Connecting with chronically ill patients to improve treatment adherence Abstract: This study presents an integrative review of the literature assessing the relationships among a patient’s style in coping with a long-term health condition, the patient-practitioner therapeutic alliance, and treatment adherence among chronically ill adults. Evidence-based recommendations to improve nurse practitioner-patient therapeutic alliance and treatment adherence are suggested. hronic diseases have become increasingly prevalent on an international scale.1 Fortunately, primary care nurse practitioners (NPs) are uniquely poised to form effective, long-term By Giovana G. Silva, MSN, RN, AGNP-C; clinical relationships with chronically ill patients and their Martha K. Swartz, PhD, RN, CPNP, FAAN; and families while assisting them through the disease process. Sheila L. Molony, PhD, RN, GNP-BC The quality of the patient-practitioner relationship (or therapeutic alliance) is particularly important when caring for chronically ill patients because it is a determinant of treatment adherence.2-4 Nonadherence to a medical regimen (for example, a patient’s behavior not matching agreed recommendations from the clinician) is estimated to affect approximately 30% to 50% of patients with chronic conditions and generates negative outcomes, including increased medical costs and rates of hospitalization.5,6 Keywords: attachment theory, chronic illness, patient-practitioner relationship, therapeutic alliance, treatment adherence
42 The Nurse Practitioner • Vol. 39, No. 9
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Connecting with chronically ill patients to improve treatment adherence
When a patient is confronted with a debilitating disease, his or her style of coping with stress may contribute to a nonproductive clinical relationship with the healthcare practitioner. Practitioners may feel frustrated and confused by patients who are under or over concerned about their health status as well as those who are over dependent on the practitioner’s opinion.7,8 As a result of this pattern, essential and positive patient-practitioner relationships are not formed, which may lead to poor quality of care. This article presents an integrative review of the literature that assesses the relationships occurring among the following variables: the patient’s style in coping with a long-term health condition; the patient-practitioner therapeutic alliance; and treatment adherence among chronically ill adults in primary care settings. The review of empirical and theoretical studies will be grounded in Bowlby’s attachment theory and will result in evidence-based recommendations for tailored strategies aimed to improve therapeutic alliance and treatment adherence. ■ Theoretical framework Conceptualized by Bowlby in the 1950s, attachment theory is considered a widely accepted and validated approach in developmental psychology.9 According to Bowlby, infants depend on close interaction with their mothers or other attachment figures for protection and survival.10-12 Disruption or inability to form attachments can create vulnerability in one’s sense of self and in one’s capacity to regulate, contain, and modulate affective experience.13,14 Attachment needs and behaviors (seeking proximity to an attachment figure) are held throughout the life span and can be activated by illness events.10,15 Based on Bowlby’s work, attachment theorists have been able to identify attachment orientations in adolescents and adults. A model of adult attachment orientation developed by Bartholomew and Horowitz reveals four attachment types: secure, anxious-preoccupied, dismissive-avoidant, and fearful (see Bartholomew’s model of adult attachment).16 Adults with secure attachment are believed to have received consistently responsive caregiving in early childhood, thus developing positive views of self and others along with the tendency to feel comfortable when depending on or being comforted by others. Persons with anxious-preoccupied attachment are believed to have received inconsistently responsive caregiving, and thus may become excessively aware of attachment relationships and emotionally dependent on the approval of others while also developing poor self-esteem.17 Adults with dismissive-avoidant attachment are believed to have received consistently emotionally unresponsive caregiving, becoming compulsively self-reliant and uncomfortable in situations of close or trusting interactions.12,18 Finally, adults with fearful attachment are believed to have had excessively critical or harsh rejecting caregiving, resulting in a desire for social www.tnpj.com
contact that is inhibited by fear of rejection. These individuals often demonstrate approach-avoidance behavior patterns that arise from a fear of intimacy.19,20 ■ Attachment orientations and stress model of coping behaviors Mikulincer and Shaver further developed a useful model that illustrates how differences in attachment orientations affect emotional regulation and stress coping strategies.21 This model sheds light on how an individual may cope with physical illness. In this model, activation of the attachment system is triggered by a threatening situation or illness. Securely attached individuals invoke positive mental images of attachment figures to cope with the stress and experience a sense of security, relief, and positive emotional regulation. Anxious-preoccupied individuals may, under distress, react with anxiety and seek intense/frequent close proximity to an attachment figure.13 In contrast, a dismissive-avoidant individual may be self-reliant and avoid seeking proximity with an attachment figure.21 Fearful individuals may also act in a disorganized manner.21 A meta-analysis by Bakermans-Kranenburg found that between 31% and 74% of adult subjects exhibit dismissiveavoidant or anxious-preoccupied attachment orientations.22 Attachment insecurity has also been linked