Artwork for podcast You Are Not A Frog
Is My Attachment Style Causing My Burnout?
Episode 22916th July 2024 • You Are Not A Frog • Dr Rachel Morris
00:00:00 00:53:01

Share Episode

Shownotes

The ways we deal with difficult situations at work and tricky relationships in general is massively influenced by our childhood. Discover what role attachment styles play in how we handle stress, and learn what practical steps you can take to avoid burnout.

Burnout: How to Manage Your Nervous System Before it Manages You – Claire’s book

Download the episode’s podsheet. You can use it for reflection and to submit for your appraisal as part of your CPD.

Join the You Are Not a Frog Facebook group

Visit our website for more links and show notes

Mentioned in this episode:

Join FrogXtra
The monthly membership for doctors and busy professionals in high stress jobs, who want to beat burnout and work happier.

The Work Well Programme for Healthcare staff
Help everyone in your organisation beat burnout with resources that really work.

Transcripts

Rachel:

When's the last time you went walking and unconsciously took a shortcut?

Rachel:

You see this all the time paths created by lots and lots of pairs of feet, picking the same quicker route between two points.

Rachel:

Now our brains do exactly the same thing.

Rachel:

As kids we learn how to form relationships and how to respond to certain situations like fear or stress and we start creating little pathways to help us cope when our close relationships may also be causing us fear and anxiety.

Rachel:

Over time, these pathways and patterns of behavior become more and more ingrained, until we find ourselves grown up and using the same old coping mechanisms that we've always relied on.

Rachel:

The thing is these old pathways often don't serve as well and they always lead to the healthiest outcome.

Rachel:

But the good news is we can create new pathways that are better for us, and help us navigate relationships and stressful situations more easily.

Rachel:

This week, I'm talking to Dr.

Rachel:

Claire Plumbly who's written a book all about burnout.

Rachel:

Now we discuss the relationships between attachment theory and burnout.

Rachel:

And attachment theory helps us understand how those pathways get created, and recognize when we might be treading an old pathway from the past in our current way of relating to people.

Rachel:

And in our chat, we think about ways that we can start to make newer, more healthy pathways, which help us thrive rather than just about cope.

Rachel:

So, if you want to get a better understanding of the way you handle stressful situations, close relationships, relationships with colleagues or just difficult people, then this is definitely the episode for you.

Rachel:

If you're in a high stress, high stakes, still blank medicine, and you're feeling stressed or overwhelmed, burning out or getting out are not your only options.

Rachel:

I'm Dr.

Rachel:

Rachel Morris, and welcome to You Are Not a Frog

Claire:

Hi, my name's Dr.

Claire:

Claire Plumbly.

Claire:

I'm a clinical psychologist and I work in Taunton, Somerset.

Claire:

And I also have a practice that's based online with associates.

Claire:

So I'm Director of Good Therapy Limited.

Claire:

We specialize in trauma focused therapies.

Claire:

And I also have a specialist interest in burnout.

Rachel:

It's wonderful to have you back on the podcast, Claire.

Rachel:

I think you were with us just under a year ago in August, 2023 talking about how little T traumas lead to burnout.

Rachel:

And I wanted to get you back for loads of different reasons.

Rachel:

Firstly, I know you've got a book coming out, which you've been working on for a couple of years and I'm very excited about that.

Rachel:

We'll talk about that as we go through.

Rachel:

But also when we've had conversations following your podcast, we've been talking a lot about something that just seems to be coming up again and again and it's come up with other guests I've talked to recently as well.

Rachel:

And that is attachment.

Rachel:

And if I'm honest, I don't know much about attachment and attachment styles, but I know that it's important.

Rachel:

And I learned a bit more about it 'cause my daughter did a level psychology last year and I thought, wow that's really interesting.

Rachel:

And if I'm honest, it's something that I was never ever taught at med school.

Rachel:

I wasn't taught it as a GP.

Rachel:

But it seems to impact a lot of the way that we behave, a lot of, uh, what we do in life, our thought processes, how we deal with stress, how we appraise situations.

Rachel:

So I thought, actually, this is something we need to be thinking about a lot more, both for ourselves, but also I guess for the people we interact with, our patients and our colleagues.

Claire:

Yes, totally.

Claire:

It can be helpful to know for yourself and also why you keep rubbing up against certain issues with certain clients or patients in your practice.

Rachel:

So let's talk a little bit more about attachment.

Rachel:

Firstly, what is it?

Claire:

Okay, so attachment is that special, emotional and psychological bonds that we have with the important people in our lives.

Claire:

So in adulthood that would typically be a partner, your family members maybe close friends.

Claire:

And it's really important for our wellbeing because humans are born with all the physiology so that we are ready to connect with other humans because connection is so important for our survival.

Claire:

So our, you know, babies come out with all that inbuilt ability to turn their head to the sound of a familiar voice.

Claire:

We're searching out patterns that look like faces.

Claire:

This is all this social engagement chemistry in us that enables us to form these close bonds.

Claire:

So that's generally what attachment is.

Claire:

And we know how disruptive any ruptures in attachment are because when we feel abandoned or rejected or when a relationship ends, that has a massive impact on how we feel.

Claire:

It's really painful.

Claire:

And that pain is telling us, we, we need this.

Claire:

This is important to us.

Claire:

And attachment gets talked about a lot in books about relationships and friendships.

Claire:

And in my book, I'm bringing this lens to thinking about, well, how does it impact on our relationship with work?

Rachel:

So attachment is simply the way that we form bonds with other people at its most simplest.

Claire:

Exactly, and so attachment theory says that there are four typical patterns that appear in the way we form these bonds and that this all relates back to those really early two to three years of life.

Claire:

John Bowlby who introduced this in the fifties was the first person who started to look at this and think, hang on a minute, what's going on when children start to struggle with their mental health?

Claire:

At that time, the dominant idea was all the Freudian stuff around egos and fantasies and it being something internal with the child that had gone wrong.

Claire:

And his work began to look at what happens when a child is separated for long periods from their mother or the mother's unable to provide what she should or ideally would for them.

Claire:

And he was seeing that actually, they were the children who fared worse.

Claire:

They were most likely to be labeled delinquents or really struggle.

Claire:

So his thesis was that, the child needs to have one primary caregiver, AKA mother, who needs to have this strong attachment.

Claire:

And his original idea said that basically you can't come back from it if you don't have that early secure attachment in your life.

