Attachment and Health - Wikipedia
Dismissing attachment in the setting of poor patient–provider communication is associated with poorer treatment adherence in patients with diabetes. (PsycINFO . Promotion of patient–provider adherence to current health guidelines is essential in .. relationship: attachment theory and adherence to treatment in diabetes. Journal of Diabetes Nursing Volume 17 No 7 ARTICLE factors which may influence a person's adherence to medication, including biological, cognitive .. patient provider relationship: Attachment theory and adherence.
They often desire to have emotional relationships but feel uncomfortable when others get too close. They tend to agree with statements such as "I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them.
I sometimes worry that I will be hurt if I allow myself to become too close to others. In health care appointments, their narrative is full of intense negative emotion but relatively sparse in the specific detail desired by health care providers.
They may delay seeking healthcare see healthcare utilizationminimize reporting symptoms and disclose limited personal information. Due to their degree of distress, they can present a disorganized narrative that is difficult for providers to follow and interpret diagnostically.
The cognitive schema for attachment consists of views of the efficacy of self and other to create security in times of distress. Bartholomew and Horowitz Model[ edit ] Bartholomew and Horowitz proposed and verified a working model based on two dimensions; the view of the self self-esteem and the view of others sociability  Secure- Positive view of self, Positive view of other Dismissive- Positive view of self, Negative view of other Preoccupied- Negative view of self, Positive view of other Fearful- Negative view of self, Negative view of other Prototype-Insecurity Classification Model[ edit ] In Maunder and Hunter  combined the internal working model with the attitudes, behaviours and emotional expression of the different styles to create a prototype based classification that included severity of insecurity.
This model was designed to be clinically useful, allowing healthcare providers to identify and predict the behaviours of patients whose attachment systems were activated by pain and illness. They distinguish the different attachment styles by; 1 attachment anxiety, the discomfort someone feels when separated, 2 attachment avoidance, which is discomfort associated with closeness and 3 severity of insecurity Secure- Low anxiety, low avoidance, low severity of insecurity Dismissive- Low anxiety, high avoidance, moderate insecurity Preoccupied- High anxiety, low avoidance, moderate insecurity Fearful- High anxiety, high avoidance, high insecurity Disorganized- High anxiety, high avoidance, high insecurity.
The difference between disorganized and fearful is that people with disorganized attachment do not use a consistent strategy to find security. Attachment and health outcomes[ edit ] Attachment and health interact on multiple levels. Attachment is a biologically based system tied to our response to distress and attachment styles appear to confer differences in stress physiology.
Accordingly, attachment styles influence patient perception of illness, health care utilization, medication compliance and treatment response. Specifically, they found preoccupied individuals reported more heart disease, and dismissive individuals more pain conditions. A prospective study followed children until the age of 32 and found a similar pattern of results. They found that people with anxious-resistant dismissive styles of attachment reported vague, non-specific symptoms more often, and those with anxious-preoccupied classification had a higher rate of inflammation-based illnesses.
This prospective study was particularly important because of the difficulty assigning causation in the often observed relationship between chronic pain and insecure attachment.
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Prospective evidence research starting with infant attachment and following up over time is mostly limited to studies following infants into childhood or adolescence as opposed to adulthood, but does demonstrate that insecure attachment is a general risk factor for both internalizing and externalizing symptomatology.
For example, clinical depression is often associated with negative thoughts about the self, and this cognitive bias may influence the self-report in attachment questionnaires.
There may be interpersonal consequences from untreated mental health conditions. Pre-existing psychological problems can increase the likelihood of secure attachment changing to insecure attachment over time.
The HPA axis has garnered particular attention from attachment researchers because it is known to be activated by social stressors. The HPA axis also follows a circadian rhythmwith highest release within about 30 minutes to 1 hour upon awakening, called the cortisol response to awakening CRAand a slow taper throughout the day.
Researchers have looked at both cortisol response to stress CRS and CRA to determine if attachment anxiety and avoidance underlie individual differences in HPA activity. Findings in the field have inconsistent.
The evidence suggests that a individuals with high attachment anxiety perceive a higher degree of distress when faced with a stressor and have higher baseline anxiety compared to those low in attachment anxiety,     b most studies suggest higher cortisol reactivity to stress in anxiously attached individuals,       while two studies did not support this trend   c avoidant-dismissive attachment has been less consistent, with some studies showing an increase in cortisol produced in response to a stressor,   and others not finding any differences in comparison to securely attached individuals   d fearful attachment is associated with lower cortisol both upon awakening and in response to a stressor   although one study in pregnant women found less diurnal variation in those fearfully versus securely attached, leading to a higher bedtime cortisol level in the fearful group.
