relationship that is linked to their health. The close dynamics of these relationships can influence self-care behaviour and transform it from a self-centred behaviour to a relationship-centred behaviour. Adopting a relationship-centred mindset can lead to enhanced motivation for both partners to carry out self-care behaviours and support one another in the process.

Multiple studies have demonstrated the significant role that caregivers play in promoting self-care in persons with an illness. A study observing the effects of a supportive intervention for caregivers of patients with heart failure found higher and statistically significant self-care behaviour scores in the intervention group. Another research study conducted by Chen et al. identified higher social support as one of the main factors associated with improved functioning and a higher quality of life in patients with chronic obstructive pulmonary disease (COPD). The presence of higher social support also had positive effects on the physical and mental health of these persons. COPD patients with a caregiver were found to have lower rates of depression and increased participation in pulmonary rehabilitation, indicating the critical role a caregiver plays in influencing patient success.

As mentioned, caregivers can promote self-care in a variety of ways. A research study performed in Lebanon found that family-centred self-care has the potential to reduce the risk of hospital readmission in patients diagnosed with heart failure. Additionally, having the support of a family member can motivate patients to perform adequate self-care and increase adherence to their treatment plan. The environment surrounding a patient and disease has proved to be an important factor in improving clinical outcomes. Specifically, family-focused caregivers providing supportive interventions can help to improve the self-care behaviours of patients with various different diseases. When patients were asked to describe the influence of family or caregiver support, they stressed the critical role these supporters played in remaining on track with their medications, dietary choices, and exercise behaviours.

Clinical Decision-Making

Despite the evidence of self-care promotion, caregivers are consistently underused during clinical encounters. Caregivers can contribute significantly to promoting patient wellness, including promoting patient independence and self-care. However, despite studies demonstrating caregivers’ daily and positive contributions to patients’ self-care, and their ability to offer perceptions, insights, and concerns, providers are not meaningfully engaging caregivers during the decision-making process for chronic care management. Ignoring the caregiver not only leaves the burden of illness on patients’ shoulders but may also prevent caregivers from obtaining the knowledge they need to provide clinically effective care and promote self-care.

The perceptions and needs of caregivers are inconsistently and seldom incorporated in designing and implementing interventions. Supporting research concludes that when caregivers are engaged in provider-patient encounters, patients report higher satisfaction with the clinical experience. The benefits of engaging caregivers during the clinical decision-making process include – and are not limited to – better patient understanding of provider advice, enhancement of patient-provider communication, better prioritisation of patient concerns, and emotional support for the patient. These benefits are essential to the performance of self-care.

Caregiver Stress

Refer to Caregiver Stress.

The stress associated with caring for chronically ill family members may result in stress for the caregiver. This caregiver stress has been associated with higher risk of mental, and physical health problems, poorer immunity and higher blood pressure.

Home care providers i.e. spouses, children of elderly parents and parents themselves contribute a huge sum in the national economy. In most parts, the economic contribution or quantification of home care providers is not accounted for. However, along with the unseen/unaccounted for economic contribution, the work toll and the loss of opportunity and the physical and mental burnout is also substantial. Sometimes to provide for the sickly and the ailing proves to be both a huge physical and mental strain. In the case of professional caregivers, it has been well researched and documented in last few decades that this mental strain is much higher than those providing care for family members. Care provided for family members- especially partners who are mentally challenged/with non-physical disorders, the degree of mental strain are high to the point of the caregivers themselves at risk of being psychologically broken due to the high demanding situations both of physical toll complicated with non-professional work environment (lack of institutional care-giving equipment – both in terms of work-safety equipment and care providing equipment), safety concerns and behavioural issue.

The physical, emotional and financial consequences for the family caregiver can be overwhelming. Caregivers responsible for an individual with a psychiatric disorder can be subject to violence. Elderly caregivers appear to be at particular risk. Respite can provide a much needed temporary break from the often exhausting challenges faced by the family caregiver.

Respite is the service most often requested by family caregivers, yet it is in critically short supply, inaccessible, or unaffordable regardless of the age or disability of the individual needing assistance. While the focus has been on making sure families have the option of providing care at home, little attention has been paid to the needs of the family caregivers who make this possible.

