Motivation and emotion/Book/2021/Safety as a psychological need

What is safety?
Safety is a perception that one "feels safe" and is "confident that they will not be harmed" (Gorman, 2010).

Maslow's Hierarchy of Needs


Maslow's Hierarchy of Needs was originally proposed by Abraham Maslow in his 1943 article, A Theory of Human Motivation, and was continually refined throughout his career (Maslow, 1943; Maslow & Frager, 1987). The model examines human motivation and suggests an individual's basic needs must be met before they can begin to grow and develop. A pyramid is often used to represent the model and the identified needs at the base of the pyramid (deficiency needs) must be satisfied before higher needs (growth needs, which are physically higher on the pyramid) can be addressed (Figure 1; Figure 2).

Five-tier model
Maslow identified five key human needs influencing motivation (Figure 1):


 * 1) Physiological needs (e.g. food, water, air, shelter);
 * 2) Safety needs (e.g. safey  and security);
 * 3) Social belonging and love needs (e.g. meaningful social, family, and community connections);
 * 4) Esteem needs (i.e. self-esteem and being held in esteem by others); and
 * 5) Self-actualisation needs (i.e. seeking and achieving growth and potential) (Malow, 1943).

Each need must be met for any further needs to be addressed.

Eight-tier model


Maslow later developed the model and added three additional needs (Figure 2):


 * 1) Cognitive needs (curiosity, knowledge, understanding, purpose, and predictability);
 * 2) Aesthetic needs (appreciation of aesthetic qualities in the environment); and
 * 3) Transcendence (motivation influenced by values that transcend oneself, e.g. religion, experiencing nature, and caring for others) (Maslow, 1970).

Maslow's Hierarchy of Needs reflects safety and security as a psychological need by identifying the concepts as a foundational necessity for psychological functioning and higher achievement.

Attachment Theories
Attachment theory was first developed by John Bowlby (1950), who defined attachment as "lasting psychological connectedness between human beings" (Bowlby, 1969). He suggested a child's attachment to their parent is an evolutionary protective mechanism to ensure they receive safety and security, increasing the child's survival chances.

Adult attachment styles are often consistent with attachment styles developed during childhood and adolescence (Kim et al., 2021). A systematic review and meta-analysis from 2021 found anxiety-related and avoidance-related attachment to parental figures were particularly persistent into adulthood, with external social relationships found to positively impact attachment styles that were avoidant but not anxious (Kim et al., 2021).

The level of parental involvement in childhood and adolescence can impact a child's attachment style to parents, caregivers, and peers. Overprotective parenting behaviours and unattainable expectations that restrict the autonomy and self-determination of the child can contribute to more anxious and/or avoidant attachment styles. This pattern presents commonly in families living in Asia or who have immigrated from Asian countries (Kim et al., 2012). Kim and colleagues (2012) studied families of South Korean descent living in the US, parenting styles, and attachment styles of the children. They found some cultural aspects of parentaing, including expectations of achievement for academic and extracurricular activities and of choice of university, career, and spouse, triggered anxiety, negatively impacted interpersonal relationships, and was associated with a negative self-concept. Anxious and avoidant attachment styles were more likely to be developed in childhood and continued into adult life (Kim et al., 2012). In contrast, underprotective and uninvolved parenting such as neglect has been associated with the same outcomes as overprotective parenting with high expectations (Bowlby, 1969). Attachment styles can affect an individual's functioning throughout adulthood.

Types of Attachment
John Bowlby (1960) identified four styles of attachment: secure, avoidant, ambivalent, and disorganised. A child's attachment style shapes their adult attachment style, although this can change over time. A secure attachment is formed when the caregiver appropriately and quickly responds to the child's needs. Avoidant attachments are formed when the child avoids interaction with the caregiver, likely due to previously unmet needs. Ambivalent attachments are formed in infants who are 'anxious' about being separate from their caregiver and 'clingy'. Disorganised attachment is often observed in infants with attachment disorders, as there is a confusing relationship between wanting their needs met and being fearful of their caregiver.