The qualitative data that we present were taken from Although an interview guide was utilized in the interview and focus group, for the interview to be emergent in nature care was taken to ensure that the unique perspectives of each participant, and important and relevant information from their point of view came to the forefront of each interview. The interview with the PCP included a semi structured interview guide that covered a range of topics, such as conditions of prescribing the eating plan, strategies for patient engagement and adherence and social support Appendix A.
The interview with the focus group covered a range of topics including their engagement with the eating plan and the support group, social support, their relationship with their physician and their environment Appendix B.
Data analysis The survey sample responses were analyzed using general descriptive statistics and multivariate analyses were performed on pre-post changes in therapeutic alliance and adherence measures.
Explorative analyses were conducted on changes between post and six-month follow-up changes. The data presented in the qualitative section, represent our findings from the narratives of the PCP and the support group members as they describe their everyday experiences.
Transcripts from interviews were coded by two PhD-level researchers trained in qualitative data analysis using constructivist grounded theory techniques Charmaz, Two reminder emails were sent as a follow-up to the initial invitation. Of the 57 participants, 23 or Sixteen percentage reported high school as their highest educational level.
Gender was equally represented in the sample with The mean age of participants was The sample was fairly evenly divided between three average household income levels: Health status A more comprehensive description of the pre-post health status of the sample was provided elsewhere Van Zyl et al.
The leading chronic diseases included in the self-report of respondents were hyperlipidemia high cholesterol The mean poor health rate before starting on the no added oil eating plan was 3. Four reported being on the no added oil plant-based eating plan for less than three months. Health outcomes Improved health outcomes were reported by respondents since being on the eating plan across a number of conditions including total cholesterol, body mass, medication load, general health rating, mobility and general feeling.
Results of health outcomes are reported in more detail elsewhere Van Zyl et al. Most of the patients included in the survey were from the same practice of the primary care provider at the time the survey was conducted.
The mean PDRQ-9 during the time of the survey was Adherence Overall the adherence to the NOP was high as reflected by the An even higher percentage By far most respondents This change provided an ideal opportunity to further explore therapeutic alliance and adherence.
How do patients and the PCP view the doctor-patient relationship and adherence? Adherence to plan Both the physician and the patients described the challenges and successes in adhering to the eating plan. Some common challenges for the physician were: I found that there are a lot of people who do really well for six months or a year and then they kind of slide off and then they get sick and then they have to decide on getting back again. There were also patients who follow the plan with little encouragement or follow-up.
They outline strategies and tactics that they used to stay adherent. In addition, the PCP used the tactic of discussing medication load reduction as a way of initially engaging with patients around conversations about the eating plan. A strategy used by the PCP to engage patients in their care and adhere to the plan was to include their family members in the plan: I gave them a movie a Netflix movie to watch it is called Forks Over Knives and the reason why I think that is helpful is because it gives the spouses a topic to look at something together.
This is not an individual treatment here. If someone sought this treatment the whole family is affected. Anyhow once I saw what it was about I decided to commit myself to it.
January 31st 19 … I started … Patients found advocating for healthier options on menus at restaurants helpful to them to be adherent. Most helpful to adherence for patients was making a mind shift to where they saw being on the eating plan as a new way of living. Once you have crossed this threshold where it is no longer a diet that I do but it is how I live my life. It is basically empowerment by getting life skills back.
You know we eat what we want we are not really on a diet. But it is really good because you can cramp this much food in you and then you stop and you eat two hours later you know for doctors to really you know if they are having a patient that you know has some overeating issues that would be really good to you know to recommend this lifestyle because you know they can eat and eat and eat and be healthy.
Therapeutic alliance Both the PCP and the support group members spoke about the relationship between the patient and the physician being a central to the change process.
Through the process of the patients and physician engaging with each other, and relating to each other over a shared investment in the eating plan created an environment which made change possible for the patient. The PCP acknowledged that people in his profession have a significant amount of influence over patients due to the power dynamics of the medical field.
When asked about the dynamic, the PCP replied, Yes I think it is very important the trust relationship between the physician and patient so I think that is a big part in why a lot of my patients have actually looked at it.