Without respite, not only can families suffer economically and emotionally, caregivers themselves may face serious health and social risks as a result of stress associated with continuous care-giving. Three fifths of family caregivers age 19-64 surveyed recently by the Commonwealth Fund reported fair or poor health, one or more chronic conditions, or a disability, compared with only one-third of non-caregivers.

In the United States today there are approximately 61.6 million people (referenced above) who are caring at home for family members including elderly parents, and spouses and children with disabilities and/or chronic illnesses. Without this home-care, most of these cared for loved ones would require permanent placement in institutions or health care facilities at great cost to society.

A 2021 Cochrane review found that remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms. However, there is no certain evidence that they improve health-related quality of life. The findings are based on moderate certainty evidence from 26 studies.

Caregivers and Occupational Therapy

Non-Paid Caregivers’ Health

Non-paid caregivers, such as adult children or spouses, are particularly at risk for increased stress. Caregiving tasks may require 24/7 attention and supervision, which reduces the amount of time participating in other meaningful occupations such as paid work and leisure activities. In a study examining the role of spousal caregivers for stroke survivors, many non-paid caregivers reported their experience as immensely exhausting and challenging. Furthermore, spouses and other non-paid caregivers have a higher risk of developing physical and mental health problems than the general population. The British GP Patient Survey shows that the health of unpaid carers is significantly poorer than that of their non-carer peers.

Guidance from social workers and occupational therapists has proven beneficial in reducing anxiety and a lower sense of burden among non-paid caregivers. Occupational therapists provide caregiver training to promote self care and holistic wellness, fall prevention, home modification, and aging in place. The goal of occupational therapy intervention is to reduce the burden of care on the caregiver. A typical plan of care begins with a questionnaire (Caregiver Burden Scale), an at-home environmental risk assessment, and determination of patient independence level to identify resources to reduce caregiver stress. Occupational therapy’s underlying framework is based upon participation in meaningful tasks to promote mental, physical and emotional health.

Occupational Therapists can also conduct evaluations, conduct certain interventions and consultations services remotely via telehealth. For caregivers living remotely, working from home, or otherwise have limited access to healthcare this is a vital service. Other health providers are increasingly providing services to caregivers, such as psychologists and social workers.

Society and Culture

Caregiving Certification

Some agencies, such as nursing homes and assisted living communities, require caregiver certification as a condition for employment. Most US states have caregiver resource centres that can assist in locating a reputable training class. In many cases, training is available at local colleges, vocational schools, organisations such as the American Red Cross, and at local and national caregiver organisations. National organisations include the National Association for Home Care and Hospice, the Family Caregiver Alliance and the National Family Caregivers Association. To become a certified home care aide in the state of Washington, the candidate will need to: Complete a home care aide application, including the Employment Verification form. Undergo a Washington State Department of Social and Health Services (DSHS) criminal background check. Complete a 75-hour basic training course approved by DSHS. Pass the home care aide knowledge and skills certification examinations.

The Social Psychology of Caregiving

Informal caregiving for someone with an acquired disability entails role changes that can be difficult. The person with the disability becomes a care-receiver, often struggling for independence and at risk of stigmatisation. Simultaneously, family and friends become informal caregivers, a demanding and usually unfamiliar role. Adaptation to these role changes is complex. Caregivers and care-receivers often work together to avoid stigma and compensate for the disability. However, each side experiences divergent practical, social and emotional demands which can also fracture the relationship, creating disagreements and misunderstandings.

Caregivers and care-receivers have been found to disagree about many things, including, care needs, risks and stress, and level of knowledge. it has also been found that caregivers rate care-receivers as more disabled than care-receivers rated themselves. Noble and Douglas found that family members wanted intensive interventions which were support focused, whereas care-receivers placed emphasis on interventions that fostered independence. Many disagreements centre on caregivers’ identity, particularly their overprotectiveness, embarrassment, independence, and confidence.

These disagreements and misunderstandings, it has been argued, stem in part from caregivers concealing the demands of care. Caregivers often conceal the demands of care in order to make the person receiving care feel more independent. But, this can result in the person receiving care feeling more independent than they are, and subsequently a range of misunderstandings. It has also been argued that caregivers concealing the burden of care may end up undermining their own identity, because they do not get the social recognition necessary to create a positive identity – their toil becomes invisible. This has been termed ‘the caregiving bind,’ namely, that caregivers concealing the demands of care to protect and support the identity of the care-receiver, may end up undermining their own caregiving identity.