Claire:

Since then, he updated his theory later on in life and there's a lot more that's kind of built on this, which shows us that, you know, we tend to have a dominant attachment style, but we have many attachments in our lives.

Claire:

'cause it's not just one attachment figure early on.

Claire:

But.

Claire:

Unfortunately, that part of it sometimes gets stuck in people's minds and they kind of think, oh, there's nothing I can do if I don't have a secure attachment style early on.

Claire:

But that's actually not the case, and that's something that I want to make sure anyone listening, um, understands.

Claire:

Because I think that's important.

Claire:

The research says if you attending to yourself and interested in this, you're very likely to be able to make moves in updating any unhelpful, insecure attachment styles in adulthood.

Claire:

And about 30% of adults go on to do that.

Rachel:

That's quite a relief, isn't it?

Rachel:

'Cause my next question was gonna be, well, if attachment is formed and set in stone so many years ago then there's literally no hope for us, is there?

Rachel:

Nothing, nothing can be changed, but the good news is it can be changed, but presumably you need to understand a bit about it first.

Claire:

True.

Claire:

Yeah.

Claire:

That's what we're doing today,

Rachel:

So this chap, John Bowlby.

Claire:

Bowlby.

Rachel:

John Bowlby.

Rachel:

John Bowlby, he thought it was set when you were small.

Rachel:

And did, was he the one that looked into the various different types of styles or did that come later on?

Claire:

That came a little later.

Claire:

So he kind of set the ball rolling.

Claire:

And it was someone he supervised, Mary Ainsworth, who developed this interesting experiment, which has become kind of very well known in psychology circles.

Claire:

We all learn it at a level and it's called The Strange Situation.

Claire:

So what she did was, um, her researchers and her set up a room, which was big enough for some toys and some chairs.

Claire:

It had a two-way mirror.

Claire:

And then they invited a mother and child pairing into the room.

Claire:

Typically quite a young, you know, eight, 12 to 18 month old.

Claire:

And they were observing the interactions at different points and kind of scoring up through throughout.

Claire:

And essentially what happens is they have a few minutes in the room orientating, getting to know the room, playing with the toys, so they're observing that.

Claire:

And then a stranger walks in, stranger has a bit of time without them, and then tries to interact with the child.

Claire:

And then after a short period of that, the mother then leaves.

Claire:

Again, the child is left alone with the stranger, and then the mother returns.

Claire:

So the raters are looking at what happens when the mother leaves, what happens when the mother returns, how does the child relate to the stranger, whether they go off and explore what the reunion, uh, is like in terms of whether the child initiates contact or not.

Claire:

And so from this work, they pulled out the three attachment styles.

Claire:

So it start, it evolved into four.

Claire:

It started off as three attachment styles.

Claire:

So, these were generally called organized attachments.

Claire:

So we've got secure, and then we've got insecure, anxious and insecure avoidant.

Claire:

And then the fourth attachment style came a bit later on, and this was known as disorganized or fearful.

Claire:

So, as a general rule of thumb, the way I think about it is that the organized ones, the first three were all ways of understanding a child's behavior because they'd managed to fall into a pattern of responding to a parent based on a typical consistency there.

Claire:

Whereas the disorganized fearful, the parents were very chaotic.

Claire:

It was very hard for the child to consistently act in a way that helped them maintain that relationship.

Claire:

This is all what attachment is about.

Claire:

The child's behaviors make sense as a way of trying to stay as close to the parent as they can whilst also protecting themselves, getting their own needs met.

Claire:

So this was the kind of, basis for the attachment styles.

Claire:

Attachment obviously is how we attach to others, but it's also how we attach to ourselves.

Claire:

So our relationship with ourselves is in there as well.

Claire:

And so if that is tricky, that can make our sense of identity a bit wobbly.

Claire:

We might always be trying to get external validation to get our sense of self.

Claire:

And so work obviously is a way to try and get that.

Claire:

' Cause if we are getting validation from our clients, our patients or our bosses, that can give us sense of identity.

Claire:

And that can mean it's very difficult for us to have, you know, a balanced life work-life balance.

Claire:

It also affects our ability to tend to ourselves in our distress or when we're stressed with sensitivity and care.

Claire:

So our self-compassion, and our stress management tools are all impacted on this.

Claire:

It affects our ability to accept, support or ask for it.

Claire:

It also impacts on our reasons for trying to achieve.

Claire:

So there are two reasons that we might try to achieve.

Claire:

The first is for personal growth.

Claire:

That's coming from a positive place of motivation, you know, we're driven in a positive kind of warm way.

Claire:

The second reason is for validation, but coming from a negative kind of threat, avoiding a threat kind of way.

Claire:

And again, in the attachment styles, there's a slight difference in terms of that validation, how we do it.

Claire:

So the fourth part of this is that everybody has a, like, might have a dominant attachment style that they resonate with.

Claire:

And if you come up against a member of staff or a client for example, or patient who's got a different attachment style that presses your buttons, there can be some tension there, friction that causes problems.

Claire:

So for example, in relationships, someone who's got a partner with an avoidant attachment style and they're very anxious, this can cause problems 'cause they're, they've got different needs and different ways of relating to each other that need to be kind of looked at and supported.

Rachel:

It, it, It's really, really fascinating.

Rachel:

And the thing that's going through my head right now is this attachment thing.

Rachel:

Is really important.

Rachel:

It's really important when he talks about, it's how we relate to other people.

Rachel:

It contributes to burnout, how we accept ourselves, self-compassion, how we achieve.

Rachel:

Why haven't we been talking about it more?

Claire:

I dunno.

Claire:

We should be talking about it more.

Claire:

I completely agree.

Claire:

I mean there's, there is political difficulty there as well sometimes, you know, like with, Bowlby's stuff kind of got misused as well as being helpful.

Claire:

So attachment theory obviously gets talked about a lot in parenting and with relationships.

Claire:

So gentle parenting, for example, attachment parenting, that's all coming from this.

Claire:

And you know, during the war, John Bowlby was the one saying we shouldn't be sending little children off to be evacuated if they're under five.

Claire:

This could be really very negative for our population.

Claire:

But it didn't really suit anyone to listen to him until after the war when they wanted women to come back from work into the home.

Claire:

And so that's when all this stuff started to get used as a way of saying, well, you're damaging your child as a mother if you're not at home, you need to kind of give up work.

Claire:

And that mentality has stayed with us.