The PCP went on to describe how this alliance extends beyond medication adherence or simple engagement in care: Support group members reflected on their relationship with their PCP and how this relationship engaged them in the eating plan: So anyway that is how I kind of came around to it and why I am doing that for myself but it really helps and we have physicians who are supporting the patients and it is the best situation.
Exactly we have a lot of respect for our doctors and what they say so and what they mean you know when you are talking about a condition that is life or death and your doctor is saying no that is not going work that is not enough protein you really are going to take that to heart. Moving beyond therapeutic alliance Both the PCP and the support group members credit this program as being successful and feasible due to the relationships that they formed with their doctor and support group members.
All of the participants described this program as a local community movement which involved not only support, but politics and activism, which required a collective approach to organizing the network of patients. The PCP spoke about removing the power of the plan from his practice, and giving it to his patients: So I am a strong proponent of this being a grass roots program not a medical doctor person program and something that if I was the one in charge I need lots of you know an army out there encouraging people and helping me so that is what I did.
I did discover a few folks that were very strong proponents of it and found the benefits for their lives and then encouraged them to start support groups and they did just that.
Discussion Patients included in the survey rated their relationship with their PCP as high, a mean of almost 40 out of a maximum of By far most patients In general, these patients did not find it too expensive to buy fresh fruit and vegetables, but cost may be a factor in lower income patient populations.
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Both the PCP and the support group members acknowledged the importance of the doctor-patient relationship as central to the change process of going on a plant-based eating plan and staying on the plan. Although the PCP and the support group members attribute successful adherence to the relationships that they formed, at least initially, they also see success in the longer term as depending on more than the therapeutic alliance.
In the end, patients must own the plan and when power is transferred from the PCP practice to a local community movement which involved not only support, but community organizing and advocacy, an environment for adherence is successfully created over the longer term. This move beyond relying on the doctor-patient relationship is supported by the finding that although the mean score for patient-doctor relationship decreased significantly to In general, the findings of this study were supportive of what Reese and Williams found in their systematic review.
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The focus on positive self-care behavioral and health outcomes and recognition that self-care management involves both social and medical components were found to be important in both studies.
In this study the PCP also made use of additional reading material and watching a video, there was a focus on monitoring and outcomes. Furthermore, education and collaboration with partners in the wider community was elevated by the support group to a level of advocacy. The promise of a cost-effective, low-risk intervention for many chronic conditions that, for example, lowers body mass index, blood pressure, HbA1C, cholesterol levels, and chronic osteoarthritis offers new hope to many patients with chronic conditions.
The finding that a considerable a change in health status from poor to much improved, is associated with higher rates of adherence, means that the eating plan is potentially even more beneficial for those with severe conditions. A focus on medication load reduction, involving family members, and engagement with the support group, contributed in the view of respondents to adherence.
Challenges for adherence for the physician include patients saying that they are adherent when they are not, and patients becoming a vegan and not an oil free vegan, as well as patients who do not read or have access to the internet. The PCP found it difficult to predict who will be adherent to the plan and who will not, and was surprised by some patients who were strictly adherent for six months or longer and then stop following the treatment plan, while others will follow the plan with almost no or minimum encouragement.
Although the study included a cross-sectional pre-post and six-month follow-up survey, focus group and case study, there are limitations. The case study was of only one PCP, the focus group was of members of one support group, the sample size was relatively small and the survey did not include a control group.
Despite these limitations the study offered a multi-faceted view of adherence to a treatment plan that demanded life style changes over the longer term.
Conclusion Therapeutic alliance correlated significantly with strictness in adherence to the no added oil plant-based eating plan and both the PCP and patient-run support group members attributed successful adherence to the provider-patient relationships that they formed. However, their view of long term adherence shifted from this relationship to active patient involvement in managing their health and a transfer of power form the PCP practice to a local community movement.
This finding underscore the importance of provider-patient relationship for adherence during the initial phase of change before a habit of adherence has been developed.
Attachment and Health
Also the transfer from provider-relationship reinforcement of adherence to reinforces that occur in the natural environment of patients, is significant for sustainability of the desired behavior. Adherence rates, ameliorated by the doctor-patient relationship, indicate that the NOP is feasible option for the treatment of chronic disease. Funding The authors received no direct funding for this research. References References Barnard, N. A systematic review and meta-analysis of changes in body weight in clinical trials of vegetarian diets.
Journal of the Academy of Nutrition and Dietetics, 6—