Economics

The amount of caregiving which is done as unpaid work exceeds the amount done as work for hire. In the United States, for example, a 1997 study estimated the labour value of unpaid caregiving at US$196 billion, while the formal home health care work sector generated US$32 billion and nursing home care generated US$83 billion. The implication is that since so much personal investment is made in this sector, social programmes to increase the efficiency and efficacy of caregivers would bring great benefit to society if they were easy to access and use.

Terminology

The term “caregiver” is used more in the United States, Canada, and China, while “carer” is more commonly used in the United Kingdom, New Zealand, and Australia.

The term “caregiver” may be prefixed with “live-in”, “family”, “spousal”, “child”, “parent”, “young” or “adult” to distinguish between different care situations, and also to distinguish them definitively from the paid version of a caregiver, a Personal Care Assistant or Personal Care Attendant (PCA). Around half of all carers are effectively excluded from other paid employment through the heavy demands and responsibilities of caring for a vulnerable relative or friend. The term “carer” may also be used to refer to a paid, employed, contracted PCA.

The general term dependent care (i.e. care of a dependent) is also used for the provided help. Terms such as “voluntary caregiver” and “informal carer” are also used occasionally, but these terms have been criticised by carers as misnomers because they are perceived as belittling the huge impact that caring may have on an individual’s life, the lack of realistic alternatives, and the degree of perceived duty of care felt by many relatives.

More recently, Carers UK has defined carers as people who “provide unpaid care by looking after an ill, frail or disabled family member, friend or partner”. Adults who act as carers for both their children and their parents are frequently called the Sandwich Generation. The sandwich generation is the generation of people who care for their aging parents while supporting their own children.

What is Caregiver Stress?

Published on by Andrew Marshall2 Comments

Introduction

Caregiver syndrome or caregiver stress is a condition that strongly manifests exhaustion, anger, rage, or guilt resulting from unrelieved caring for a chronically ill patient. This condition is not listed in the Diagnostic and Statistical Manual of Mental Disorders, although the term is often used by many healthcare professionals in that country. The equivalent used in many other countries, the ICD-11, does include the condition.

Refer to Caregiver and Dignity of Risk.

Over 1 in 5 Americans are providing care to those who are ill, aged, and/or disabled. Over 13 million caregivers provide care for their own children as well. Caregiver syndrome is acute when caring for an individual with behavioural difficulties, such as: faecal incontinence, memory issues, sleep problems, wandering, impulse control problems , executive dysfunction, and/or aggression. Typical symptoms of the caregiver syndrome include fatigue, insomnia and stomach complaints with the most common symptom being depression.

Signs and Symptoms

Those who are providing care for a friend or family member with a long-term illness undergo what is known as chronic stress. Caregiving has been shown to affect the immune system. It was found that caregivers to persons with Dementia particularly Frontal temporal patients were more depressed, and they showed lower life satisfaction than the comparison samples. The caregivers also had higher EBV antibody titres and lower percentages of T cells and TH cells. Caregiving has also been shown to have adverse effects on wound repair. Further, these biological vulnerabilities are also evident in younger caregivers, implying that it is not an age and caregiver stress interaction. For example, caregivers of children with developmental disabilities have been found to have lower antibody responses to vaccination compared to age and gender matched non-caregiver controls. Further, a higher level of blood pressure has also been observed in those younger caregivers compared to a control group of parents and this particularly strong for those without social support.

Symptoms include depression, anxiety, and anger. Chronic stress can create medical problems including high blood pressure, diabetes, and a compromised immune system. The impact may reduce the care-giver’s life expectancy.

Caregiver syndrome affects people at any age. For example, elderly caregivers are at a 63% higher risk of mortality than non-caregivers who are in the same age group. This trend may be due to elevated levels of stress hormones circulating throughout the body. These levels are similar to someone with PTSD. Because caregivers have to be so immersed in their roles, with day/night hours, they often have to neglect their own health. They are experiencing high amounts of stress along with grief since the health of their loved one is declining. Since their roles are changing from a partnership or mother/daughter, mother/son, etc. relationship to a caregiver and patient relationship, caregivers are turning to online forums such as the Alzheimer’s Association for support. This role change is difficult for many people to make, causing them to experience anger, resentment, and guilt. It is difficult to provide quality care in this state of stress.

