Unconditional positive regard?

I would like to think a little bit about the use of language within mental health. I have struggled for a couple of years with the kind of language that we use on a regular basis, but don’t really give it much more thought. I know we all have words or phrases that when heard, make your hackles rise. Here is a small selection of mine!  How about “therapeutic relationships” for a start, hands up if you can give a definition? I’m sure we all can, but it will mean something different to everyone. Yet we use it often, how many times do we hear people say, “well, first of all I’d build a therapeutic relationship with the person” No! No! No!

Conversation (click to see photographer)

I noticed that even Jim Chapman and Cheryl Chessum struggled with this concept in their chapter in “The fundamentals of mental health nursing”. Their research shows that Aldridge (2006) states that brief definitions of the therapeutic relationships are scarce, giving only one which is, “Building a genuine human alliance that might begin to address the person’s problems with living.” (Barker & Buchanan-Barker, 2005). Jim and Cheryl say that engagement with the client starts the therapeutic relationship. But does it ever get underway? And if it does, where to then?

Maybe it’s on to “Unconditional positive regard”. The good old statement that says I’m not really troubled that you have been violent and aggressive to people in the past, that you beat up your girlfriend so badly she lost her baby, or that you threw your 9 week old puppy down the waste disposal chute, I’ll accept you as you are now because I believe you were lacking “insight” at the time. But what it really means is that I will try and disguise the disgust I feel for your actions because I’m only human and because I’m told you have a mental health problem – but I’m not promising anything.

Speaking of insight…….The Collins English dictionary defines insight as;

“The ability to perceive clearly or deeply”

 And “a penetrating and often sudden understanding, as of a complex situation or problem. There is also, “3. psychol; The capacity for understanding one’s own or another’s mental processes”

“4. Psychia; the ability to understand one’s own problems, sometimes used to distinguish between psychotic and neurotic disorders”.

Now I consider myself to be a fairly rational, responsible and capable human being, but am I always insightful according to the definitions? I don’t think so! So why do we often hear, “Mr Jones, suffering from schizophrenia, lacks insight”. How dare we? A double whammy there – who says that everyone suffers from or with schizophrenia? I know of many people who have and still do enjoy their experiences.

I’m not so stupid as to think we can, or should get rid of this type of language, but I think we need to consider the implications of using it. Are we really being honest in our use of it? Does it exclude people because we as mental health professionals have a shared, common understanding of its meaning and others don’t? Is it a cunningly disguised way of stigmatising and discriminating against “service users/patients/clients” (there’s another area that we should really get sorted!)

What do you think?

 

(NB Click images to see photographers)

12 thoughts on “Unconditional positive regard?

  1. I found your post really interesting. All of the words you take issue with formed the basis of many a lecture during my nurse training at BCU, and can only remember one lecturer highlighting that ‘lacking insight,’ could be translated as ‘doesn’t agree with the doctor’s opinion.’ So I throw back to the Lecturing fraternity – are you brave enough to move away from the safety of Roger’s core conditions and confront your own posted question – ‘Are we being honest in our use’ (of such words) ??

    As lecturers, you are surely ideally placed to debate the use of such words…or would it be too big an ask during nurse training to move outside the confines of the well rehearsed theory of the ‘therapeutic relationship,’ and it’s constituent elements ?

    I think, as you raised, that having ‘unconditional positive regard’ for a client is a fallacy. But let’s be practical, I am not a robot, I am a person with my own prejudices, opinions and feelings. However, as a professional , my role is to use my nursing skills to ensure that this client’s mental health issues are assessed and treated appropriately. I am not there to stand in judgment. Having said that , the sort of examples you give (gratuitous physical violence) are surely more appropriate for the judicial system, rather than the mental health system, unless of course there is an underlying mental condition that has led to such actions.

    I do not profess to have ‘unconditional positive regard’ for anyone in this world and it is indeed irrelevant to my ability to build a ‘therapeutic relationship.’ I understand your disdain for this phrase, but to me these words convey professionalism and an objective, i.e., I am here to help you work through the issues that have led to your admission into hospital and plan for your discharge. So to me, the phrase is about their pathway through an acute admissions ward and onward. This relationship ends upon discharge, where hopefully another professional will take up this mantle. I often use the actual phrase with clients and stress to them that they need to be open and honest with the mental health team. This is not a wholly reciprocal relationship – I will be honest in my conduct but if I was asked a question that I felt it was inappropriate to answer I would not and would give my reasoning for that to the client.

    The ‘language’ debate rages in service user literature and professional circles. We have to be led by our client’s use of vocabulary and how they describe their experiences – but what of our responsibility as nurses and especially those of you reading who are lecturers, in continuing to propagate the myth of ‘unconditional positive regard.’