Rachel:

It's been used as a stick to just another stick to beat women with, right?

Rachel:

Another thing for us to feel guilty about, perhaps.

Claire:

And helpful to understand mother guilt, where that kind of comes from as well, isn't it?

Claire:

That's a part, an element of it.

Rachel:

That makes a lot of sense.

Rachel:

I think one thing I love about your work, Claire, is that you are really focusing how on how the brain works and, you know, the neuroscience and the real theory behind this.

Rachel:

And I think for doctors and other listeners that we've got, we just need to understand how things work.

Rachel:

'Cause once you understand it, and the what and the how, we can then make the changes.

Rachel:

It's, we struggle to make changes when there's just some sort of theory that no one's really saying how that works.

Rachel:

But what I love about you is you really get into the details.

Rachel:

So yes, we wanna hear the detail.

Rachel:

Tell us about these four different styles.

Claire:

So secure attachment is it is the one that most people have, like 60, 70%, but the numbers differ depending on the research, but they vary from like about 55 to 70%.

Claire:

So in the strange situation, these were the children who showed distress when their mother left the room, but were able to be comforted when they were reunited.

Claire:

They were able to be soothed and so they showed appropriate fear of the stranger.

Claire:

But when the stranger was there, the mother was there, they could be calm, soothed, and then they could go off and explore.

Claire:

So the mother was the secure base, which is what we all, you know, would like for ourselves really, isn't it?

Claire:

To be able to go off into the world, explore, play, but come back when there's something going on.

Claire:

And so they generally tend to grow up with primary caregivers who are attuned to their needs, reliable enough to be able to trust that they'll be there when they need them.

Claire:

And so obviously when parents hear this, often a question is, oh my God, but I'm not doing that for my children.

Claire:

So it's important to come back to the kind of good enough idea that if we are doing that, as often as we can within the realms of being human and having our own moments of dysregulation, that actually, that's still helpful for a child to see all of that, that they can navigate the world with stresses and learn to get through them.

Claire:

So we don't need to be perfectly meeting all our chil children's needs all the time.

Claire:

And actually that might be unhelpful 'cause they never then learn any strategies or see any modeling of how to cope.

Claire:

So in adulthood, the children with secure attachment tend to grow into adults with secure attachment.

Claire:

Same is true of all of the attachment style, unless you do some work to change that.

Claire:

So they would generally be people who do feel worthy of others affection and have an appropriate fear of abandonment because humans, like I said, that's important for survival.

Claire:

So it's not the thing that dominates all your decision making, but it's, you know, shows itself if someone does something that feels like they're rejecting us.

Claire:

We um, find that securely attached people tend to have boundaries that feel kind of healthy or even if they don't, they're able to kind of get them more easily.

Claire:

They maybe just haven't got them in place 'cause they haven't been well modeled to them, or they've been ground down by life and work and bosses, but can kind of start to put them in place because they kind of got that internal working model that I'm worthy, I can do this.

Claire:

So we can still burn out in with secure attachment styles.

Claire:

Of course we can because it's, well, we're in a very difficult, busy, modern environment where stimuli has always been thrown at us and our nervous systems are being ground down constantly all the time.

Claire:

The moments to reset are not there like they used to be.

Claire:

But striving is a normal part of human nature, for the growth and for getting resources.

Claire:

So that can be kind of, taken for granted by bosses, by companies and things.

Claire:

So, but the good news is that you are more likely to have access to stress management tools, more likely to kind of get back on your feet with all of that, more quickly.

Claire:

In Mary Ainsworth's study, about 15% of the kids had an anxious attachment style.

Claire:

So for them, when the parent left the room, they were intensely distressed.

Claire:

They were very fearful of the stranger.

Claire:

And when the mother returned, there was this kind of really tricky dynamic where they really wanted the mother, but they couldn't be comforted.

Claire:

So they would be resistant.

Claire:

They might sit on their lap and then push away, um, not look at her, this kind of thing.

Claire:

So this pattern seems to come from a style of parenting where the primary caregivers really struggling to meet the needs of the child consistently.

Claire:

There might be mixed messages of what's required of the child.

Claire:

The adult might be unable to soothe themselves.

Claire:

They might often be dysregulated, highly anxious.

Claire:

They might be overprotective because of how anxious they are.

Claire:

They might be quite needy parents.

Claire:

So the child is having to kind of think all the time about what their parent needs in that kind of, role early on.

Claire:

And so what that means in adulthood is you've kind of become very skilled at that.

Claire:

You've become very skilled at being sensitive to others' needs.

Claire:

And you might have that overinflated responsibility that's carried with you for others.

Claire:

You might struggle to soothe yourself because you weren't modeled it.

Claire:

So using healthy, soothing strategies might not feel so natural to you.

Claire:

And also there's this pattern of being very hyper responsive if there's a problem.

Claire:

So that means reassurance.

Claire:

Seeking that means quickly jumping in to try and fix the problem.

Claire:

Being able to tolerate watching how it might pan out feels really tricky.

Claire:

So of course here you're probably alert to the fact that this sounds a lot like people pleasing, and that's where we go with this.

Claire:

So there's this insecure striving.

Claire:

So do you remember earlier I talked about, you know, striving for growth or striving for validation?

Claire:

This is the insecure, like seeking validation from others that shows up.

Claire:

So, self-worth very much depends on how we think others perceive us, how we're seen in the others eyes of others.

Claire:

If you say to someone who's a people, please, with all of this in the backstory, we need to start setting boundaries, that's gonna be super hard for them if they don't understand why these boundaries are so hard, because it feels dangerous to start just putting boundaries in.

Claire:

It feels like this, my life is gonna depend on not being rejected.

Claire:

And here I am saying no to someone.

Claire:

I'm gonna be jumping into that head first.

Claire:

So, you know, this is the thing with a lot of burnout kind of advice, is things like just start setting boundaries, but it's just not that simple.

Claire:

If you've got all of this going on in your background.

Rachel:

We've done a course recently called Get Your Life Back, which is all about how to say no and set boundaries.

Rachel:

And I think the advice yeah, absolutely stands about the stories you're telling yourself and you know why you're doing it and all that.

Rachel:

But if you layer attachment on the top of it, those stories become even stronger, and I guess it's that worry.

Rachel:

And with this insecure anxious attachment, you say it's often with a parent who is, dysregulated themselves, they can be very anxious or very overprotective.

Rachel:

Is that true of a parent who gets crossed very quickly, very angry?

