Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example
Please answer the following 2 questions:
1. In what ways might Peplau’s theory of interpersonal relations need to be revised to be the most useful to nurses in the health care environment in which contact time between nurse and client is limited?
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2. One of the patterns of attachment is referred to as “earned secure” This pattern, characterized by coherence and balance, is achieved by adults who experienced unloving or harsh parenting. What individual characteristics or life experiences might contribute to achievement of this pattern? Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
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Text: Middle Range Theories: Application to Nursing Research
Sandra J. Peterson PhD RN, Timothy S. Bredow PhD RN NP-C
LWW, Fourth, 2017 (ISBN-10: 0060000449)
Other sources: Articles within the last 5 years, from from peer-reviewed nursing journals may be used. Please attempt to add at least two other sources.
Refer to the Rubric for further assignment details. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
Peplau and Bowlby Theories
Question 1. In what ways might Peplau’s theory of interpersonal relations need to be revised to be the most useful to nurses in the health care environment in which contact time between nurse and client is limited?
Peplau’s Theory holds that the core function of nurses is to aid others who are in difficulty and need their help. In fact, it explains that nurses are therapeutic agents. In this case, it emphasizes the importance of the contact between nurses and their clients since this allows the nurses to have closer interactions with patients. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. For that matter, it views maintaining good interpersonal relationships as a core responsibility of nurses. Longer interaction times allows the relationship between the nurse and client to become mature at a faster rate so that they arrive at an acceptable goal speedily. The implication is that should the contact time between the patient and the client be limited, then the relationship will mature at a much slower pace and an acceptable solution will only be developed at a later time (Barker, 1998). To address the concern of limited contact time between the nurse and client that results in slower rate of relationship maturity, there is a need to revise Peplau’s Theory so that it allows for adoption of information technology solutions, particularly self-guiding applications that direct the clients through routine processes such as acting as a resource that offers specific required information on a situation or emerging problem. Self-guiding applications entail simple operations without the need for complex user guides. This would allow the theory to be abreast with the social transformations that have characterized the 21st century to include information technology advances and Internet developments (Peplau, 1997). Social transformations refer to social changes that have been experienced to include the internet and social media. These information technology solutions (such as smartphone applications and online resource centers) can substitute for the nurses in routine activities and only require nurses to intervene in areas where automated application cannot substitute for them. It is important to note that the revision does not eliminate the need for nurses Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. Rather, it assigns them a supervisory role where they only intervene when in-depth clarification is necessary (Peplau, 1997). For instance, when the nurse acts as a contact point and is required to assess the patient’s suitability for the technology or when building the interpersonal aspect of the relationship. In this respect, Peplau’s Theory should be revised to adopt information technology solutions and self-guiding applications to address the issues brought about by limited contact time between the nurses and clients.
Question 2. One of the patterns of attachment is referred to as “earned secure” This pattern, characterized by coherence and balance, is achieved by adults who experienced unloving or harsh parenting. What individual characteristics or life experiences might contribute to achievement of this pattern?
The term ‘earned secure’ refers to a specific pattern of attachment that describes persons who had initially been evaluated to be insecure but later in time would change their assessment to secure. The change between secure and insecure describes the level of trust assigned to relationships. For instance, a trusting relationship is considered secure. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. The change from insecure during childhood to securing in adulthood is typically seen in adults whose childhood was particularly difficult and caused an expected assessment of insecure and yet their state of mind turns out to be secure in adulthood. In essence, it can be interpreted that the adult being assessed has an interchangeable attachment status since he or she does not have a specific way of regulating attachment distress and can regulate it over time. There are specific individual characteristics and life experiences that might contribute to the achievement of ‘earned secure’ pattern of attachment (Peterson & Bredow, 2017). The most common contributor is relationships that allow children to change from insecure when younger to secure as they turn into adults. In this case, the child understands the difficulties associated with insecurity and tries to address these difficulties by striving for security in adulthood. For that matter, if the child had uncooperative and insensitive parents and complained about the detriments of such a relationship, then he or she would try to be cooperative and sensitive as an adult so that a secure relationship is created. It can be understood that security and insecurity are resultant of relationships so that ‘earned secure’ ensues when the individual gains greater control over the relationship and can pursue desired outcomes. Additionally, it would explain an acknowledgment of attachment needs. For instance, being avoidant and failing to acknowledge attachment needs results in insecurity with ‘earned secure’ resulting when an attachment is acknowledged. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. This is typically seen when clingy children deal with unpredictable and preoccupied parents who are caught up in their attachment experiences. The children envision the security that they desire and apply it as they grow older resulting in ‘earned secure’ (Peterson & Bredow, 2017). As a result, experiencing insecure childhoods with disorganized, insensitive, uncooperative, dismissive and preoccupied parents can result in secure adulthoods when the child seeks to reverse the bad childhood-relationship experiences.