Schaffer & Emerson
In 1964, Schaffer & Emerson (1964) devised stages through observations to describe how infants form attachments to caregivers:


 * 1) Asocial;
 * 2) Indiscriminate attachment;
 * 3) Specific attachment; and
 * 4) Multiple attachment

The stages were based on measures of stranger anxiety, separation anxiety, and social referencing. According to their model, an infant aged 0-6 weeks will not necessarily respond to social stimuli and will produce age-appropriate facial expressions, such as a smile (asocial stage). After reaching 6 weeks of age, an infant will respond positively to any caregiver and will become distressed if interaction stops (indiscriminate attachment stage). Once the infant is 3 months of age, they will begin to recognise familiar caregivers. From 7-9 months of age, the infant will begin to prefer a single caregiver and fear strangers (specific period). During this time they will experience separation anxiety, such as if held by another caregiver. Infants aged 10 months and older begin to form multiple attachments with family members and familiar caregivers other than the primary caregiver (multiple attachment). Many infants will have developed attachments to multiple caregivers by 18 months of age, which are often hierarchical in nature. Stronger attachments were had with caregivers who quickly and correctly met the infant's needs, rather than who spends the most time with the infant.

Ainsworth
Ainsworth developed four stages of attachment (Ainsworth, 1970; Ainsworth 2014):


 * 1) Pre-attachment;
 * 2) Attachment in the making;
 * 3) Clear-cut attachment; and
 * 4) Goal-corrected partnership.

Hierarchical Attachment Representations

An improved hierarchical structure was proposed in 2016 to further describe attachment models that include attachment elements specific to relationships (Gillath et al., 2016). They posited that attachment-specific behaviours are not constant and are influenced by specific interpersonal relationships, the context, and episodic factors. Episodic factors are temporary influences on attachment and may include goals and behavioural strategies.

The Self Regulation Model of Attachment Trauma and Addiction


The self-regulation model of attachment trauma and addiction (SRM) related trauma-related attachment disorder with self-regulation difficulties (Padykula & Conklin, 2009). It was developed to provide a clinical perspective of addiction and trauma, and how they are impacted by attachment, particularly disordered attachment. The model suggests trauma can "injure" an individual's attachment style and ability to self-regulate, and suggests sustance use is an effort to self-regulate to cope with the injured attachment system and experienced trauma. The benefits of this model are that multiple contributing factors are considered when working with individual and it informs a method to measure and identify addictive behaviours and various presentations of self-regulation.

The SRM suggests the concept of dialectical poles of self-regulation (Figure 3). Every individual falls along a multi-faceted spectrum of over or under-regulation regarding:

For individuals suffering with addiction and a history of trauma, such as in this model, chronic dysregulation is often experienced at extreme ends of the various dialectical poles.
 * Behaviour (pathological caretaking ↔ harm to self and/or others);
 * Physiology (hyperarousal ↔ dissassociation);
 * Affect (over-emote ↔ alexithymia);
 * Interpersonal domains (pathological dependence ↔ counterdependence);
 * Cognition (negative self-concept ↔ positive self-concept); and
 * Self-pathological (grandiosity ↔ self-loathing).

Disrupted and disordered attachment resulting from trauma results from feeling unsafe and insecure. Safety is foundational psychological need to assist with functional self-regulation.

Childhood Experiences of Trauma
Trauma is an emotional response to an individual's experience that they perceive as stressful and are unable to manage the associated emotions. Trauma can result in trauma disorders such as post-traumatic stress disorder (PTSD), acute stress disorder (ASD), reactive attachment disorder (RAD), disinhibited social engagement disorder (DSED), adjustment disorders, and other related disorders. While the impact of trauma is caused by a psychological response, the responses and possibly disorders that follow can have overwhelmingly physical, as well as psychological, symptoms (Wamser-Nanny & Vandenberg, 2013).

Common types of childhood trauma

 * Abuse and neglect
 * Unstable family home
 * Exposure to family violence
 * Natural disasters
 * Perception.

Out of home care
There are three main forms of out of home care for children in Australia - kinship, foster, and residential care.