Claire:

Yeah.

Claire:

It can be any dysregulation.

Claire:

And it depends on how that level of anger, how, I guess, how severe it is, because that might be more where they're acting in a way that makes the child very fearful.

Claire:

So yeah, anger might be more the last one.

Claire:

And remember with all of this it, there's fluidity, and people often resonate with different parts of different attachments.

Claire:

You think about what's the dominant one for me rather than I have it, I don't have it.

Claire:

Tick box type thing,

Rachel:

So we're talking about dysregulated emotions.

Rachel:

So anxiety, or it could be moodiness, or it could be a bit, you know, a bit crossed, not like full on anger, hitting things, but just sort of like when the child is feeling, I guess, starts to feel a bit responsible for how the adult is?

Claire:

Yeah.

Claire:

And so when their behavior seems to also have a knock on impact, you know, if they're being quite tiptoe around the house, the parent's not, you know, angry, then this would lend itself to this behavior where the child is monitoring themselves all the time.

Claire:

Whereas in the last disorganized fearful attachment where there's a maybe a lot of anger and scariness in the adult, that's different in that the child might do the tiptoeing, but then be told off for that because they, you know, they, there isn't any consistency to what they can do to not be targeted and told off.

Rachel:

Okay, so second one, insecure, anxious.

Rachel:

The next one was insecure avoidant?

Claire:

Right, so in the strange situation, these children wouldn't show any external signs of distress when the mother left, nor would they show any interest in the reunion when the mother joined in the room again, and they're generally okay with the stranger.

Claire:

What we now know about children with this type of attachment is that even if there's no external signs of distress, their heart rates are showing that they are just as distressed as the other children.

Claire:

Generally these children of had parents, primary caregivers who struggled to validate and see their needs.

Claire:

So they might have been dismissive, untuned, um, the child was searching for connection, but was Reno ignored or rejected.

Claire:

And with all of these things, I want to get the message across that, I'm not saying this in a blaming way of parents.

Claire:

There's often many, many reasons why parents weren't able to meet a child's needs.

Claire:

Their own mental health stuff, you know, work pressures, culturally expectations, parenting norms at the time.

Claire:

There's so much in there.

Claire:

We won't go into that anymore, but I don't want this to become a blame game.

Rachel:

Not a blame game, but it's just helpful to understand, isn't it?

Claire:

Yeah.

Claire:

In adulthood then these children with, or adults with avoidant attachment stars, find that intimacy might be accompanied by fear of being let down.

Claire:

So they might be a kind of keeping guard up, keeping people at arms length, not really letting people in.

Claire:

They might be hyper independent.

Claire:

So very used to dealing with problems on their own, 'cause that's what they've had to do if they wanted to get anywhere as a kid.

Claire:

And again, they're so used to having their signs of distress dismissed and needs dismissed, they might be misattuned to what their needs are, and might not pause to check in and do anything to support themselves when they're getting stressed.

Claire:

So, of course this then adds up to burnout because of course, stress tips into burnout after a certain level of chronic stress.

Claire:

So.

Claire:

I sometimes find if people have this dominant attachment style, when you're trying to teach stress management, you have beliefs that you have to work on, which is around deserving it.

Claire:

You know, sometimes people, if I use words to do with self-compassion and things like, they just almost freeze up and close off.

Claire:

It just feels like a really intense word.

Claire:

I sometimes jokingly refer to it as the C word, compassion, because it can, just feels like that's not for me, that's not gonna help me.

Claire:

But other issues that relate this to burnout is there might be that hyper independence prevents 'em from delegating.

Claire:

Feel like I need to do it all myself.

Claire:

Feeling unable to lean on others or not even sure how you'd go about delegating.

Claire:

And again, the insecure striving shows up here.

Claire:

Whereas in the previous one it showed up as people pleasing, this is where there's more focus on competitiveness in order to stay safe.

Claire:

So if I am reaching this promotion level, if I've got a hundred percent, I basically can't be pulled down and I'm safer up here.

Claire:

So this lends itself to perfectionist behaviors where we don't want to be rejected or.

Claire:

And of course work is a very nice way of avoiding intimacy.

Claire:

So for those people in this style where there's that fear of being let down and intimacy, throwing yourself into work can easily solve that.

Rachel:

I was just about to say, what do these adults' relationships look like?

Rachel:

Did they they struggle to be intimate and really connect with people on a deep level?

Claire:

Yeah, I mean, sometimes people find themselves in a relationship that works alongside this attachment style where they might have, you know, fairly independent lives and they have relations where might not live together or might have quite independent social lives and, you know, just do little bits together.

Claire:

Or they come to therapy and they get support to work on becoming more intimate, 'cause often there's some sort of, apart from burnout and work related issues, there can be unintended consequences that feel negative for them.

Claire:

You know, if you are always holding someone at arm's length, you're gonna feel lonely and you're gonna feel like no one really gets you.

Claire:

And after a while, this relationship style can just feel like this isn't benefiting me now and maybe I don't need it anymore.

Claire:

I can let go of it because this person is ready to meet my needs in a way that I didn't have for myself as a kid.

Rachel:

So fascinating.

Rachel:

As you are talking through, I'm thinking, Oh yeah, that person, this person, it's probably really bad to label other people.

Rachel:

You could probably only label yourself with these things.

Rachel:

But it's absolutely fascinating.

Rachel:

So, I've got lots of questions, but let's just go through the last one that you've mentioned the disorganized and fearful style.

Claire:

So this didn't come from Mary Ainsworth's research.

Claire:

This was added to a few years later, and it's thought roughly five to 10% of children might have this.

Claire:

So they are parents who were scary, um, abusive, very chaotic and changeable.

Claire:

And like I said earlier, unpredictable.

Claire:

So you couldn't guarantee that this one thing would tend to keep the peace, keep me in my parents', kind of, you know, good positive regard.

Claire:

And so what that means in adulthood is there is this kind of chaos that's taken with you.

Claire:

So there's a tendency to maybe crave, 'cause we all crave intimacy and something that is craves good connection with others.

Claire:

But when we move towards that, it feels too much, and the fear system is activated, because that's what would happen before, you know, it would be ripped from under your feet again.

Claire:

So there's this push and pull kind of experience for people.

Claire:

Sometimes in therapy, for example I've definitely had experiences of this where it might be helpful for.

Claire:

And your doctor's listening, where you get idolized.