References
Barker, P. (1998). The future of the Theory of Interpersonal Relations? A personal reflection on Peplau’s legacy. Journal of Psychiatric and Mental Health Nursing, 5, 173-180.
Peplau, H. E. (1997). Peplau’s Theory of Interpersonal Relations. Nursing Science Quarterly, 10(4), 162-167.
Peterson, S. J. & Bredow, T. S. (2017). Middle Range Theories: Application to nursing research (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
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The legacy
In formal terms, psychiatric nursing has been the
beneficiary of Peplau’s interpretation of the theory of
interpersonal relations for more than 45 years (e.g. Peplau
1952, 1962, 1963, 1964, 1969, 1987, 1990, 1992, 1996).
For those nurses who were her colleagues, or her early students, the legacy of her understanding of the significance of
that theory, and of the proper focus of nursing, is even
longer. As someone whose encounter with Peplau’s work
was serendipitous, and occurred relatively late in my
career, my appetite for her theoretical, professional and
practical writing derives, in part, from an appreciation of
what I might have missed. That said, I hope that this
paper will be read neither as an apologia for Peplau’s position on psychiatric–mental health nursing (PMHN) nor a
hagiography. Whichever perspective one takes, Peplau’s
exploration and clarification of the theory, and her examination of its relevance to various practice contexts, has significance. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. However, the greatest compliment anyone
might pay to this pioneer, in the professional and academic development of PMHN, would be to submit her work to
continuing critical appreciation and appraisal.
A significant dimension of Peplau’s work involves its
focus on human issues. It is that aspect of Peplau’s oeuvre
that I shall emphasize, in this estimate of her value for
future generations of PMH nurses (cf. Peplau 1995).
Peplau’s humanity has been acknowledged by her colleagues, who recognize the ‘mother of psychiatric nursing’
(Lego 1996) as a:
wise, caring and gentle person (who) is one of the finest
and best scholars the profession has known . . . for over
60 years her scholarship has been evocative, informative, and provocative (Sills 1989, p. viii).
This suggests the complex dimensions of true leadership,
and connotes the benefits accrued by the field during her
tenure as one of its leaders. Today, PMHN is under threat
in most of the countries in the developed world, either in
terms of its presumed function or its substantive focus
(cf. Barker 1995, Dawson 1997). During the writing of this
Journal of Psychiatric and Mental Health Nursing, 1998, 5, 213–220
© 1998 Blackwell Science Ltd 213
The future of the Theory of Interpersonal Relations? A personal
reflection on Peplau’s legacy
P. BARKER P h D RN FRCN
Professor of Psychiatric Nursing Practice, Department of Neuroscience and Psychiatry, University of Newcastle,
Royal Victoria Infirmary, Newcastle Upon Tyne
BARKER P. (1998) Journal of Psychiatric and Mental Health Nursing 5, 173–180
The future of the Theory of Interpersonal Relations? A personal reflection on
Peplau’s legacy
The work of Hildegard Peplau represents the most significant influence, worldwide, on the
development of psychiatric nursing practice. Her use of the Theory of Interpersonal
Relations created the basis for defining the potential significance of the psychiatric nurse’s
role as a therapeutic agent. Forty years later she has indicated the means by which nurses
might sharpen their focus on the person often overshadowed by the ‘patient’ label. Peplau’s
writings have, over this 40-year period, helped clarify the broad range of roles required of
the nurse in general and in particular, within psychotherapeutic nursing.