Kinship Care

When a child is first removed from their family, child protection bodies first seek to find an appropriate placement with kin, known as a kinship care placement. Kin can include immediate and extended family, friends, and other people in the child 's community, such as ex-step-parents. For children who are Aboriginal and Torres Strait Islander, kinship placements are deemed the most appropriate placements to maintain vital connections to culture and community, which is a key feature of their culture. By keeping connection to community and culture, displaced children can reduce the number of changes presented by a new placement and the loss of stability and security. Along with case plans developed with a social worker or case manager to maintain and build capacity around care domains such as stability and security, cultural plans are common practice to help children from culturally and linguistically diverse backgrounds continue to feel connected and continue positively learning and experiencing their culture.

Kinship care placements have the most favourable outcomes for children in out of home care, compared to other types of care. Children in kinship care will typically experience fewer behavioural issues and mental illnesses, improved well-being, and fewer placement moves than children in other forms of out-of-home care (Winokur et al., 2014). They are also more likely to successfully achieve permanency, such as Enduring Parental Responsibility (in Australian Capital Territory), compared to foster placements. This may be due to difficulties faced by blood relatives securing adoption rather than other forms of permanency, so as not to alter the family tree and the child's sense of family and belonging.

Kinship care placements are generally more stable and are more likely to end after placement restoration with the birth parents, rather than by relationship or placement breakdown (Perry et al., 2021). This may be due to fewer lifestyle changes and increased feelings of stability and security, resulting in less frequent and less severe behavioural issues, which are often the reason for placement breakdown (Font, 2015). Alternatively, this may be due to behavioural issues that present prior to placement impacting a child 's suitability for a kinship placement and the kinship carer's willingness and capacity to provide care (Font, 2015).

Adults who have transitioned to independence from kinship care placements report strong relationships with their kinships carers, very similar to the bond usually held by a child and their biological parent (Dolbin-Macnab et al., 2009). The increased stability, safety, and security from the caregiving relationships between children and their kinship carers can have significant psychological benefits for the child.

In Australia, kinship carers receive payments and can access further funds to cover the additional costs borne by caring for children, such as food, shelter, and medical needs. This is not the case for all countries or for informal kinship placements where child protective services are not officially involved. The unexpected placement of the child can lead to lack of money and financial insecurity, which becomes stressful for the carer and for the child. Research conducted in Denmark and USA found worse outcomes for kinship carers compared to foster carers - kinship carers receive less financial support, reduced access to respite care, reduced eligibility to access government financial support, and reduced access to professional and peer support (Sakai et al., 2011).

Foster Care
If no appropriate kinship care placements are available, a child may be placed with foster carers. This may be in a short-term placement initially, or planned to be long-term.

Children who were initially placed in foster care at age 3 or less on average remained in their placements for 5 years longer than children who were placed at older than 3 (Oosterman et al., 2007). Neglect, abuse, family issues, and abandonment as reasons for entering the out of home care system were associated with a greater number of foster placements than were children voluntarily placed into care and behavioural issues.

While a child becomes more independent with age, they still require a sense of psychological security and safety, and this need is also reflected in children in the out of home care system (Kungl et al., 2019). Foster children however require greater and more frequent proximity and reassurance to feel the same sense of security and safety. This may be due to the relationship with the caregiver being newer than with a birth parent, meaning the relationship may still be progressing through the stages of attachment and the child is still forming a schema of their relationship with the caregiver (Kungl et al., 2019). When a child experiences their first and likely susequent placement breakdowns, their experiences of psychological safety are negatively impacted, feeling as though they cannot develop safe attachments with caregivers due to their own self-esteem, fear of being judged or not accepted, and they do not expect they will benefit from the developing an attachment long-term. This is mirrored across all types of out of home care. Placement stability is a necessity to ensure safety, and in turn, psychological wellbeing.

Residential Care
Children placed in residential care often do not feel safe in their placement and experience difficulties developing safe and secure relationships with caregivers and peers. Attachment disorders are common in children in residential care. This is often resulting from the trauma they experienced with their birth families prior to removal from home, the trauma of the removal, the trauma of multiple placement breakdowns, and the inability to form secure attachments with residential carers due to high staff turnover, casual staff rosters, and the rotating roster of staff. Trauma-informed case management can protect from further psychological harm and promote psychological healing of children, young people, carers, and families who have experienced trauma (Topitzes et al., 2019). Ongoing connection to their birth family, where safe and appropriate, can maintain a sense of belonging and psychological safety for the child (Collings et al., 2021). This is particularly important for children Aboriginal and Torres Strait Islander descent, given the cultural importance of family and community and the very recent Stolen Generation.

Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy (DDP) was developed by Dan Hughes and is a form of family therapy used to support primarily with attachments and feelings of safety and security within relationships between children and their caregivers (Becker‐Weidman & Hughes, 2008). DDP focuses on developing the understanding and abilities of the child, caregiver, and therapist to attune to each other's needs, with the therapist removed from the therapeutic relationship after the capacity is sufficiently developed. DDP is funded by some public health systems, such as through Canberra, Australia's public Child at Risk Health Unit (CARHU). By increasing the child and caregiver's attunement to needs, they can each exist in the relationship with healthier attachments and more psychological safety and security.

Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT) can be an effective therapy for assisting with healing from various forms of trauma, including domestic abuse and childhood trauma. CBT is a very common form of therapy in Australia and is publicly funded under Medicare.

Therapeutic Life Story Work
A child's understanding of where they come from and their journey, or life story, to their present experience is a crucial element of healing from the trauma and lack of safety experienced by the child. Life story work promotes trust, feelings of safety, and ability to adapt to changes (Coman & Rainey, 2016).

Domestic Abuse and Wellbeing
Domestic abuse, otherwise known as domestic violence or intimate partner violence, is defined by Wong and Bouchard (2021) as "any act of physical violence (e.g., punching, choking, slapping) or psychological abuse (e.g., manipulation, verbal assault, threatening) that occurs between current or former partners/spouses [and] can also include sexual harm (e.g., coerced sex, sexual assault) and economic abuse (e.g., financial control/deprivation)". Domestic abuse is illegal in Australia and many countries across the world. Survivors of domestic violence are facing overwhelmingly unsafe environments, which negatively impacts psychological wellbeing.

Help-seeking behaviours for domestic abuse vary across different groups. Survivors who are Black Muslim women in America may first seek help first from social and community, religious, professional services, and finally law enforcement (Oyewuwo-Gassikia, 2020). Female survivors are more likely to suffer abuse for many years before seeking help, compared to male survivors who on average seek help after six months of suffering abuse. Male survivors are more likely to suffer psychological abuse and less likely to report the abuse, while female survivors more likely to suffer physical, financial, and a combination of abuse (Peraica et al., 2021). Help-seeking may be inhibited by lack of knowledge of options, accommodation insecurity, financial insecurity, lack of social support, fear of losing one's children, fear of the abusive partner, and the complex psychological mechanisms involved in domestic abuse (Weatherall & Tennent, 2021).

Increasing and maintaining social and community support, engagement in education and employment, capacity-building, and formal support services for domestic violence and other community services can serve as protective factors for domestic abuse and support survivors to break free of the abuse (Sinko et al., 2021).

Perpetrator interventions can have varying success with reduction in and prevention of future abuse (Karakurt et al., 2019).

Leadership and Performance
An employee's feelings of psychological safety at work and with the people they work with can be positively influenced by organisational leadership. Leaders have the power to enhance and improve employee psychological safety in the workplace to the benefit of the employee and the organisation. Leadership style and values play an important role in the psychological safety of employees. Consultation in the development and/or evaluation of processes or projects regarding the organisation and regarding decisions that will impact employees can assist employees to feel valued and feel a sense of control, which is important for psychological safety. Modelling the values a leader wishes to see in their employees such as participation, contribution, productivity, and support and acceptance of others can influence others to demonstrate and take on the same behaviours and values in the workplace (Wong et al., 2010).The same applies inversely. Psychologically unsafe workplace cultures, which can be fostered by leaders, can lead to burnout and poor performance (Hoprekstad et al., 2019). Aggression and bullying in the workplace is very common in the healthcare sector, resulting in a psychologically unsafe working environment. Europe's healthcare sector has one of the highest rates of workplace violence, with up to 90% of staff suffering verbal abuse, 64% verbal threats, and 32% physical violence (Pompeii et al., 2013). The negative environment can cause employees to experience sadness, anger, and fear, resulting in counter-productive work behaviour (Fida et al., 2018). Psychological safety is needed to improve and maintain psychological wellbeing.