The health of caregivers should be monitored in various ways. There are tests for measuring the amount of stress on a caregiver.

Caregivers are at risk for adverse effects on their health, due to emotional distress. Even after caregiving has terminated, these stressors can have long-lasting effects on the caregiver’s body due to these immune alterations.

Since caregiving can further erode the caregiver’s own health, many studies are being done to assess the risks that a caregiver poses when they assume this job and its effects on their immune functioning, endocrine functioning, risk for depression, poor quality of sleep, long-term changes in stress responses, Cardiovascular diseases, an increased risk of infectious disease, and even death. Resentment from the patient is what may lead to the depression and distress typically seen in caregivers. This anxiety and depression can then lead back into the health of the caregiver.

The World Health Organisation’s categorisation of health conditions, the ICD-11, has a category of “QF27 Difficulty or need for assistance at home and no other household member able to render care”. Its browser and coding tool also associate this condition with the term “caregiver burnout”, connecting it to occupational burnout.

Caregiver Burnout

Bodies such as the United States government’s Centres for Disease Control and Prevention, the American Diabetes Association, and Diabetes Singapore identify and promote the phenomenon of “diabetes burnout.” This relates to the self-care of people with diabetes, particularly those with type-2 diabetes. “Diabetes burnout speaks to the physical and emotional exhaustion that people with diabetes experience when they have to deal with caring for themselves on a day-to-day basis. When you have to do so many things to stay in control then it does take a toll on your emotions… Once they get frustrated, some of them give up and stop (maintaining) a healthy diet, taking their medications regularly, going for exercises and this will result in poor diabetes control.”

Causes

Caregiver syndrome is caused by the overwhelming duty of caring for a disabled or chronically ill person. Caregiver stress is caused by an increased stress hormone level for an extended period of time. Caregivers also suffer the grief of a declining loved one, as causing a depressive exhaustive state, deteriorating emotional and mental health. “Double-duty caregivers” are those already working in the healthcare field who feel obligated to also care for their loved ones at home. This over-exhaustion and constant caregiving role can cause an increase in physical and mental health deterioration. It is actually being thought that a part of the stress of being a caregiver is from how they feel about the job. In other words, if a caregiver does not like or want to be a caregiver, they will inflict more stress on themselves by accepting the role. Support from the religious community is directly and negatively associated with anger.

Risks

The American Academy of Geriatric Psychiatrists reports one out of four American families provide care for a family member over the age of 50. By 2030, the US Census Bureau estimates a population of 71 million Americans over 65. In the UK, over 450,000 dementia patients are cared for at home. Nevertheless, over half of the caregivers (52.6%) indicated that they had some desire to institutionalize their relatives with dementia.

The American Academy of Family Physicians and the National Centre on Caregiving both believe all caregivers should be screened for stress and depression and recommend providing caregivers with their own resources to help them cope.

Since family and more often one member most assumes the primary caregiver role, these strains fall upon them. Care for those who are chronically ill is irregular, so there are not many facilities that can provide adequate care. This caregiving role is more commonly assumed by women than men. Since there are some illnesses that create a more intense need for caregiving, the caregiver is responsible for almost every aspect in the patient’s life. One of the positive aspects of caregiving for a loved one is that it can improve their quality of life, but when the caregiver is depleted of confidence, the recovery may be fostered.

Parents of children with CHD experience psychological distress such as high levels of caregiver stress, anxiety and depression.

Caregiving for military service members who have experienced a traumatic brain injury or PTSD can be very challenging as well. On 21 April 2010, the U.S. Congress passed what is known as the “Caregivers and Veterans Omnibus Health Services Act of 2010”. This act recognises the importance of caregivers who are caring for Veterans, and established a programme of assistance for them with benefits including covering counselling and mental health services under the benefits of Department of Veterans Affairs.