Keywords: interpersonal relations, Peplau’s theory, psychiatric–mental health nursing
Accepted for publication: 15 January 1998 Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example
Correspondence:
Phil Barker
Department of Neuroscience and
Psychiatry
University of Newcastle
Royal Victoria Infirmary
Newcastle Upon Tyne NE1 4LP
UK
paper, I received requests, simultaneously, from colleagues
in Spain and England to help them argue the case against
the removal of nurses from specific mental health care settings (especially for people with ‘chronic mental illness’)
and their replacement with ‘generic care workers’. Nurses
around the globe, almost daily on the Internet, echo such
defensive actions. As the ‘mother of psychiatric nursing’
grows toward her 90th year, one wonders who might, conceivably, take her place in providing the evocative and
provocative advocacy that psychiatric and mental health
nursing appears to need now more than ever. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
Paper models and living theories
Peplau is, unarguably, the most widely acclaimed psychiatric nursing theorist. However, McKenna (1993) discovered that, at least at the level of implementation in practice,
she had only limited popularity. It is not altogether clear
what this might mean for nursing theory or practice. Given
the academic significance of Peplau’s exposition of the
theory of interpersonal relations in nursing, no obvious
acceptable explanation exists for the disinterest or apparent hostility towards her work (Gournay 1995). These
conditions may be a function of cultural differences. The
North American nursing tradition, within which Peplau’s
work is embedded, characteristically differs from that of
other countries. There exists a well-established graduate
tradition within PMHN, including a 40-year history of
Master’s level education. These twin traditions also have
enjoyed a theoretical and practical understanding of psychotherapeutic nursing which, arguably, is to be found in no other part of the world. In 1994 the American
Psychiatric Nurses Association hosted a conference based
upon a critical appraisal of psychiatric nursing spanning
almost five decades (1947–94). No other nation could
match the sheer quantity of literature published since the
end of World War Two, far less the quality of its academic
standing. In that sense most, if not all, other nations are
‘underdeveloped’ by comparison with the USA. Nurses in
other countries who have tried to ‘implement’ Peplau’s
theory may, in a professional sense, simply not be ready for
the challenges associated with Interpersonal Theory.
In more specific terms, it is clear that many of the
nurses who have tried to accommodate the Theory of
Interpersonal Relations in their work will have only
limited opportunity to experience, at first hand, the experiential teaching dimension (Peplau 1957) of education in
practice, for practice. In the UK, for example, many generations of nurses have been taught in classrooms by nurse
teachers, both of which are remote from the everyday clinical practice context to which Peplau referred (cf. Reynolds
1982). By contrast, many North American nursing students will have been exposed to ‘clinically focused learning’ by their teachers – up to and including the Professor of
Nursing – in the clinical milieu.
If there are any grounds for accepting this professional–cultural hypothesis, it may be that the nature of
their educational preparation generates, unwittingly, a
contextual threat when nurses are required to ‘experience
directly’ and ‘reflect upon the experience’ of relating to
their patients, far less (how they experience) themselves.
Such anxieties may encourage nurses to elect to employ
‘models’ of nursing (as opposed to a theory) that provide
them with the security they desire: structures that will
contain their interactions with patients. Such ‘containment’ may also serve as a buffer against too close an
engagement with people in severe mental distress. A
handful of authors have, within recent history, expressed
overtly critical views of Peplau and her theorizing, wishing
to consign them both to the dustbin of history, or to write
them off as mere footnotes to nursing history. Such criticisms may have a critical subtext. They may merely be
extreme examples of the ‘continuing critical appreciation
and appraisal’ of Peplau’s contribution Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. They may, alternatively, be illustrations of the experiences of nurses who
have not been acculturated in the experiential tradition
that underpins Peplau’s theorizing. Such criticisms may
even be interpreted as indicative of a lack of understanding
of Peplau’s work, or a failure to appreciate its significance.
In Lego’s view, some critics – such as Gournay (1995) –
may even be harbouring competing ambitions for the
future of PMHN (cf. Lego 1997). What is not in dispute,
and is remarkable, is that the first theory to be applied rigorously within nursing, and its advocate, should still be at
the heart of an academic controversy almost 50 years after
its first publication.
Despite having been in retirement for more than two
decades Peplau continues to contribute to debates about
nursing, mental illness and health, and the role of the
nurse in describing and responding to such phenomena.
However, her recent re-emphasis of the personal dimension of interpersonal theory presents some nurses with a
conundrum. As Rolfe (1996) has observed, Peplau is
proposing that everyone should be treated as individuals,
emphasizing how people differ from one another. However, this may mean that (Rolfe 1996, p. 332):
She is saying, in effect: my model, which applies to
everyone, is that there are no models which apply to
everyone. Thus, if the proper focus of nursing is the
unique and individual therapeutic relationship, then
neither models nor theories (nor indeed, research-based
practice) have a primary role to play in the planning and
implementation of nursing care.
Rolfe’s view presents an intriguing challenge: does the
P. Barker
214 © 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 213–220
mere existence of any model or theory of interpersonal
relations prejudice naturalistic inquiry into the ‘uniqueness’ of the individual patient? Alternatively, how shall we
‘map’ the unique territory of the individual person qua
patient, without the guiding parameters of some model or
theory? (cf. Grinder & Bandler 1976). Given that the
answers to such questions are not immediately apparent,
they may represent areas of further research into the roles
and functions of models and theories for professional practice.