to the development of chronic illnesses, mortality, poor therapeutic alliance, and treatment nonadherence.7,23-26 ■ Methodology In this integrative review, the authors seek to systematically review three topics as they relate to health: attachment theory, treatment nonadherence in chronically ill patients, and patient-practitioner relationships. The CINAHL, Ovid Medline, and Ovid PsycINFO databases were searched in the spring of 2013 using the terms attachment theory, chronic disease, patient compliance, physician-patient relations, and nurse-patient relations. Subsequently, ancestry searching of the retrieved articles was performed. Studies of adults age 19 and older were included. Non-English language articles and articles before 2001 were excluded. The overall methodological approach was guided by strategies as described by Whittemore and Knafl.27 This approach allows for the inclusion of diverse methodologies in the review, which acknowledges the complexity inherent in the process and results in a more comprehensive discussion of complex phenomena. The evidence-leveling system, as described by the American Association of Critical Care Nurses (AACN), was applied to appraise the quality of the evidence generated (see AACN’s new evidence-leveling system).28 In keeping with the approach suggested by Whittemore and Knafl, the AACN system addresses a wide variety The Nurse Practitioner • September 2014 43
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Connecting with chronically ill patients to improve treatment adherence
of methodologies found within clinical studies, including qualitative research and metasyntheses. The initial search resulted in 27 citations. To further narrow the search, the following additional inclusion criterion was applied: articles that contained at least two or three of the core variables of interest in the study (attachment theory, treatment nonadherence, and patient-practitioner relationship). Of the 27 articles initially identified, 9 met the criteria for inclusion in the review (see Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes). Results highlight the linkage among attachment theory, nonadherence behavior, and the role of the patientpractitioner relationship in fostering positive outcomes. ■ Findings The studies included in this review revealed three associations among attachment orientation and the problems of poor patient-practitioner relationship and treatment nonadherence behavior: Patient-practitioner relationship. Results showed that a patient’s vulnerability may create a need for attachment to a caregiver. This need is activated in adults when they are sick or scared and become in need of a regular practitioner.29 It is also possible for practitioners’ own attachment orientations to adversely affect clinical relationships with patients, and practitioners with insecure attachment styles may have difficulty forming therapeutic alliances with patients.23,30 Stress coping behavior. Results suggest that attachment orientation may play a crucial role in how individuals cope with stress and how patients subsequently interact with their practitioners.8 Securely attached individuals seem to have better clinical relationships with their practitioners, trusting them for support during periods of crisis. Dismissiveavoidant patients may be overly self-reliant and believe that caregivers are unreliable and will let them down when the need is greatest.27,31 Anxious-preoccupied patients may be perceived by their practitioners as needy and dependent and
tend to amplify physical symptoms of chronic illness to evoke frequent care from practitioners. Patients with fearful attachment orientation often display a help-seeking yet help-rejecting behavior as the patient attempts to exert pressure on the practitioner to deliver more care that may subsequently be rejected by the patient due to a high level of mistrust toward others.8 Treatment adherence. Results showed that dismissiveavoidant patients had significantly higher glycosylated hemoglobin levels than did patients with preoccupied, secure, and fearful attachment styles among patients with diabetes.20 In addition, dismissive-avoidant subjects who perceived a poor quality of communication with their practitioner also tended to have higher levels. A theoretical study suggested strategies on how primary care practitioners may improve medical outcomes by recognizing patients’ unique attachment relationship patterns.7 ■ Discussion The attachment orientations of patients (as well as practitioners) may strongly affect the patient-practitioner relationship. Identifying these patterns may serve to indicate potential barriers to care and foster individualized care based on an awareness of how individuals may mediate stress through their attachment styles. While securely attached patients seek support and are trustful of practitioners during periods of crisis, dismissiveavoidant patients are less eager to seek help from practitioners, often reporting less trust and satisfaction in their clinical interactions and more psychological distress.7,8,31 They appear to have lower rates of treatment adherence when compared with patients with secure and anxiouspreoccupied orientations.20,25 Thus, a tailored approach that considers these patients’ attachment orientation may lead to improvement of adherence.20 Fearful individuals experience high levels of mistrust toward others. They tend to interact in a pattern of seeking
Bartholomew’s model of adult attachment Dependence (view of self)
Avoidance (view of others)
Low (positive)
High (negative)
Low (positive)
Secure Comfortable with intimacy and autonomy
Anxious-preoccupied Preoccupied with relationships
High (negative)
Dismissive-avoidant Dismissing of intimacy; Counter dependent
Fearful Fearful of intimacy; Socially avoidant
Adapted from Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol. 1991;61(2):226-244. Adapted with permission.