Issues in Health Care

Since this term, “Caregiver syndrome” is widely used among physicians, but is not mentioned in the DSM or in medical literature, physicians are not always sure how to approach the issues that arise with this syndrome. Therefore, this is not addressed frequently. In a survey given by the American Academy of Family Physicians, they found that fewer than 50% of caregivers were asked by their doctors whether or not they were experiencing caregiver stress. If this were listed in the DSM with an official diagnosis, it could possibly stigmatise those who have it. Many believe it would be beneficial for this to receive a clinical name though, so caregivers would be able to receive the appropriate resources they need. This would encourage health care professionals to develop better strategies for treatment of Caregiver Syndrome, as well as requiring health insurance agencies to pay for appropriate treatment. Some ways to improve this syndrome have been agreed upon by experts and include the following suggestions:

  • Expanding the support system for the caregiver.
  • Finding help in various sources for caregiver tasks.
  • Educating caregivers.
  • Paying caregivers salaries competitive with those paid to professional healthcare providers doing similar tasks, thus allowing them to retire from salaried jobs for companies where management is wilfully ignorant of or unsympathetic to their workers’ family caregiving burdens.
  • Encouraging the growth of telecommuting jobs that enable caregivers to work at home while caring for their patients.
  • Providing full medical benefits for caregivers and their patients.
  • Providing nursing and medical advice when needed, including home visits.
  • Providing respite services on demand.
  • Providing psychological counselling or psychiatric intervention for stress management.
  • Collecting data documenting savings for the national healthcare system made possible by home caregivers.

Although previous studies indicate a negative association between caregivers’ anger and health, the potential mechanisms linking this relationship are not yet fully understood.

Prevention

Effective coping strategies such as sleep, exercise and relaxation can help prevent stress. Caregivers fare better when they have active coping skills, such as these coping interventions:

  • Mindfulness-based stress reduction.
  • Writing therapy.
  • Coping effectiveness training.
  • Stress management.
  • Relaxation training.
  • Assistive Technology.

Nearly 15 million Americans provide care that is unpaid to a person living with Dementia. Alzheimer’s disease is the most commonly diagnosed type but research says that caring for a person with Frontal Temporal Dementia is more burdensome on carers. Early onset Dementia has even greater difficulties for carers. In many cases carers are overburdened and not supported and their health suffers. In order to maintain their own well-being, caregivers need to focus on their own needs. They need to take time for their own health, and get the appropriate support that they need such as respite from their care-giving duties. Through training, caregivers can learn how to handle the behaviours that are challenging them, and improve their own communication skills. The most important thing the caregiver can do is keep the person with Alzheimer’s safe. Research has shown that caregivers experience lower stress and better health when they learn skills through this caregiving training and participate in support groups. Participating in these groups allows caregivers to care for their family members longer in their homes.

Support

A 2014 Cochrane review found that telephone counselling can reduce symptoms of depression for caregivers and address other important caregiver needs.

Services that may be helpful to caregivers include:

  • Health services in the home.
  • Companion or chore services.
  • Day care centres for adults.
  • Respite care, time out at nursing homes, or assisted living facilities.
  • Counselling.
  • Legal advice.
  • Money management.
  • Support groups.
  • Psychotherapeutic programmes.
  • Educational programmes.

Remotely Delivered Information for Caregivers

A 2021 Cochrane review found that remotely delivered interventions including support, training and information may reduce the burden for the informal caregiver and improve their depressive symptoms. However, there is no certain evidence that they improve health-related quality of life. The findings are based on moderate certainty evidence from 26 studies.

REACH Programme

The Resources for Enhancing Alzheimer’s Caregiver Health (REACH) Project was created in 1995. This project was designed to enhance family caregiving for those who were taking care of relatives that have Alzheimer’s disease and other related dementia (ADRD). This programme includes:

  • Support groups.
  • Behavioural skills training programmes.
  • Family-based systems interventions.

This programme was designed specifically for people who are caring for a loved one with Alzheimer’s Disease or Dementia at home, and makes it possible for those with dementia to live in the own homes longer by addressing these problems of caregiver health that force the caregiver to move their loved ones to assisted-living facilities. If they can manage the challenges that come along with caregiving better, both will benefit from this. Special one-on-one training is provided for the caregiver, as well as counselling. This allows them to be more effective in their caregiving roles. They receive help directly from dementia care specialists who work with the client on an individual basis to find solutions to problems such as:

  • Caregiver stress.
  • Challenging behaviours.
  • Home safety.
  • Depression.
  • Self care.
  • Social support.

Benefits of Caregiving

Caregiving can actually provide a health advantage as well for some caregivers. Caregivers maintained higher physical performance when compared to non-caregivers. They declined less in tasks than the low-intensity caregivers and non-caregivers such as: walking pace, grip strength, and the speed with which they could rise from a chair. Caregivers also did significantly better on memory tasks than did non-caregivers over a 2-year time frame. Caregivers scored at the level of someone 10 years younger than them, although both groups (caregivers vs. non-caregivers) were both in their eighties.