The identity of psychiatric nursing: paradigms
old and new
Although not specifically concerned with consciousness per
se Peplau’s use of the Theory of Interpersonal Relations
encouraged nurses to look beyond the delimiting parameters of the patient label and to begin to consider what it
might mean to be the person. Indeed, her recent interest in
‘persons’ (Peplau 1995) suggested the almost infinite possibilities afforded by the exploration of interpersonal dialogue. As Oatley (1990, p. 83) observed:
Freud’s striking proposal is that in a dialogue, that can
be retold in a story form, about abuses of power, about
imperfections and evasions, we can take a few steps
towards truths that may be transformative. It was this
idea that Freud glimpsed; even if not quite clearly
enough to transform himself .
Peplau had earlier remarked that: ‘language influences
thought, thought then influences action; thought & action
together evoke feelings in relation to a situation or context
(Peplau 1969, p. 267). The interest in the role of language
extends to contemporary cognitive scientists. Fodor (1983,
p. 56) has acknowledged that:
Our privileged access to thoughts is, to a considerable
extent, a matter of the contents of our beliefs and
intentions being available for verbal report [emphasis
added].
Common sense logic decrees that we could hardly overstate the importance of such ‘verbal reports’, as contributions towards our understanding of what it means to be a
person, in any given situation – including that of health or
illness. Yet, increasingly the examination and exploration
of the state of being – on an existential level – has been
marginalized. The emerging consensus is that we might
understand what it means to be human, by unravelling the
mysteries of the brain through which our beliefs and intentions are expressed.
This raises the question, what is the proper focus of
nursing? (Barker & Reynolds 1996). More specifically, we
might ask is nursing concerned with the ‘mind’ or its
brain? Almost 20 years ago the US government pledged its
support for a portfolio of neuroscientific research earning
the 1980s the title ‘Decade of the Brain’. Although the
impetus for that paradigm shift has grown exponentially, it
remains unclear to what extent laboratory-based research
will explain, far less resolve, human problems that may
derive from a complex of person–environment interactions
in the organized chaos of the everyday world (Barker
1996a). The influence of the ascendancy of neuroscience is
now being felt within PMHN. It has been advocated that
psychiatric nurses should accommodate various biomedical models of understanding human problems (e.g.
Torrance & Jordan 1995) and should employ biological or
psychopharmacological models as a means of understanding their patients (cf. Gournay 1995). Whether or not such
approaches will help us understand those patients as
persons (cf. Rolfe 1996) remains unclear. These views
appear closely aligned to the contemporary drive towards
‘clinical effectiveness’ and ‘evidence-based practice’ (e.g.
NHSE 1993), both of which appear to favour the perceived ‘gold standard’ of randomized control trials (RCTs)
and the virtue of quantifying human experience.
At the risk of stereotyping, these latter-day representations of the ‘old (Cartesian–Newtonian) paradigm’ (cf.
Capra 1976) appear to represent an overtly ‘masculine’
psychiatric world view: focused on the negative attributes
of people; their conflicts and past traumas, or their contemporary consequences. That paradigm adopts an essentially rational, analytic, linear, objectifying, fragmenting,
dismantling, disempowering and distancing approach to
human distress; assuming the presence of a subject-object
duality that neither fits with everyday experience nor with
the propositions of contemporary physics, far less psychology and sociology. Ultimately, its conjoint aims may be the
control of such psychiatric phenomena, through the
refinement of its techniques. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. The ‘old paradigm’ may represent the patriarchal imbalance in post-modern society,
one that fails to acknowledge – far less approve of – its
‘feminine’ side. Dawson (1997, p. 70) has argued that:
the language of nursing, of meaning, of care, of subjectivity and of spirituality has been suborned by the onedimensional language of the technocratic society, which
purchases a spurious exactness at the cost of meaning.
In healthcare that ‘old paradigm’ technocracy finds
expression in materialism and managerialism, both of
which implicitly challenge the principles upon which many
nurses believe that nursing is founded, and is (Dawson
1997 p. 70):
revealed in the tortured vocabulary that attempts to
reconstitute the whole from the pieces left strewn on the
battlefield of rational investigation: ‘biopsychosociocultural’, ‘psychosocial’ mantras that are repeated ad
nauseam in psychiatric nursing texts. The words themFuture of Interpersonal Relations
© 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 213–220 215
selves indicate the essentially divided and atomistic
nature of the constructed reality that their enforced
unity parodies; the mode of reasoning being employed is
still, in essence, analytic rather than holistic, and the
praxis is instrumental and objectifying.