    Just because abacus’s were useful tools thousands of years ago doesn’t mean that it’s the best way to learn maths…..come on mental health lecturers, have the courage of your convictions, if you don’t like the language – encourage your students to debate it’s relevance.

  2. I don’t so much have a problem with the language as with the concept of “unconditional positive regard.” I’m a former patient and I think that is totally inappropriate.

    + If you have, or act like you have, unconditional positive regard for me, someone who has unconditional negative regard for herself, and ask me to see myself as you see me (as I was often told to do), that asks me to jump from one extreme to the other, entirely skipping over the middle ground called “realism”. And that jump is an entirely unrealistic jump. I was often told to think in terms of “baby steps”, to not expect too much of myself at one time. This is not a baby step. I am someday able to regard myself as you do, you will have created an arrogant monster.

    + Treating me with unconditional positive regard teaches me nothing about what to expect from others. No one else is going to treat me this way, nor should they. It will only make it seem worse when people treat me appropriately.

    + Treating my with unconditional positive regard teaches me not to take responsibility for my own actions.

  3. Yes, I’d agree with Jessa insofar as I don’t think anyone can have *unconditional* positive regard for a person. Even if we start from a positive point of view we are always going to make some judgments about them – that’s just human nature. And sad to say, I think human nature being what it is prejudice will chase language around until it catches up with it – in the way that ‘special needs’ is already becoming a playground insult. But that doesn’t mean we should stop trying; above all to treat other people as individuals and with kindness without losing our integrity. But that’s easier said than done of course which is where all the problems begin!

  4. I wonder whether you’re targetting the right issue with this. I agree with you that it’s easy to misunderstand or even to misuse terms like therapeutic relationship for example.

    However perhaps the problem isn’t with the term itself but with the way so many people substitute stock mantras such as this for real thought. The term itself is perfectly reasonable so long as people can understand what they mean by it.

    Regarding the term ‘unconditional positive regard’ itself I don’t think it has anything to do with people not taking responsibility for their actions. On the contrary I think it is about helping the person to take resonsibility without getting into value judgements about their worth as a human being.

    After all – we do people no favours by pretending that healthy functioning doesn’t involve taking resonsibility – there’s nothing positive about that. We simply don’t have to get into value judgements or guilt throwing in order to make that happen.

    So unconditional positive regard involves respecting the individual whilst being clear about their problems, working on errors in judgement to bring about change and helping them to take that succession of ‘baby steps’ mentioned above. It’s a relatively dispassionate process and certainly isn’t pejorative. That’s the strength of it. UPR has nothing to do with mawkish sentimentality or with saying

    “There, there, it doesn’t matter, everything’s wonderful really!”

    Cheers,

    Stuart

    The same is true for unconditional positive regard. The key is in understanding what we mean by it and that springs from introspection and reflective practice – the cornerstones of good mental health care in my opinion.

    For example – in training sesions on almost every subject I tend to ban the word ‘support’ – not because it isn’t possible to give support but because without further explanation the term becomes meaningless.

    Just like the phrases you have identified the difficulty arises when we allow ourselves to become complacent and believe that because we can label a process that’s the same as understanding it.

    This mirrors the diagnostic fallacy that to label a condition implies understanding when we all know that in reality nothing could be farther from the truth.

  5. I agree with Stuart in that we do have a lot of ‘stock phrases’ that get trotted out without any thought as to what they mean. I think there is no doubt that terms such as ‘Unconditional positive regard’ have been bent out of shape by the way they are used now.

    We do seem to borrow a lot of ideas from psychotherapy and of course also from medicine/psychiatry. I wonder whether this is because there is a relative vaccum in terms of thinking about what mental health nursing actually is?

    Whatever the truth of this, as lecturers we do sometimes find ourselves having to impress upon people the need to respect others. To give just one example, it is not uncommon to find that students are intent on actively discriminating against gay people – often on grounds such as a strongly held religious views.

  6. Quote: Are we really being honest in our use of it? Does it exclude people because we as mental health professionals have a shared, common understanding of its meaning and others don’t? Is it a cunningly disguised way of stigmatising and discriminating against “service users/patients/clients” (there’s another area that we should really get sorted!)

    Not forgetting carers/family members who can play an important role in their relatives recovery. A person’s recovery is not all based on the professional but interaction with everyone involved.

    That said !:

    I think certain terms are used to show you can talk the talk, it is impressive amongst professionals to be able to share a common langauage that is understandable to them. I have seen words used on professional forums that do not even exist in the dictionary, almost like they are made up words that mean nothing to the people that care is being delivered to.