Claire:

So this is the person who's gonna save me.

Claire:

And so, you know, you kind of know this isn't gonna last and then it doesn't.

Claire:

The bubble bursts when you do something, what makes them see that you are just a human being.

Claire:

So there's kind of a wishing to be kind of almost saved and this idolization can happen.

Claire:

And then a lot of anger when there's something that doesn't, you know, that bursts that bubble, like I said.

Claire:

Tends to also be an experience of.

Claire:

Hypervigilance around body language, facial expressions of others because you're constantly on guard watching what does this mean?

Claire:

So that obviously lends itself to misinterpreting those cues.

Claire:

So I've had the experience again in therapy when I work people with this where, you know, my neutral, I thought was neutral expression.

Claire:

They were kind of thinking all sorts of things about me thinking negative things about them or, you know, that I was bored or that I was, you know, rejecting them.

Claire:

So that can happen.

Claire:

And in terms of burnout, really, there's an overlap with a lot of the other ones that I've mentioned already for the insecure, avoidant, insecure anxious, where there's insecure striving again, like trying really hard to people please and be perfectionist.

Claire:

And what I would just also add which is relevant to all of these, is that, you might avoid anything that triggers strong emotions as far as you can.

Claire:

So using work to avoid it helps, um, which I've already said.

Claire:

Secure attachment is the one that gives your autonomic nervous system the best kind of start in life in a way because you're kind of toning it to react to stress appropriately.

Claire:

So I like to think of the nervous system like gears.

Claire:

You're kind of moving up and down fluidly depending on what's needed.

Claire:

But if your start off in life is one where there's this fear and you have to watch yourself in order to be accepted and stay close to your primary caregiver, it means that you are, gonna have to work at that in adult life to find your ways of moving your gears fluidly up and down your nervous system.

Claire:

Because you didn't learn that early on in life, but you can learn it at any time.

Claire:

It's all about how to regulate nervous system, which will be really important for you.

Claire:

It's important for everyone, but it's harder in adulthood to learn these skills.

Claire:

But just because it's hard doesn't mean you can't do it.

Rachel:

So is there any particular one of these styles that might specifically lead, or that you see more frequently in people with certain mental health problems or personality disorders?

Claire:

So there's definitely a big overlap with disorganized and the personality disorders like borderline and EUPD.

Claire:

Yes, I think that's helpful.

Claire:

I think when you are in a patient relationship as well, but as well as with friends.

Claire:

All of this is helpful, isn't it?

Claire:

Because if your friends or family act in a way that doesn't make sense, I think trying to hold in mind that I might have pressed a button here that comes from an old attachment wound or, you know, pattern just takes the pressure off a bit.

Rachel:

Yeah.

Rachel:

And it helps you understand what, what's going on with that relationship as well.

Rachel:

I was gonna ask you, which two do you see clashing the most?

Rachel:

Or have you got experience of?

Rachel:

I mean, I can imagine that they all clash, but could you tell us a bit about, so say for someone with an insecure anxious is with, uh, or say partner partnering with, or even working closely together with someone who's insecure, avoidant, what conflicts and clashes might you see with that?

Claire:

I mean, in a work context I would say, this isn't based on research, this is based on my clinical experience, like if you've got someone who's worked with the perfectionism, pushing them to become very high up.

Claire:

So maybe an avoidant attachment style there where, you know, not having proximity to others has given them the space to throw themselves into their work every hour of the day, they find other people's emotions really tricky.

Claire:

So if you've then got someone who's on your team that you're managing, who's got an anxious attachment style who seeks reassurance, wants quick resolution of problems, sending emails saying, can you just tell me this?

Claire:

Like sending flowery language as they kind of try to ingratiate themselves to their, insecure avoidant boss then these are gonna cause problems for each other because they're not getting their needs met, so they're gonna feel very unheld.

Claire:

And the avoidant attachment style boss is gonna feel very kind of handpicked and angry and that will show on their face.

Claire:

And then you kind of get this kind of toxic feedback loop where the employee's gonna struggle even more.

Claire:

'cause they're like, now I've really annoyed them.

Rachel:

When you say they're not getting their needs met, what would you specifically say the needs are for an avoidant, someone who's got an avoidant attachment style?

Claire:

Well, there's the needs that they feel they have in the moment if they haven't done any attachment exploration work, which is, you know, just to go inwards and to be, like I said, hyper independent deal with it because any kind of like letting on how they feel or sharing or asking for help feels like a threat.

Claire:

But in the long term, if you're working with someone, you would, in therapy, you would be supporting 'em to see where that stops being helpful and trying to experiment with letting go of that level of doing all of that to see if actually in adulthood there are safe ways to connect, build, you know, connections up.

Rachel:

Right.

Rachel:

So that's really helpful in my mind.

Rachel:

So you've got people, your surface needs are, if you are got the insecure action style, you want to be reassured, you want to be, you know, you want to know that you want to please everybody.

Rachel:

You want people to think well of you.

Rachel:

You want, you know, you want to not upset anybody.

Rachel:

You want everything to be peaceful.

Rachel:

If you're avoidant, you know, you wanna deal with stuff yourself.

Rachel:

You want to be fiercely independent.

Rachel:

You want to be achieving and people, you know, and deal with your stuff yourself.

Rachel:

But actually the way to fix some of this is actually go to the opposite, right?

Rachel:

So learn how to rely on other if you, if you feel the need to be independent, 'cause you've got that avoidant attachment, then in therapy what and work on yourself, you'd be actually working on how to rely on other people and ask for help.

Claire:

Well, so if the underlying question here is what can we do then to update our insecure attachment styles?

Claire:

So I would say start with your attachment to yourself.

Claire:

So start with the work here in, in yourself.

Claire:

So, that involves starting to respond to your distress with sensitivity.

Claire:

So we're talking about self-compassion again.

Claire:

Learning this is a skill.

Claire:

So in therapies like compassionate mind therapy, we literally go through what the practices are.

Claire:

We break down what compassion actually is and why it's helpful because often that's been missing building up skills in mindfulness because mindfulness is that ability when you've had a stimulus and you've got your response.

Claire:

So in this situation, someone saying, see me in my office now as a stimulus, and maybe the response being, oh, people pleasing mode.

Claire:

What have I done?

Claire:

There's a gap between, and that mindfulness practices, you do help to make that gap bigger so that you can choose mindfully what is my response going to be, rather than default patterns.