In its ambition to ‘treat’ people, albeit compassionately,
approaches derived from the ‘old paradigms’ largely
eschew attempts at understanding. Despite its continued
celebration of the value and relevance of post-positivist
methodology (cf. Guba 1991), Western culture has been
flooded with proposals for a ‘new paradigm’ of science;
one that suggests the inherent wisdom of balancing ‘masculine’ and ‘feminine’ world views. Borrowing the Oriental
metaphor of Yin and Yang, this new paradigm recognizes
that science and the arts are complementary and, more
importantly, emphasize the need to view human experience
in terms of contexts and wholes, rather than isolated parts
(cf. Barker 1998). Within the context of mental distress
and health the new paradigm emphasizes the value: in
research, of co-operative inquiry (Heron 1996); in practice,
of working alliances (Anderson 1991); in mental health, of
valuing personal experience (Chamberlin 1984, Fisher
1992); and, generally, of tolerating paradox and uncertainty (Ikehara 1995). Given these assumptions, the ‘new
paradigm’ honours people’s feelings and intuition, recognizing that in deciding upon and enacting life change a
person must first reclaim her (sic) inner wisdom and
power.
Qualitative research methods are integral to this paradigm shift and nursing has, perhaps, embraced such
approaches to human inquiry, more so than other health
care disciplines. Several studies have suggested that the
‘value’ attributed to psychiatric nursing, by people receiving nursing, is predicated on the form and function of
the interpersonal relationship (Barker 1995, Barker et al.
1997, Beech & Norman 1995, Hellzen et al. 1995, Wray
1994). These studies echo the dictum of the ANA (1980)
that nursing is focused on human responses to health care
problems rather than on the problems themselves. Of particular note, in this context, was the English national
survey of over 500 former ‘patients’ which not only
reported greater value attached to nurses over any other
discipline, but a preference for the ‘soft focus’ of relationships over formal methods of counselling or therapy
(Rogers, Pilgrim & Lacey 1993).
Even some psychiatrists have challenged the potential
confusion between what might be happening in the brain
as opposed to what might be happening within the person
(cf. Thomas 1997). Given the importance of psychopharmacology in contemporary psychiatry, Healy (1990) proposed the need to re-establish a phenomenological
approach to drug treatment: how do drugs affect the mind
or the individual consciousness? These examples suggest
that reflective psychiatrists also recognize the interpersonal
importance of the psychiatric experience: persons may
have as much of a relationship with their brains as they do
with other aspects of their experiential world.
Relationships, partnerships and alliances
These contemporary developments carry discrete implications for the role of the PMH nurse. As awareness of the
interdependent, or reflexive, nature of the interpersonal
relationship grows, it has been recognized that ‘consumers’
of mental health services need (or perhaps rather deserve) a
voice to determine their own affairs. This has led, indirectly, to greater emphasis being put upon the potential
for, or desirability of, a more collaborative style of relationship; one guided more by co-operative inquiry than the
objective style of inquisition often favoured by the ‘old
paradigm’. Contemporaneously, the value (and virtue) of
psychotherapy in general has been attacked (Masson
1988), and many mental health service consumers appear
openly antagonistic to any form of ‘systematic’ therapy
(Rogers, Pilgrim & Lacey 1993). Although representing
differing perspectives, these critiques invite us to consider
the potential of concepts such as ‘working in partnership’
(cf. DoH 1994).
Given that partnerships are predicated on equality, conspicuously absent from most, if not all, care and treatment
settings, it might be more appropriate to consider a future
established on alliances (cf. Bordin 1976). Such a concept
might form the basis for exploring the interpersonal relationship between nurse and patient (sic). This concept
might also represent a new dimension for the supervisory
and mentoring relationship which, despite widespread
popularity, is still misunderstood (Barker 1990). More
than 30 years ago Peplau began to identify some of the
issues involved (O’Toole & Welt 1989, p. 165):
(what would it [clinical supervision] be like?), e.g. a systematic study of instances of clinical data in one case or
several cases; relevant literature; and a beginning formulation of an explanation of the data.
The kind of supervisory relationship which Peplau was
discussing appeared to be predicated on a power relationship: where the supervisor and supervisees were defined, at
least in part, by their respective qualifications, experience,
etc. Currently, I am a member of a peer supervision group
where, despite my professional status as ‘the Professor’ I
am re-defined – by my colleagues – as being on the same
level as the most ‘junior’ staff nurse member. The agenda
for all meetings of the group are mutually negotiated and,
despite the differentials in length of experience and social
status, my contribution is (in principle) of no greater value
P. Barker
216 © 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 213–220
than that of any other member. Such developments in the
structure of clinical supervision suggest the potentially limitless range of ways in which nurses might come to know
their professional practice (cf. Reynolds 1982). Such developments might even reflect one way in which the basic
tenets of Interpersonal Theory might be used in contemporary practice to cover the processes governing the relationship with self and others, of both patients & nurses.
The focus on the person: a future for human
inquiry?