While this role brings with it high costs, high rewards are also there too. This is known as “Caregiver gain”. These rewards are emotional, psychological, and spiritual such as:

  • Growing confidence in one’s ability.
  • Feelings of personal satisfaction.
  • Increased family closeness.

Women who become caregivers are healthy enough to take on the task, therefore it makes sense that they would be stronger than their non-caregiver counterparts, and remain stronger than them. The demands of caregiving cause caregivers to move around a lot, and stay on their feet. Therefore, exercise can improve both physical health and cognition. The complex thought as required by caregiving can ward off cognitive decline. This includes activities such as:

  • Monitoring medications.
  • Scheduling.
  • Financial responsibilities.

Other benefits mentioned by caregivers are that it gives their life meaning, and produces pride in their success as a caregiver. They are also able to give back to someone else. It has also been noted that psychological benefit finding can be an important way of dealing with stress. The Perceived Benefits of Caregiving scale includes 11 items with questions such as, “Has caregiving given more meaning to your life?” and “Has caregiving made you feel important?” There was an alpha coefficient of 0.7 for this scale. These benefits of caregiving have been found to be associated with improved caregiver adaptation to those who are caring for someone with dementia, end of life caregiving, and bereavement. A study done with dementia caregivers showed that finding the benefits in caregiving predicted a better response to a caregiver intervention over a time period of 12 months.

What is Dignity of Risk?

Published on by Andrew Marshall2 Comments

Introduction

Dignity of risk is the idea that self-determination and the right to take reasonable risks are essential for dignity and self esteem and so should not be impeded by excessively-cautious caregivers, concerned about their duty of care.

The concept is applicable to adults who are under care such as elderly people, people living with disability, and people with mental health problems. It has also been applied to children, including those living with disabilities.

Refer to Caregiver and Caregiver Stress.

Brief History

The concept was first articulated in a 1972 article The dignity of risk and the mentally retarded by Robert Perske:

Overprotection may appear on the surface to be kind, but it can be really evil. An oversupply can smother people emotionally, squeeze the life out of their hopes and expectations, and strip them of their dignity. Overprotection can keep people from becoming all they could become. Many of our best achievements came the hard way: We took risks, fell flat, suffered, picked ourselves up, and tried again. Sometimes we made it and sometimes we did not. Even so, we were given the chance to try. Persons with special needs need these chances, too. Of course, we are talking about prudent risks. People should not be expected to blindly face challenges that, without a doubt, will explode in their faces. Knowing which chances are prudent and which are not – this is a new skill that needs to be acquired. On the other hand, a risk is really only when it is not known beforehand whether a person can succeed. The real world is not always safe, secure, and predictable, it does not always say “please,” “excuse me”, or “I’m sorry”. Every day we face the possibility of being thrown into situations where we will have to risk everything … In the past, we found clever ways to build avoidance of risk into the lives of persons living with disabilities. Now we must work equally hard to help find the proper amount of risk these people have the right to take. We have learned that there can be healthy development in risk taking and there can be crippling indignity in safety!

In 1980, the concept was relied upon by Julian Wolpert, Professor of Geography, Public Affairs, and Urban Planning at Princeton University, to support his argument in a paper, “The Dignity of Risk”, which has since been described as “seminal”. Wolpert’s argument was that a paternalistic approach to people living with disability, prioritising safeguarding over the rights of individuals to independent decision-making, is a limitation on personal freedom.

Conflict with Duty of Care

Allowing people under care to take risks is often perceived to be in conflict with the caregivers’ duty of care. Finding a balance between these competing considerations can be difficult when formulating policies and guidelines for caregiving.

Problems of Overprotection

Overprotection of people with disabilities causes low self-esteem and underachievement because of lowered expectations that come with overprotection. Internalisation of low expectations causes the person with a disability to believe that they are less capable than others in similar situations.

In elderly people, overprotection can result in learned dependency and a decreased ability for self-care:

“It is possible to deliver physical care that has positive outcomes and returns a person to full function, yet, if during that care they have not been involved, allowed to make choices and respectfully assisted with activities of daily living, it may be possible to cause psychological damage through undermining that person’s dignity.”