Claire:

And learning tools to regulate your nervous system.

Claire:

So this, again, just takes practice like you would do with physio, exercises or any healthy eating, just as little and often ,doing it when you're not dysregulated to begin with, so that you can use 'em strategically when you are dysregulated.

Claire:

And all of this then is a way of sensitivity, meeting your ne own needs and then moving that well as part of that, it is finding people you can start to allow in, in small ways maybe to begin with.

Claire:

And if you are in the anxious attachment style, then it would be, yeah, seeing what it's like to sit with a problem before responding and gently kind of building up that tolerance for that.

Rachel:

So it's like you've got to almost re reboot your system, the system attachment 2.0, so that, so that we can have better relationships, we can, you know, we can handle stress better, we are not gonna burn out so quickly.

Rachel:

And part of that you've been talking about is self-compassion is mindfulness, so you can actually see how you're reacting and, and notice that.

Rachel:

What else do you find makes a big difference to people?

Claire:

I do find tracing back your backstory and having good understanding of it helps a lot.

Claire:

This is not always a level you wanna go to in your burnout journey immediately 'cause you've gotta think about what's needed and when.

Claire:

But if you're in a space to delve into it, it does help people to become more self-compassionate.

Claire:

Often in therapy people come for an issue, you know, to do with here everyday life issue right now, like at work or in the relationship or a bereavement or something like this, and it's cause a reaction that they don't fully understand.

Claire:

What we do is we trace it all the way back to the beginning.

Claire:

So I start even pre-birth, you know, what was going on for parents, because that will impact on their ability to attach to their, you know, their child if they had traumatic things going on, or there was ruptures and they were moving abroad and stuff.

Claire:

So I trace it all the way back.

Claire:

And in my book I invite people to consider the types of messages that were given to them in their early life about work as well.

Claire:

I kind of try to keep it related to your relationship with work in my burnout book.

Claire:

But, any tracing back understanding will help you to be more understanding of why you react like you do.

Claire:

And it takes the pressure off.

Claire:

So rather than going inwards and a self attacking, I'm such an idiot, why do I say that?

Claire:

It never makes sense when I behave like this.

Claire:

You can go, oh, it makes total sense.

Claire:

Because when she looked at me like that, it was just like how my mother used to look at me when she was going into one of her cross days, you know?

Claire:

And then we can kind of think, well, that, that was painful for me.

Claire:

What was that like for me then?

Claire:

What did I need then?

Claire:

I needed connection.

Claire:

I needed a hug.

Claire:

I needed somewhere to go and be away from her.

Claire:

So I can get that for myself now.

Claire:

How, what does that look like?

Claire:

What are my resources now?

Claire:

Connection's, obviously massive.

Rachel:

And so we've talked a lot about, you know, what we do if we spot this in ourselves.

Rachel:

And it sounds like all those things, you know, mindfulness, self-compassion, getting some therapy, talking about it, reading your book sounds like it's gonna be really helpful when that comes out, it's very helpful.

Rachel:

But what do we do if we spotted this in a colleague or a partner, perhaps or a relative?

Rachel:

And you've gotta, you've gotta deal with them.

Rachel:

They might not be in a place where they want to go and access any therapy or whatever.

Rachel:

They might be continuing on with their, you know, difficult behaviors.

Rachel:

But you've spotted that maybe that person is avoidant, they're displaying an avoidant pattern.

Rachel:

So what can you do to sort of manage those relationships and just help oil things along a little bit?

Claire:

I think having your own awareness of this can help you to maybe soften your response.

Claire:

Because I think when someone is reacting, usually it's in a fight or flight kind of way, it can tip them into being quite angry or quite, you know, even like behaving in a way that's very anxious can be difficult for us to see.

Claire:

So, tending to yourself and slowing yourself down, you know, arranging your face so it's got a soft tone so it's looking warm, can allow that person to see, well you are not getting on board with that fight or flight stuff over there, you are, okay, you are kind of calm.

Claire:

That is called co-regulation, then.

Claire:

There's an opportunity for their nervous system to kind of co-regulate.

Claire:

You might wanna point it out as well, but it depends on your relationship.

Claire:

But you know, if it's someone you feel close to, I've definitely had people who've come to therapy who said this was hard to hear, and maybe they didn't take it well at the time, but someone has pointed out that I always tend to react in an over anxious way or that I seek reassurance or that I'm always

Claire:

sending emails again to confirm what I really meant, and that must've been taking up a lot of time and I hadn't really realized that I was doing it.

Claire:

You know, somebody has taken the jump to go, actually, is everything okay?

Claire:

Because I've noticed this and it doesn't really feel to me like you need to be doing all of that.

Claire:

I'm wondering if it comes from an old place.

Claire:

I, that's quite tricky, isn't it?

Claire:

You'd have to feel comfortable, but, you know, I've definitely feel, I personally have had that where someone's pointed something out to me and I've gone, oh, okay.

Claire:

And it's been a moment of like, ouch, but also reflection.

Claire:

So, in therapy, obviously we've got permission as therapists to point these things out, so that's a bit easier.

Rachel:

You have to be careful, don't you, about how you point things out.

Rachel:

I think using the word oh I've noticed there that you looked a little worried or .Anxious and for me, I guess it's been thinking that anger, 'cause often anxiety can be expressed as anger, can't it?

Rachel:

Anger, defensiveness, snarkiness.

Rachel:

Often there's anxiety and for me, realizing that it's the inner chin that's coming out, it's anxiety, helps me have more compassion towards that person rather than getting annoyed myself about it.

Claire:

I agree.

Claire:

Yeah.

Claire:

I think remembering that so that you can slow down your response and go are you okay?

Claire:

when they snap at you.

Claire:

Like usually they're not okay, which why they snap there at the end of their tether, um, So you're kind of giving them permission to kind of go, actually maybe something's going on here.

Rachel:

Maybe asking you what was behind that reaction there that I just elicited from you.

Rachel:

Have to be careful in the wedding, don't you?

Rachel:

Another question I've got is, you know, I think there, there will be a lot of people that listening to this, that can identify with one of these difficult attachment styles.

Rachel:

What do we call them?

Rachel:

Abnormal attachment styles or

Claire:

So yeah.

Claire:

Insecure, yep.

Rachel:

insecure attachment styles.

Rachel:

But when they look back, they think, well, I had a pretty happy childhood.