In her keynote address to the second ‘State of the Art
in Psychiatric Nursing’ conference, held in Columbus,
Ohio in 1974, Peplau returned to one of her prevailing
interests – people in schizophrenia. Perhaps, of equal
significance to her consideration of how nurses might
address the human responses associated with schizophrenia (cf. ANA 1980), was her assertion that nurses needed
to emphasize the ‘personhood’ of patients. Two decades
earlier, at the first ‘State of the Art’ conference, she urged
her colleagues to recognize that (Peplau 1995):
It is not enough to preach commitment to nursing or to
patients. The commitment of a professional requires
thinking deeply about unanswered questions, doing
something to clarify them, and reporting results of
actions to colleagues in the profession at large.
Peplau’s concern to explore the ‘personal’ and ‘human’
context of the expression of mental distress echoed the
early writing of Harry Stack Sullivan, with whom Peplau
worked early in her career at Chestnut Lodge (Barker
1993). Sullivan had observed that even the ‘most peculiar
behaviour’ of the acutely schizophrenic patient was intelligible, since it comprised interpersonal processes ‘with
which each one of us is or historically has been familiar’
(Sullivan 1947). In Sullivan’s view people were ‘all much
more simply human than otherwise’, leading him to conclude that it was possible to understand psychotic phenomena, since we are all more alike than different. Sullivan
represented a radical stance in post-war psychiatry that
most of his contemporaries found too uncomfortable. His
emphasis of the interpersonal and human nature of psychiatric care and treatment was revived 20 years later when
Laing paid homage to Sullivan’s respect for the ‘patient’,
repeating the apocryphal story that Sullivan told all young
psychiatrists who came to work with him (Laing 1967):
I want you to remember that in the present state of our
society the patient is right and you are wrong.
It was not surprising that Sullivan’s views found an echo
in the psychiatric counterculture of the 1960s. Given her
history, neither is it surprising that Peplau should appear
to be advocating a more inductive approach to gaining real
understanding of the human experience of what is designated mental illness – through an acknowledgement of the
personal nature of such experience. What is, perhaps, surprising is that in the late 1990s some psychiatric nurses
advocate that we should return to the method of approaching patients (sic) against which Sullivan cautioned more
than 50 years ago: treating people designated patients as if
they were all likely to present the same phenomena (cf.
Gournay 1995). There is room for all manner of inquiry in
PMHN. However, attempting to understand the experience of human distress associated with mental illness (sic)
may well be the ‘proper focus of nursing’ (Barker &
Reynolds 1996; Barker, Reynolds & Stevenson 1997). The
furtherance of an ‘existential epistemology of mental
health’ may be one of the threads of human inquiry that
will link tomorrow’s psychiatric nurses with Peplau’s original theory and may, in practice terms, be the royal road to
care.
Psychiatric nursing practice research:
grounded inquiry
As Peplau observed, nursing has for at least a generation
espoused the virtues of person-centredness or holism or
both (Peplau 1995). In keeping with such an attitude it
may be appropriate for nurses to approach the person (sic)
in much the same way that a student approaches any
‘subject’; with the expectation of learning something of
interest or value. In my own clinical work and research I
have attempted to extend the basic Peplau method (if there
is such a thing) to integrate the twin philosophies of ‘personhood’ and ‘holism’ (Barker 1996b).
Almost a decade ago I counselled a young woman who
had been described as having a depressive illness, in association with an ‘interpersonal relationship problem’, involving ‘especially men’. Her problems were attributed to her
experience of rape in her early teens. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. When I first met
her she was reluctant to discuss anything at all, and
mumbled inaudibly in response to my question: ‘What
have you brought along that you would like to talk about?’
(cf. Robinson 1983). Wholly intuitively I found myself
saying:
OK, maybe there is nothing that you would like to talk
about. Maybe there is something that you need to talk
about but don’t want to talk about. Talk about that
then, but don’t tell me what it is.
When she appeared perplexed by this suggestion, again
intuitively, I said: ‘well . . . just call it “X” or the “blue
banana”!’ (at which point she laughed, incredulously).
After a pause, I returned to the tried-and tested interviewing technique that I had derived from Peplau’s writings:
OK, tell me . . . when did you first notice that X (or are
Future of Interpersonal Relations
© 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 213–220 217
you going to call it the blue banana) was a problem for
you?
