CHILDREN’S ATTACHMENTS WITHIN CHILD AND ADOLESCENT INPATIENT MENTAL HEALTH UNIT RENÉE KEYS B.A., Psychology, University of Calgary, 2012 A Project Submitted to the School of Graduate Studies of the University of Lethbridge in Partial Fulfillment of the Requirements for the Degree MASTER OF COUNSELLING Faculty of Education University of Lethbridge LETHBRIDGE, ALBERTA, CANADA © Renée Keys, 2018 CHILDREN’S ATTACHMENTS WITHIN CHILD AND ADOLESCENT INPATIENT MENTAL HEALTH UNIT RENÉE KEYS Dr. B. Shepard Professor Ph.D. Project Supervisor Dr. S. Dixon Assistant Ph.D. Project Committee Member Professor Abstract Despite differences in presenting complaints, backgrounds, and diagnostic status amongst children and adolescents within hospital mental health inpatient units, common deficits exist in many patients’ abilities to form meaningful and trusting relationships. Young patients suffering from mental illness have also been found to have unsatisfied attachment needs. With research on attachment remaining relatively new, gaps and fragmentations within hospital policies and treatment plans continue to exist. Such gaps have consequently led to a noted lack of mastery amongst many hospital staff in successfully providing services to patients. This is particularly true when navigating complex scenarios such as when dependent relationships between staff and patients form. Based on a thorough literature review, a set of guidelines and a concise checklist that foster consistency, sensitivity, and increased felt competency was developed to guide the actions of mental health staff when patients develop dependent relationships to the unit and staff members. iii Acknowledgements I would like to extend my greatest gratitude to Dr. Blythe Shepard for her ongoing support, patience, and encouragement through the completion of this project. During times of frustration it was your ongoing faith and positivity that helped me to continue pushing forward. You are truly a source of inspiration and I could not be more thrilled, and honoured, to have created this project that is so dear to my heart with you. To Dr. Sandra Dixon, your dedication and commitment to this project have been appreciated beyond words. Without your continued assistance this project would not be what it is today. I am truly grateful for your valuable comments and suggestions through this Masters project. iv Table of Contents Abstract ............................................................................................................................. iii Acknowledgments ............................................................................................................. iv Table of Contents ............................................................................................................... v List of Figures ................................................................................................................. viii Chapter One: Project Overview .......................................................................................... 1 Background ............................................................................................................. 1 Question .................................................................................................................. 4 Purpose and Value .................................................................................................. 5 Personal Interest ...................................................................................................... 7 Summary ................................................................................................................. 8 Definitions of Terms ............................................................................................... 9 Attachment theory ...................................................................................... 9 Attachment bond/affectional bond ............................................................. 9 Confirmation bias ..................................................................................... 9 Dependency ................................................................................................ 9 Insecure attachment .................................................................................... 9 Insecure-anxious (insecure ambivalent/resistant) ....................................... 9 Insecure-avoidant ...................................................................................... 10 Insecure-disorganized/disoriented ............................................................ 10 Over-dependency ...................................................................................... 10 Primary attachment figures/caregivers ..................................................... 10 Secure attachment ..................................................................................... 10 v Surrogate figures ....................................................................................... 10 Under-dependency .................................................................................... 10 Chapter Two: Review of Related Literature ..................................................................... 11 Attachment Theory ............................................................................................... 11 Attachment in Inpatient Settings ..........................................................................13 Internal Working Models of Attachments ............................................................ 16 Insecure-anxious ....................................................................................... 18 Insecure-avoidant ...................................................................................... 20 Insecure-disorganized ............................................................................... 22 Secure-attachment ..................................................................................... 23 Summary ............................................................................................................... 24 Over-Dependent Relationship Formation ............................................................. 25 Dependency .............................................................................................. 25 Over-dependency ...................................................................................... 27 Under-dependency .................................................................................... 29 Patient Experiences .............................................................................................. 30 Ethical Considerations .......................................................................................... 31 Guidelines Needed ................................................................................................ 33 Guideline Foundations .......................................................................................... 34 Chapter Three: Methodology .......................................................................................... 37 Literature Review ................................................................................................. 37 Development of Guidelines .................................................................................. 41 Ethical Considerations .......................................................................................... 41 vi Chapter Four: Suggested Guidelines ............................................................................... 43 Establishing Trust ................................................................................................. 44 Insecure-anxious ....................................................................................... 45 Insecure-disorganized ............................................................................... 49 Establishing Discussion ........................................................................................ 49 Debriefing ............................................................................................................. 53 Establishing Pre-Planning ..................................................................................... 54 Consistency ............................................................................................... 55 Predictability ............................................................................................. 56 Establishing Tapering ........................................................................................... 57 Chapter Five: Synthesis of Guidelines ............................................................................. 59 Overview .............................................................................................................. 59 Benefits ................................................................................................................. 60 Limitations ............................................................................................................ 60 Summary ............................................................................................................... 62 References ........................................................................................................................ 64 Appendices ....................................................................................................................... 77 A: Blank Identification Template ........................................................................