Independent Living

The right to fail and the dignity of risk are basic tenets of the philosophy of the independent living movement.

Convention on the Rights of Persons with Disabilities

The first of eight “guiding principles” of the United Nations’ Convention on the Rights of Persons with Disabilities states: “Respect for inherent dignity, individual autonomy including the freedom to make one’s own choices, and independence of persons.”

What is Transference?

Published on by Andrew Marshall7 Comments

Introduction

Transference (German: Übertragung) is a phenomenon within psychotherapy in which the feelings a person had about their parents, as one example, are unconsciously redirected or transferred to the present situation.

It usually concerns feelings from a primary relationship during childhood. At times, this transference can be considered inappropriate. Transference was first described by Sigmund Freud, the founder of psychoanalysis, who considered it an important part of psychoanalytic treatment.

Occurrence

It is common for people to transfer feelings about their parents to their partners or children (that is, cross-generational entanglements). Another example of transference would be a person mistrusting somebody who resembles an ex-spouse in manners, voice, or external appearance, or being overly compliant to someone who resembles a childhood friend.

In The Psychology of the Transference, Carl Jung states that within the transference dyad both participants typically experience a variety of opposites, that in love and in psychological growth, the key to success is the ability to endure the tension of the opposites without abandoning the process, and that this tension allows one to grow and to transform.

Only in a personally or socially harmful context can transference be described as a pathological issue. A modern, social-cognitive perspective on transference explains how it can occur in everyday life. When people meet a new person who reminds them of someone else, they unconsciously infer that the new person has traits similar to the person previously known. This perspective has generated a wealth of research that illuminated how people tend to repeat relationship patterns from the past in the present.

High-profile serial killers often transfer unresolved rage toward previous love or hate-objects onto “surrogates”, or individuals resembling or otherwise calling to mind the original object of that hate. It is believed in the instance of Ted Bundy, he repeatedly killed brunette women who reminded him of a previous girlfriend with whom he had become infatuated, but who had ended the relationship, leaving Bundy rejected and pathologically rageful (Bundy, however, denied this as a motivating factor in his crimes). This notwithstanding, Bundy’s behaviour could be considered pathological insofar as he may have had narcissistic or antisocial personality disorder. If so, normal transference mechanisms cannot be held causative of his homicidal behaviour.

Sigmund Freud held that transference plays a large role in male homosexuality. In The Ego and the Id, he claimed that eroticism between males can be an outcome of a “[psychically] non-economic” hostility, which is unconsciously subverted into love and sexual attraction.

Transference and Counter-Transference during Psychotherapy

In a therapy context, transference refers to redirection of a patient’s feelings for a significant person to the therapist. Transference is often manifested as an erotic attraction towards a therapist, but can be seen in many other forms such as rage, hatred, mistrust, parentification, extreme dependence, or even placing the therapist in a god-like or guru status. When Freud initially encountered transference in his therapy with patients, he thought he was encountering patient resistance, as he recognised the phenomenon when a patient refused to participate in a session of free association. But what he learned was that the analysis of the transference was actually the work that needed to be done: “the transference, which, whether affectionate or hostile, seemed in every case to constitute the greatest threat to the treatment, becomes its best tool”. The focus in psychodynamic psychotherapy is, in large part, the therapist and patient recognising the transference relationship and exploring the relationship’s meaning. Since the transference between patient and therapist happens on an unconscious level, psychodynamic therapists who are largely concerned with a patient’s unconscious material use the transference to reveal unresolved conflicts patients have with childhood figures.

Countertransference is defined as redirection of a therapist’s feelings toward a patient, or more generally, as a therapist’s emotional entanglement with a patient. A therapist’s attunement to their own countertransference is nearly as critical as understanding the transference. Not only does this help therapists regulate their emotions in the therapeutic relationship, but it also gives therapists valuable insight into what patients are attempting to elicit in them. For example, a therapist who is sexually attracted to a patient must understand the countertransference aspect (if any) of the attraction, and look at how the patient might be eliciting this attraction. Once any countertransference aspect has been identified, the therapist can ask the patient what his or her feelings are toward the therapist, and can explore how those feelings relate to unconscious motivations, desires, or fears.