The rest was, as they say, history. I saw the young
woman only twice: the second time when she came back to
report that ‘things are much better’ and that she had ‘got
my life back on track’. From that single clinical experience,
I developed a method for teaching nurses how to interview
people without knowing what (exactly) was the patient’s
problem. This allows the exploration of at least eight
dimensions of any anonymized problems: from its ‘origins
in time’ to its holistic context (Barker 1997). A delimited
study (Barker 1996b) suggested that nurses can explore the
person’s problem without becoming overly concerned with
the detail of the story, and in the process appear, by the
patient’s account, to develop considerable rapport. More
importantly, the approach affords the person qua patient a
degree of security that might prove helpful in the early
stages of the development of therapeutic relationship.
Although nurses could apply this method in any clinical
situation, it may have special applications in contexts
where the patient is reluctant to discuss the focal phenomenon, for fear of negative evaluation by the nurse or others:
experience of sexual abuse or hallucinations.
Other areas of practice that offer fertile conditions for
the further examination of Peplau’s theory in its original
form, or as part of some wider research brief include:
• the assessment of the patient’s interpersonal world
(Barker et al. 1997);
• mutual assessment of the nurse–patient relationship;
• the outcomes of focused relationships – e.g. on the experience of discrete phenomena such as hearing voices;
• the experience of long-term drug therapy; and
• invisible forces and subconscious crises.
I was honoured to be asked to give the first keynote
address to the inaugural conference of the nursing section
of the Association of Psychoanalytic Psychotherapists in
the NHS (APP) at the Tavistock Clinic in London in 1996.
In my paper I discussed the respective contributions made
by Peplau – and her British counterpart, Annie T. Altschul
– to the development of interests and expertise in the therapeutic use of the nurse-patient relationship (Barker 1997,
Winship 1997). I was struck by the number of participants
– many of them sophisticated nurse psychotherapists –
who knew little of Peplau’s work, or the huge literature
associated with her Theory of Interpersonal Relations. I
was similarly intrigued by the relative absence of references
to the nursing literature in some of the clinical papers that
followed. This experience echoed Peplau’s observation,
made in her Preface to the report on the first state of the art
conference (Huey 1975; Peplau 1995, p. ix):
Psychiatric nures need to judge what has been done in
the light of such questions as: How adequate is the published theory? Is it all borrowed from other basic or
applied sciences or have psychiatric nurses suggested
new concepts or practices or expanded existing ones? In
the light of changing nurse practice acts and other social
and health care trends, what are the weak, unexplored,
untouched areas that should capture the interest of psychiatric nurses in theory scholarly and research efforts
in the years ahead?
In that same Report Lego (Lego 1995 p. 82), describing
developments in the ‘one-to-one nurse–patient relationship’, observed that, despite Peplau’s primacy in the
nursing theory literature, at that time (1974 – Peplau 1995,
p. 2):
most psychiatric nursing textbooks, while emphasising
the nurse-patient relationship, base nursing actions on
non-nursing theory, particularly psychoanalytic or
sociocultural theory.
Twenty years later, Peplau echoed that observation,
when she commented on ‘seven recently published books
on PMHN’:
I expected to find a psychiatric nursing approach to the
care of persons diagnosed as schizophrenic that would
be complementary to but different from the prevailing
biomedical model of psychiatric treatment. The
DSMIII-R . . . was presented in whole or in part in virtually all chapters. In several texts, schizophrenia was
described with pessimistic words such as ‘irreversible’,
‘chronic’ and life-long, rather than as a persistent
enigma for which the health professionals have not yet
found reliable explanatory theories and effective remedial measures. . . . Most of the bibliographic references
cited were non-nursing psychiatric ones; only two
authors used quite a few nursing publications; one
author did not use any nursing references (emphasis
added).
I was struck by the fact that, 20 years into her retirement, Peplau retained a sense of purpose, concerning the
clarification of nursing theory and practice. She also exhibited a concern for the human condition, which appeared to
be missing from my generation, who were still young children when Peplau first published her seminal text (Peplau
1952). One might argue that, in her advocacy for ‘persons’
in schizophrenia (or indeed any other category of human
distress), Peplau is still holding the baton of human inquiry
(and compassion) that may have been held by Sullivan, and
was held briefly by Laing and others. Clara Thompson, a
long-time colleague of Sullivan’s, suggested that his principal contribution to psychiatry was a very simple idea
(Hausdorff 1985):
. . . ever present awareness of the need to convey respect
for the patient and to maintain the patient’s own selfesteem.
P. Barker
218 © 1998 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 5, 213–220
Sills’ appreciation of Peplau (Sills 1989) clearly indicates
that she perceived her in a similar light. If psychiatric
nurses could continue to explore, collaboratively – with
the people in their care – the experience of human distress,
then they might honestly be said to be ‘working in partnership’ (DoH 1994) or involved in the development of
‘mental health nursing’, predicated on human growth and
development, derived from the logic of their own experience (Barker 1996b).
