The progression of advanced disease often brings enormous adaptational challenges related to a loss of the capacity to be self-sufficient and to a heightened need for support from others. The increasing need to rely on others at the end of life may reactivate relational problems and may trigger threatening feelings of vulnerability and dependency. Clinicians may find it difficult to identify and respond appropriately to the specific relational needs of individuals receiving end-of-life care. Attachment theory is a developmentally-based approach to understanding the formation and maintenance of relationships relevant to felt security. Although attachment theory has been widely applied to parent-child relationships and to relationships of individuals with chronic medical conditions to their medical caregivers, it has not previously been applied to the understanding of clinician-patient relationships in the palliative care setting. This paper provides an overview of this theory and demonstrates its application and relevance to palliative care.
World Health Organization, 2003, http://www.who.int/cancer/palliative. Last accessed 1st October 2004.
2.
Steinhauser KE , Christakis NA , Clipp EC , McNeilly M , McIntyre L , Tulsky JA . Factors considered important at the end of life by patients, family, physicians, and other care providers . JAMA2000; 284: 2476–2482 .
3.
Engel GL . The clinical application of the biopsychosocial model . Am J Psychiatry1980; 137: 535–544 .
4.
Nelson CJ , Rosenfeld B , Breitbart W , Galietta M.Spirituality, religion, and depression in the terminally ill . Psychosomatics2002; 43: 213–220 .
5.
Hanson LC , Danis M , Garrett J.What is wrong with end-of-life care? Opinions of bereaved family mambers . J Am Geriatric Soc1997; 45: 1339–1344 .
6.
Larson DG , Tobin DR . End-of-life conversation: evolving practice and theory . JAMA2000; 284: 1573–1578 .
7.
Fallowfield L , Ford S , Lewis S.No news is not good news: information preferences of patients with cancer . Psycho-Oncology1995; 4: 197–202 .
8.
Main M , Solomon J.Discovery of a new insecure-disorganised disoriented attachment pattern. In Brazelton T , Yogman M eds. Affectivedevelopment in infancy. Norwood, NJ: Ablex , 1986: 39–51.
9.
Holmes J.Disorganized attachment and borderline personality disorder: a clinical perspective . Attachment and Human Development2004; 6: 181–190 .
10.
Goldberg S.Origins of attachment theory. In Attachment and development. London: Arnold Publishers , 2000: 3–15.
11.
Goldberg S.Early development and assessment of attachment in infancy. In Attachment and development. London: Arnold Publishers , 2000: 16–33.
12.
Bowlby J.Attachment and loss, vol. 1. Attachment. New York: Basic Books , 1969/1982.
13.
Sroufe LA , Waters E.Attachment as an organizational construct . Child Development1977; 48: 1184–1199 .
14.
Kobak R.The emotional dynamics of disruptions in attachment relationships: implications for theory, research, and clinical intervention. In Cassidy J , Shaver PR eds. Handbook of attachment. New York: The Guilford Press , 1999: 21–43.
15.
Tronick EZ . Emotions and emotion communication in infants . American Psychologist1999; 44: 112–119 .
16.
Weinfield NS , Sroufe LA , Egeland B , Carlson EA . The nature of individual differences in infant-caregiver attachment. In Cassidy J , Shaver PR eds. Handbook of attachment. New York: The Guilford Press , 1999: 68–88.
17.
Holmes J.Attachment, autonomy, intimacy: some clinical implications of attachment theory . Br J Med Psychology1997; 70: 231–248 .
18.
Bartholomew K.Adult attachment processes: individual and couple perspectives . Br J Med Psychology1997; 70: 249–263 .
19.
Bartholomew K.Avoidance of intimacy: an attachment perspective . Journal of Social and Personal Relationships1990; 7: 147–178 .
20.
Bartholomew K , Horowitz L.Attachment styles among young adults: a test of a four-category model . Journal of Personality and Social Psychology1991; 2: 226–244 .
21.
Ciechanowski PS , Walker EA , Katon WJ , Russo JE . Attachment theory: a model for health care utilization and somatization . Psychosom Med2002; 64: 660–667 .
22.
Goldberg S.Later development and assessment of attachment beyond infancy. In Attachment and developelopment. London: Arnold Publishers , 2000: 34–51.
23.
Slade A.Attachment theory and research: implications for the theory and practice of individual psychotherapy with adults. In Cassidy J , Shaver PR eds. Handbook of attachment. New York: The Guilford Press , 1999: 575–594.
24.