    I would hope that “unconditional positive regard” would not mean that “I’m not really troubled that you have been violent and aggressive to people in the past” if this was as a result of the person’s mental illness, I would hope that it would be explored as to what was going on for the person at the time and explore ways of avoiding this reaction in the future.

    The word therapy or therapeutic is used to cover a wide range of things ie: talking to friends can be therapeutic as can taking exercise so I think the word therapeutic can be hijacked to cover a wide range of activities or treatments, in my dictionary the meaning of therapeutic is: a. remedial treatment n. branch of medicine concerned with treatment and cure of disease.

    Take a.Remedial = affording a remedy; Remedy = means of curing or releiving a disease.

    Relation: = Telling; account;feeling between persons, connection between things.

    Connection: to associate; to relate; to attach; to join; to have a close relation.

    A therapeutic relationship would need to work both ways not only the professional accepting and connectiong with the person but the person also being able to do the same with the professional. Both having an understand where each is coming from and the professional having the verbal and personal skills to be able to do this.

    Plain language works best, for those the service is aimed at.

    Although I do understand how hard it can be to put words into plain language the meaning behind what you do and using commonly accepted language makes this an accepted explanation amongst those who talk the talk. Maybe the explantion could come from your aims and what you hope to achieve with the person you are working with.

  7. I am very interested in the debate that has been generated about unconditional positive regard. Most of my clinical experience has been in forensic mental health nursing – where there could be a high level of aggressive behaviour.

    I think that even when the behaviour of patients was particularly difficult many staff felt it was their role as nurses to keep the relationship with that person open – to try to treat them positively. This did not mean that difficult behaviour was ignored – and I think I certainly did make judgements.

    My judgements weren’t, however, that the people I was caring for were ‘bad’ or ‘good’. I could see that sometimes difficult behaviour was due to extreme paranoia or frustration. Sometimes I could see it was to do with a history of damaging relationships, and the expectation that all relationships would go the same way. Sometimes I made a judgement that someone’s behaviour was due to boredom – it can be very boring for people in a secure unit!

    I had all the usual human feelings about patients as I have about other people in my life. Sometimes I would find patients very hard work – people with mental health problems can be just as annoying as all the people I know who don’t have a label attached to them! But many of the patients I worked with were interesting, and had a fantastic sense of humour.

    I think it is easy to take yourself too seriously – especially if you believe that becoming a mental health nurse turns you into an expert in relating to people. Mental health nurses are real people underneath – just the same as mental health patients/clients/service-users. We have good days and bad days. It could be argued that some of my best days as a nurse were when I was crotchety, tired and negative. If you are real with people they can be real with you.

  8. Victoria, I think you hit the nail straight on the head here. If you can be honest about yourself then you can be true to others. No amount of coins of phrases ie: “unconditional positive regard” and other will change this.

    We are all real people and we all have our flaws.

  9. I can see that I have unintentionally stirred the hornets nest with this one! I wouldn’t want people to focus on “unconditional positive regard” it was mentioned amongst other phrases that make me think quite carefully about how I express myself and listen to others. I sometimes feel that we do use the jargon more often than needed as it re-inforces our professional status – no jargon and you’re “not in”. To respond to Julies comment about throwing down the gauntlet, I accept the challenge, as the phrases and words mentioned in my posting are often identified and challlenged throughout my module. As a student in my sessions, you’re never going to get away with phrases such as “lacking insight” or referring to an individual as a “schizophrenic” – thats a label attached to a person. maybe that’s what we are afraid of, it would be like taking the labels of the cans in your food cupboard – you never know what you’re going to cook for tea, until it’s too late!

  10. I find this discussion fascinating, not only because I am writing an essay on “unconditional positive regard”! I am an occupational therapy student and my last placement was in a forensic mental health setting where all my beliefs were challanged. We are taught that UPR is a core component of OT so I really struggled when I found myself thinking about the patients differently or negatively. I found that i was so good at keeping up this image of what UPR should talk and look and act like but can I truly have UPR if there are still thoughts in the back of my head saying how I really feel about someone who has committed an offense against another human being, or any living thing for that matter. Bit of a scary thought, although I think that challanging this particular paradigm or concept is a brave thing to do and has been long overdue. Very interesting reading all of your posts.

  11. Of course unconditional positive regard is possible. That is why one undergoes training, reflection and lifelong learning in order to free oneself from bias–someone who has UCP by the way would or should never say ‘lacks insight’. Rogers stated that people have answers to their problems inside them–disciplines such as solution focused therapies and approaches have again shown that this is true. Why else would we be taught to include the person as a partner in our assessment and care planning?

    If you think that through critical reflection and advanced practise that you cannot acheive unconditinal positive regard in listening to your client unconditionally then perhaps you ought to consider another occupation such as banking?

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