Another contrasting perspective on transference and countertransference is offered in classical Adlerian psychotherapy. Rather than using the patient’s transference strategically in therapy, the positive or negative transference is diplomatically pointed out and explained as an obstacle to cooperation and improvement. For the therapist, any signs of countertransference would suggest that his or her own personal training analysis needs to be continued to overcome these tendencies. Andrea Celenza noted in 2010 that “the use of the analyst’s countertransference remains a point of controversy”.

What is a Therapeutic Alliance?

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Introduction

A therapeutic alliance, or working alliance, is a partnership between a patient and their therapist that allows them to achieve goals through agreed-upon tasks.

The concept of therapeutic alliance dates back to Sigmund Freud. Over the course of its evolution, the meaning of the therapeutic alliance has shifted both in form and implication. What started as an analytic construct has become, over the years, a transtheoretical formulation, an integrative variable, and a common factor.

Alliance as Analytic

In its analytic permutation, Freud suggested the importance of allowing for the patient to be a “collaborator” in the therapeutic process. In his writings on transference, Freud thought of the patient’s feelings towards the therapist as resembling the non-conflicted, trusting elements of early relationships with the patient’s parents, and that this could serve as the basis for collaboration in this way.

In later years, ego psychologists popularised a construct that they would relate to the reality-oriented adaptation of the ego to the environment. For certain ego psychologists, the construct refocused psychoanalytic thought away from a perceived overemphasis on transference and allowed space for greater technical flexibility across different psychotherapeutic modalities. It also called into question the idea of therapist as a tabula rasa, or blank screen, and turned away from the idealised therapist stance of abstinence and neutrality. Instead, it brought attention to the real, felt dimension of the therapeutic relationship, and made an argument for the therapist as being supportive and the patient as identifying with the therapist.

Alliance as Integrative

Edward Bordin reformulated the therapeutic alliance more broadly, namely beyond the scope of the psychodynamic perspective, as transtheoretical. He operationalised the construct into three interdependent parts:

  • The affective bond between the patient and therapist;
  • Their agreement on goals; and
  • Their agreement on tasks.

This conceptualisation preserved the earlier focus on the affective aspects of the alliance (i.e. bond), while also incorporating more cognitive dimensions as well (i.e. tasks and goals). Bordin’s work led to a desire among researchers to further develop ways to measure the alliance based on his initial operationalisation. Around this time there was a surge of interest in psychotherapy integration and psychotherapy research on the alliance.

Alliance as Intersubjective

Jeremy Safran and J. Christopher Muran, along with their colleagues Catherine F. Eubanks and Lisa Wallner Samstag, advanced a further reformulation of the alliance. They agreed with Bordin that at an explicit level, patient and therapist collaborate on specific tasks. However, on an implicit level, they are also negotiating specific desires derived from underlying needs.

In this regard, the authors invoked the motivational needs for agency (self-definition) and communion (relatedness), and the existential need for mutual recognition (to see another’s subjectivity and to have another see one’s own as the culmination of knowing one exists), to advance an intersubjective consideration.

The authors suggested ruptures invariably occur as result of the inherent tensions in the negotiation of these dialectical needs. They distinguished between withdrawal and confrontation rupture markers, interpersonal communications or behaviour by patient or therapist.

  • The former includes movements away from self or other: that is, movements towards isolation or appeasement, pursuits of communion at the expense of agency.
  • The latter includes movements against the other: that is, movements towards control or aggression, pursuits of agency at the expense of communion. They defined the repair of these ruptures as a critical change process.

Alliance in Psychotherapy Research

Beginning in the 1970s, the alliance construct became a primary focus of psychotherapy research. This can be attributed largely to Bordin’s reformulation, which led to the development of Working Alliance Inventory (WAI) and Lester Luborsky’s Penn Helping Alliance Questionnaire (HAq). The Vanderbilt Psychotherapy Process Scales and the California Psychotherapy Alliance Scales (CALPAS) were other noteworthy measures.

Christoph Flückiger, AC Del Re, Bruce Wampold, and Adam Horvath conducted a meta-analysis on the alliance in psychotherapy. The researchers synthesized 295 independent studies of over 30,000 patients published 1978-2017. Results confirmed a moderate relationship between alliance and psychotherapy outcome.

In addition, Eubanks, Muran, and Safran conducted two meta-analyses on rupture repair in the alliance. The first indicated a moderate relationship between rupture repair and outcome. The second examined the effect of an alliance-focused training on rupture repair. Results suggested some support for the effect of such training.