Rachel:

And so they think, you know, in my mind, like someone's got, had a really awful start in life to have one of these insecure attachment style, but I'm presuming that's not the case actually.

Rachel:

We we can all have them just a greater or lesser extent.

Rachel:

Even if we look back and think, actually my childhood was pretty happy.

Claire:

You know, childhood isn't like a one and done thing.

Claire:

There's a lot of years in childhood and there can be pockets that are better than other pockets.

Claire:

But equally what I find is in therapy, people can think everything was hunky dory.

Claire:

But when we go back and I might say, well, who tucked you in at night?

Claire:

And who went to watch your choir rehearsals or recitals or, there might be actually less attunement there and less kind of someone being there then they had thought, so became normal to not have a, an adult there or attuned.

Claire:

Because I think a lot of people think of a bad childhood being one where there's been physical neglect or abuse or sexual abuse or all of these types of things.

Claire:

But actually children need to have an adult there who's showing an interest, who spends time with them, who interacts with 'em, not just on a transactional basis about, you know, getting uniform on, but you know, asks questions about what's going on at school and what you're interested in.

Claire:

And sometimes parents are just so busy in their own lives, they kind of forget that stuff is there.

Claire:

And so they don't really get to know their children.

Claire:

So it can be quite a mild love.

Claire:

It doesn't mean that those needs weren't being met somewhere.

Claire:

You know, maybe they did have really good friends.

Claire:

Maybe they did have a teacher or an aunt or uncle.

Claire:

So this is what I mean.

Claire:

Childhood is a long time.

Claire:

There's lots of different places where we can get different needs met.

Claire:

But equally a bit of detective work can be helpful because sometimes people think it was all fine and they don't realize that they had some unmet needs there because it was just the status quo.

Rachel:

And also 'cause we're human.

Rachel:

'Cause I, as you say that, I'm thinking, oh, crumbs of all the times why I haven't been at rugby matches and that because I've been working for my own kids and what we're not talking about is not being every single match that they've got, 'cause that's just in practical, what we talk about is being pretty, pretty absent, isn't it, I

Claire:

Uh, yeah and you know, you, maybe you knew that that match was happening and you would've asked how did it go?

Claire:

And, you know, there's lots of other ways you can show attunement and interest other than just being there.

Claire:

You know, the, on the run up to the rugby match where you, if your child was worried about it, were you there in order for them to go, oh, I'm not sure I've kind of practiced enough and whatnot.

Claire:

Like, there's all of this around it, which is practically sometimes easy if you've kind of got the job that makes you physically absent for those moments.

Rachel:

With doctors and other professionals working in healthcare,.

Rachel:

do you see one particular type playing out more than another?

Rachel:

Because actually look at them.

Rachel:

I'm thinking actually both of them leads, I'm talking about the insecure types lead to over responsibility and trying to please people and this achievement.

Rachel:

But it's interesting that both of them have the slightly different routes.

Claire:

I think people can be very high achieving and end up in jobs like becoming a doctor, lawyer, very high achieving professionals.

Claire:

And there can be definite dominant types, subtypes here that can cause or be part of that backstory, yeah.

Rachel:

What's fascinating for me is that I guess both types lead to people pleasing because the avoidant type, you are people pleasing in order to achieve, you want people to think, well, if you 'cause achievement, achievement, achievement, success, right?

Rachel:

The anxious type you want to people please, because you're so, you are wondering how people are, you are hypervigilant to their moods and their reactions.

Rachel:

So the treatment for that people pleasing and that perfectionism as well is just a bit different for each style, right?

Claire:

I mean, humans, like I said at the start, like we are designed to build connections because we're social creatures and without that, our survival is a threat.

Claire:

So this is why the people, being seen well in the eyes of others is so important to us.

Claire:

Um, and that kind of getting hold of resources is all about, not just our physical needs, but our social status.

Claire:

And so yeah, it does play out as people-pleasing in different formats, I agree.

Claire:

It's really central to a lot of human distress.

Claire:

I'd say.

Claire:

You know, really painful emotions like shame, you know, humiliation, guilt.

Claire:

They're all based on our relationships and things going wonky there.

Rachel:

So if someone was really wanting to dig down this and thinking, well, I think I, I may well have an insecure actress or maybe insecure avoidant or, or even the disorganized one, if someone was thinking, oh, crumbs, yeah, I think I need some help around this, what would you suggest that they do?

Claire:

If you would like to look online, there are adult attachment questionnaires, which are freely available.

Claire:

You could take a look at that, and working through the questions is really helpful.

Claire:

It might help people to just sift through things and start to think about it.

Claire:

There's also a scale called the Strive to Avoid Inferiority scale.

Claire:

And if you look that up again, it just looks at that insecure striving that I've talked about.

Claire:

So just getting to know yourself, your attachment styles, any insecure striving can be really helpful.

Claire:

My book helps to bring it together in a bigger picture, but if you feel, obviously if you need more than that and want to explore alongside a therapist to support you, then therapy is a great option.

Claire:

All therapists learn this as like their basic training and it comes up in different models of therapy in various ways.

Claire:

But you know, use it as a guide to start thinking about things.

Claire:

Don't see it as a concrete thing.

Claire:

Thinking about it as dominant styles and patterns.

Rachel:

So it is possible to change, even if you've identified you've got a pattern of behaving like this, you've got a dominant side of this, you can change it, it's gonna take a bit of work but you can change it.

Rachel:

So what would your three top tips be in, in all of this for people, Claire?

Claire:

So of course, coming back to learning a tool to regulate.

Claire:

So we've covered a few.

Claire:

Breathing is the quickest way to slow everything down.

Claire:

So if you can get a breathing exercise and practice that, so you can slip into it, maybe using some sort of trigger word to help you get into it, or an affirmation, you know, if something embodied that is about calming, so hands on heart or breathing, anything like that.

Claire:

Practice practice.

Claire:

The second one was do some exploration of adult attachment styles so you can recognize them in yourself and then begin to slow things down a little bit, especially when something happens in the moment that feels like set off a reaction that was bigger maybe than the situation required.

Claire:

That's often an indication that's coming from an old place and maybe an old attachment wound that could be explored.

Claire:

And then tending to that need is where the work is needed.

Claire:

My third top tip was trying to slow yourself down at the transition points in your day.

Claire:

Because I think generally slowly checking in with yourself is a really nice way as an adult to meet your needs.

Claire:

Transition points.