Notes
1 Where I am making ‘personal’ observations it seems
appropriate to employ the first person.
2 I use this conjoint title to convey the mutual interdependence that I believe Peplau intended.
3 My speculations about the future are, like most such
thoughts, woven through my past and present experiences.
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Peplau and Bowlby Theories
Question 1. In what ways might Peplau’s theory of interpersonal relations need to be revised to be the most useful to nurses in the health care environment in which contact time between nurse and client is limited?
Peplau’s Theory holds that the core function of nurses is to aid others who are in difficulty and need their help. In fact, it explains that nurses are therapeutic agents. In this case, it emphasizes the importance of the contact between nurses and their clients since this allows the nurses to have closer interactions with patients. For that matter, it views maintaining good interpersonal relationships as a core responsibility of nurses. Longer interaction times allows the relationship between the nurse and client to become mature at a faster rate so that they arrive at an acceptable goal speedily. The implication is that should the contact time between the patient and the client be limited, then the relationship will mature at a much slower pace and an acceptable solution will only be developed at a later time (Barker, 1998). To address the concern of limited contact time between the nurse and client that results in slower rate of relationship maturity, there is a need to revise Peplau’s Theory so that it allows for adoption of information technology solutions, particularly self-guiding applications that direct the clients through routine processes such as acting as a resource that offers specific required information on a situation or emerging problem. Self-guiding applications entail simple operations without the need for complex user guides. This would allow the theory to be abreast with the social transformations that have characterized the 21st century to include information technology advances and Internet developments (Peplau, 1997). Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. Social transformations refer to social changes that have been experienced to include the internet and social media. These information technology solutions (such as smartphone applications and online resource centers) can substitute for the nurses in routine activities and only require nurses to intervene in areas where automated application cannot substitute for them. It is important to note that the revision does not eliminate the need for nurses. Rather, it assigns them a supervisory role where they only intervene when in-depth clarification is necessary (Peplau, 1997). For instance, when the nurse acts as a contact point and is required to assess the patient’s suitability for the technology or when building the interpersonal aspect of the relationship. In this respect, Peplau’s Theory should be revised to adopt information technology solutions and self-guiding applications to address the issues brought about by limited contact time between the nurses and clients. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
Question 2. One of the patterns of attachment is referred to as “earned secure” This pattern, characterized by coherence and balance, is achieved by adults who experienced unloving or harsh parenting. What individual characteristics or life experiences might contribute to achievement of this pattern?
The term ‘earned secure’ refers to a specific pattern of attachment that describes persons who had initially been evaluated to be insecure but later in time would change their assessment to secure. The change between secure and insecure describes the level of trust assigned to relationships. For instance, a trusting relationship is considered secure. The change from insecure during childhood to securing in adulthood is typically seen in adults whose childhood was particularly difficult and caused an expected assessment of insecure and yet their state of mind turns out to be secure in adulthood. In essence, it can be interpreted that the adult being assessed has an interchangeable attachment status since he or she does not have a specific way of regulating attachment distress and can regulate it over time. There are specific individual characteristics and life experiences that might contribute to the achievement of ‘earned secure’ pattern of attachment (Peterson & Bredow, 2017). The most common contributor is relationships that allow children to change from insecure when younger to secure as they turn into adults. In this case, the child understands the difficulties associated with insecurity and tries to address these difficulties by striving for security in adulthood. For that matter, if the child had uncooperative and insensitive parents and complained about the detriments of such a relationship, then he or she would try to be cooperative and sensitive as an adult so that a secure relationship is created. It can be understood that security and insecurity are resultant of relationships so that ‘earned secure’ ensues when the individual gains greater control over the relationship and can pursue desired outcomes. Additionally, it would explain an acknowledgment of attachment needs. For instance, being avoidant and failing to acknowledge attachment needs results in insecurity with ‘earned secure’ resulting when an attachment is acknowledged. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example. This is typically seen when clingy children deal with unpredictable and preoccupied parents who are caught up in their attachment experiences. The children envision the security that they desire and apply it as they grow older resulting in ‘earned secure’ (Peterson & Bredow, 2017). As a result, experiencing insecure childhoods with disorganized, insensitive, uncooperative, dismissive and preoccupied parents can result in secure adulthoods when the child seeks to reverse the bad childhood-relationship experiences. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.
References
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Peplau, H. E. (1997). Peplau’s Theory of Interpersonal Relations. Nursing Science Quarterly, 10(4), 162-167.
Peterson, S. J. & Bredow, T. S. (2017). Middle Range Theories: Application to nursing research (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Peplau Interpersonal Relations Theory and Bowlby Human Attachment Theory essay example.