Psychological safety is a necessity for effective employee workplace performance. Employees need to feel they can suggest ideas, work with others, and attempt creative solutions to problem-solving. Psychological safety is needed to mediate the risk of being viewed as a social outcast for breaking the social norms and organisational traditions, offending another employee or leader for voicing contrary beliefs, or being viewed as incompetent and a failure if the employee's input is not appropriate or successful (Newman et al., 2017). The employee alone is risking their social and professional reputation, their self-esteem and self-efficacy, and potentially future employment facilitated by maintaining positive professional networks. Without psychological safety, it is easy for the risks to simply not be taken, preventing future growth and development of the individual employee and the organisation. Fostering a culture where employees are comfortable expressing themselves, seeking and providing honest and constructive feedback, working with others, and take measured risks can increase psychological safety and mediate the aforementioned risks (Edmondson, 1999).

Increased feelings of psychological safety can improve the quality and frequency of information sharing. This can be influenced by feeling safe with organisational leaders such as an employee's direct supervisor, and the sense of trust, perceived approachability, and whether the employee believes they will receive judgement or support from their leader. It is important to note that organisations in collectivist societies are more likely to willingly share information with less prompting as it is seen as for the value of the organisational community to proactively share information (Yin et al., 2019).

Reflection on past experiences can support future learning and development, which can be extremely beneficial for developing new and old sought-after skills, knowledge, and values. Organisational teams who are open to learning can more easily practice reflection, develop skills, knowledge and values, and alter their practice to better suit their own needs and organisational needs (Bunderson & Sutcliffe, 2003). A culture of acceptance surrounding reflection can increase psychological safety, creating an environment where employees feel comfortable taking risks and asking for help, knowing their skills and experiences will be valued (Wong et al., 2010). This willingness to reflect and adapt can increase employee and organisational ability to adapt to new challenges, which can increase individual self-efficacy and control, improve the strength of the team, and increase workplace social support (Košir et al., 2015). These benefits are associated with preventing or reducing burnout. Increased psychological safety allows for individuals and teams to grow and change through reflection, resulting in improved organisational and individual outcomes.

Burnout
Burnout, or occupational burnout, is a syndrome resulting from a combination of cumulative and long-term occupational stress and individual differences (Salminen et al., 2017). The World Health Organization updated its definition of burnout in the 11th revision of the International Classification of Diseases (ICD-11) to be, "1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and 3) a sense of ineffectiveness and lack of accomplishment" (World Health Organization, 2018). Burnout can be measured with tools such as the Maslach Burnout Inventory (MBI), which utilises twenty-two questions to measure emotional exhaustion, depersonalisation, personal accomplishment, cynicism, and professional effifacy . Variations of the inventory exist for employees in human services, health professions, education, students, and a general inventory (Maslach et al., 2016).

While burnout results from chronic stress, it does not have to remain a chronic experience. Individuals recover from burnout and with effective self-care and environmental strategies, they can assist in the prevention of future burnout. Circumstantial burnout, resulting from environment and things the individual can control, can be treated and managed by problem-solving any pre-existing workplace challenges, enriching personal lives such as through hobbies and social supports, and taking a period of leave from work (Abedini et al., 2018). Existential burnout, resulting from questioning the meaning of the role and professional efficacy, can be treated and managed by the employee and others (e.g. supervisor) acknowledging the presence of the burnout, developing and strengthening meaningful workpace connections, rediscovering meaningful purpose within the work, and re-examining professional identity (Abedini et al., 2018).

Conclusion
Maslow's hierarchy of needs identifies safety and security as a basic physiological and psychological requirement to reach the growth and development needed for positive psychological wellbeing. Attachment theories help to explain the underlying mechanisms of safe attachments to thrive in one's environment. Childhood trauma and involvement with the child protection system and out of home care is associated with a loss of safety and has many negative impacts psychologically, although many impacts can be mediated by a restoration of safety. Domestic abuse is another example of a loss of safety that through an increase of safety, the psychological wellbeing of both the survivor and the perpetrator can be improved. Safety in the workplace can be created and fostered by leaders and employees alike, and is necessary to recover from and treat burnout, and maintain psychological wellbeing. Safety is a psychological need that can be fostered and developed to meet the best possible outcomes.