Feeney JA . Adult romantic attachment and couple relationships. In Cassidy J , Shaver PR eds. Handbook of attachment. New York: The Guilford Press , 1999: 355–377.
25.
Ciechanowski PS , Katon J , Russo JE , Dwight-Johnson MM . Association of attachment style to lifetime medically unexplained symptoms in patients with hepatitis C . Psychosomatics2002; 43: 206–212 .
26.
Bowlby J.The making and breaking of affectional bonds. In The making and breaking of affectional bonds. London: Tavistock , 1979: 127–160.
27.
Crowell J , Fraley RC , Shaver PR . Measurement of individual differences in adolescent and adult attachment. In Cassidy J , Shaver PR eds. Handbook of attachment. New York: The Guilford Press , 1999: 395–433.
28.
Ainsworth MDS , Blehar MC , Waters E , Wall S.Patterns of attachment: a psychological study of the strange situation. New Jersey: Hillsdale , 1978.
29.
Goldberg S.Attachment theory and research: an appraisal. In Attachment and development. London: Arnold Publishers , 2000: 235–250.
30.
Hunter JJ , Maunder RG . Using attachment theory to understand illness behaviour . Gen Hosp Psychiatry2001; 23: 177–182 .
31.
Beebe B , Lachmann FM . Co-constructing inner and relational processes: self and mutual regulation of infant research and adult treatment . Psychoanalytic Psychology1998; 4: 480–516 .
32.
Thompson D , Ciechanowski PS . Attaching a new understanding to the patient-physician relationship in family practice . J Am Board Fam Pract2003; 16: 219–226 .
33.
Ciechanowski PS , Katon WJ , Russo JE , Walker EA . The patient-provider relationship: attachment theory and adherence to treatment in diabetes . Am J Psychiatry2001; 158: 29–35 .
34.
Ciechanowski PS , Hirsh IB , Katon WJ . Interpersonal predictors of HbA1c in patients with Type 1 diabetes . Diabetes Care2002; 25: 731–736 .
35.
Adshead G.Psychiatric staff as attachment figures: understanding management problems in psychiatric services in light of attachment theory . Br J Psychiatry1998; 172: 64–69 .
36.
Block SD , Billings A.Patient requests for euthanasia and assisted suicide in terminal illness . Psychosomatics1995; 36: 445–457 .
37.
Jones JM , Huggins MA , Rydall AC , Rodin GM . Symptomatic distress, hopelessness, and the desire for hastened death in hospitalized cancer patients . J Psychosom Res2003; 55: 411–418 .
38.
Breitbart W , Rosenfeld B , Pessin H , Kaim M , FunestiEsch J , Galietta M et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer . JAMA2000; 284: 2907–2911 .
39.
Chochinov HM , Wilson KG , Enns M , Mowchun N , Lander S , Levitt M et al. Desire for death in the terminally ill . Am J Psychiatry1995; 152: 1185–1191 .
40.
Brown JH , Henteleff P , Barakat S , Rowe CJ . Is it normal for terminally ill patients to desire death?Am J Psychiatry1986; 143: 208–211 .
41.
Rodin G , Jones J , Rydall A , Moore M , Donner A , Gagliese L.Physical and psychological well-being in patients with stage IV GI cancer (Abstract) . 40th Annual Meeting of the American Society of Clinical Oncology, New Orleans, June 2004.
42.
Chochinov HM . Dignity-conserving care*-a new model for palliative care: helping the patient feel valued . JAMA2002; 287: 2253–2260 .
43.
Ganzini L , Nelson HD , Schmidt TA , Kraemer DF , Delorit MA , Lee MA . Physicians' experiences with the Oregon Death with Dignity Act . NEJM2000; 342: 557–563 .
44.
Chochinov HM , Hack T , Hassard T , Kristjanson LJ , McClement S , Harlos M.Dignity in the terminally ill: a cross-sectional, cohort study . Lancet2002; 360: 2026–2030 .
45.
Chochinov HM , Hack T , McClement S , Kristjanson L , Harlos M.Dignity in the terminally ill: a developing empirical model . Soc Sci Med2002; 54: 433–443 .
46.
Vaillant G , Sobowale N , McArthur B.Some psychological vulnerabilities in physicians . NEJM1972; 287: 372–375 .
47.
Arora NK . Interacting with cancer patients: the significance of physicians' communication behaviour . Soc Sci Med2003; 57: 791–806 .
48.
Shilling V , Jenkins V , Fallowfield L.Factors affecting patient and clinician satisfaction with the clinical consultation: can communication skills training for clinicians improve satisfaction?Psycho-Oncology2003; 12: 599–611 .