Claire:

By that I mean, you know, the moment that you put your work computer away before you get up to go and get the kids.

Claire:

Like, there is a moment there where you're shifting gear from work mode into trying to connect with the kids or maybe driving somewhere.

Claire:

You know, when you sit down, tweet your meal, just take a minute to really come back.

Claire:

We did that before we started the interview, didn't we?

Claire:

We just took a few moments just to come in to the interview so that we weren't just launching in from rushing here.

Claire:

I think we often crash from one thing to another, and that means we can't check in and see what we need.

Claire:

So you are meeting your adult needs now in a way that may wasn't always done and you're listening to yourself.

Claire:

And it might just be as simple as a stretch, you know, or hands on heart.

Claire:

I've got this, something you need like that.

Rachel:

That's such good advice.

Rachel:

I love that idea of these transition points.

Rachel:

'Cause it's one thing saying catch yourself when you, in the moment when you're reacting, and yes, that's really good advice, but actually let's prevent that reaction in the first place by working on your state and thinking, okay, let's slow my stuff down.

Rachel:

Let's take that transition.

Rachel:

I'm going to get the kids.

Rachel:

Maybe if I'm someone with more of an avoidance style, I want to be independent.

Rachel:

I struggle to connect with people a bit more emotionally, maybe.

Rachel:

What can I ask them that would show that I want to connect with them emotionally?

Rachel:

Things like that instead of a bit of preparation and,

Claire:

nice.

Claire:

Yeah.

Claire:

Yeah.

Claire:

I like that because I often find I, I turn the computer off and I rush to school, and if I haven't taken that moment, my head's in work and then I feel disconnected and I don't like that feeling.

Claire:

And I think, like you say, if there's a particular knowledge there that you are more likely to roll with that because connection feels tricky, inviting yourself, you know, on that last bit, walk up to the gates asking a question.

Claire:

I think that's beautiful.

Rachel:

think in all of this, awareness is key, isn't it?

Rachel:

I think yes.

Rachel:

We need to do the work on ourselves and we need to do all the getting emotional regulation of, you know, our stress and our state and our nervous system.

Rachel:

Just understanding about how these attachment styles might impact us and other people, it you're halfway to being able to deal with them, I think.

Rachel:

So this interview has been really eye-opening for me, honestly.

Rachel:

Claire, it's so helpful and I'm definitely gonna read your book, so I want to find out more about it.

Rachel:

So what's your book called and when's it out?

Claire:

Oh yes.

Claire:

So it's out on the 18th of July in the UK.

Claire:

There's gonna be a US Edition as well, but the UK is called Burnout, how to Manage Your Nervous System Before It Manages You.

Rachel:

I love that title.

Rachel:

That is just genius.

Claire:

The, the US version has a slightly different title.

Claire:

It's called The Trauma of Burnout, how to Manage Your Nervous System Before It Manages You.

Claire:

The Trauma of Burnout was the original working title throughout.

Claire:

And then, yeah, my British publisher was like doesn't feel so hopeful as your subtitle, so we, can we make that the center point?

Claire:

I was like, yeah, fair enough.

Claire:

Um, so that's why we shifted gear.

Claire:

But I'm using my background in trauma to kind of bring that into the understanding of burnout.

Claire:

'Cause I actually see there's lots of overlap.

Claire:

You know, in the ways that we might have grown up with some little t traumas, separate episode on what little t traumas are, growing up, but also in everyday life now.

Claire:

What we don't really realize, 'cause stress is normalized to the point that it's, kind of never ending now.

Claire:

And actually our nervous systems weren't designed for that.

Claire:

So once we've been in a chronic stress state for a while, I think we tip into a trauma response in our nervous system.

Claire:

And that's why I explain in the book why certain tools are very hard for us when we're in that state.

Claire:

It's not our fault that we find certain things hard, like mindfulness, journaling, problem solving, decision making, creative thought, because we can't do that when we're in that state.

Claire:

We need to regulate tools from trauma therapies can help.

Rachel:

Just that quote alone, Claire.

Rachel:

Stress has been normalized to the point where it's never ending.

Rachel:

I think you've just described pretty much everybody working in the NHS at the moment.

Rachel:

Yeah.

Rachel:

Anyway, we've talked about that before and I'm gonna definitely ask you to come back on the podcast at some point, uh, in the next few months 'cause there'll be other bits in the book that I'll want to dig deeper into.

Rachel:

If you'd be happy to come back, that would be

Claire:

I love to, I love these interview your question's always so great.

Claire:

And um, just so your listeners know, this podcast is in the book on the resources section, so just if you want to tickle yourself, go and have a look at the back section and find your

Rachel:

Yay.

Rachel:

We've made it to a book.

Rachel:

Fame achieved tick.

Rachel:

We'll put the links to those attachment questionnaires and things like that in the show notes.

Rachel:

People wanna get hold of you, find out more?

Claire:

Yeah.

Claire:

So I'm on social media.

Claire:

On LinkedIn, uh, Facebook, Instagram, TikTok and I have a website.

Claire:

If people are thinking, actually, I need some therapy, then myself or one of my associates would be able to support you for online, possibly in person, although in person's limited.

Claire:

And the book, if you are releasing this before the 18th of July, there is a free gift for anyone who pre-orders before the 18th.

Claire:

It's tools for managing procrastination when you're feeling frozen, when you're stuck on autopilot to kind of shift gear.

Claire:

So that'll be something that people can get if they listen to this in time.

Rachel:

So what's your website, Claire?

Rachel:

Just give us the address

Claire:

Uh, www.drclaireplumbly.com.

Claire:

Plumbly is spelled P-L-U-M-B-L-Y.

Rachel:

Dot com.

Rachel:

Brilliant.

Rachel:

Okay.

Rachel:

So check that out.

Rachel:

Thank you so much for being here and we'll speak to you soon.

Claire:

Thank you, Rachel.

Rachel:

Thanks for listening.

Rachel:

Don't forget, we provide a self coaching CPD workbook for every episode.

Rachel:

You can sign up for it via the link in the show notes.

Rachel:

And if this episode was helpful, then please share it with a friend.

Rachel:

Get in touch with any comments or suggestions at hello@youarenotafrog.com.

Rachel:

I love to hear from you.

Rachel:

And finally, if you're enjoying the podcast, please rate it and leave a review wherever you're listening.

Rachel:

It really helps.

Rachel:

Bye for now.

Links

Chapters

Video

More from YouTube