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Connecting with chronically ill patients to improve treatment adherence
and rejecting help, leading to poor patient-practitioner relationships.7,8 Like dismissive-avoidant individuals, they cope with pain by minimizing it, and such behavior patterns place them at risk for developing chronic pain.32 Anxious-preoccupied individuals seek support in a pattern that often overwhelms their clinicians, which can result in practitioners’ avoidance of such patients along with poor therapeutic alliance.7,8 They experience higher subjective pain in the presence of a low-empathetic individual.33 ■ Attachment orientation and clinical management strategies Dismissive-avoidant. NPs may support these patients’ needs for space and personal control by using a patient’s surname and title, sitting down when the patient is recumbent, and addressing the patient’s needs regarding appointment scheduling. These patients should be reassured that their need for independence will be sustained while responsive care continues unabated. Additionally, NPs could use automated appointment-tracking systems, smart-phone applications, and proactive contacts, such as e-mailed or texted appointment reminders. These considerations will likely reduce patient anxiety and enhance a sense of independence.7,8,34 Anxious-preoccupied. To enhance the patients’ sense of security, they should be assured that care will be regularly provided. Practitioners should be reliable, consistent, unflappable, and concerned about patient’s care. Finally, NPs should show up on time, stay for the agreed duration, interact preemptively, and be careful to not avoid the patient. Frequent but brief, regularly scheduled appointments may decrease the patient’s acute somatic symptoms as a care-eliciting strategy.7,8 Although some practitioners may consider 20-minute appointments “brief,” many NPs may not be able to implement such recommendation due to time constraints of a busy clinic and/or billing issues. Fearful. Because these patients often have difficulties in trusting their practitioners, NPs should be attuned to patient vulnerability and work in a collaborative, nonjudgmental way to create a more mutually trustful clinical relationship. Additionally, NPs should acknowledge the negative emotions that might arise when interacting with these patients and continue to provide active treatment. This approach challenges the patient’s view of caregivers as threatening. After some time, as the practitioner develops rapport and trust, the patient may be confronted with the pattern he or she has of seeking then rejecting help.7,8 ■ Case exemplar: A dismissive-avoidant patient Mr. R is a 37-year-old obese male with hypertension and hyperlipidemia. He has been a patient for 2 years. Since he was diagnosed with those conditions, he has not fully adwww.tnpj.com
AACN’s new evidence-leveling system Level A
Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
Level B
Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment
Level C
Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
Level D
Peer-reviewed professional organizational standards, with clinical studies to support recommendations
Level E
Theory-based evidence from expert opinion or multiple case reports
Level M
Manufacturers’ recommendations only
Reprinted with permission from Armola RR, Bourgault AM, Halm MA, et al. AACN levels of evidence: what’s new? Crit Care Nurse. 2009;29:72-73.
hered to the treatment regimen. Practitioners have been trying to establish a relationship with him and get him involved in his care, but, although somewhat pleasant, he appears emotionally distant and superficial in his interactions. He often does not return to the clinic for the scheduled appointments or return calls. Whenever he comes to see a practitioner, his BP and cholesterol levels are elevated. Although he is already showing signs of hypertension-related complications, he keeps gaining weight and continues to smoke. He often acknowledges not taking his medication consistently. The adverse reactions of long-standing hypertension and the need for him to lose weight and quit smoking have been explained to him. He agrees and states that he is going to do the necessary lifestyle changes on his own. The providers feel unconvinced and frustrated. Mr. R displays a pattern of dismissive-avoidant attachment by minimizing his illness, being self-reliant, not seeking out support, and avoiding proximity with healthcare practitioners. This behavior hinders the establishment of a relationship with the patient. Practitioners decide to tailor their approach to Mr. R by considering his attachment orientation. When dealing with dismissive-avoidant patients, it is key to enhance their sense of control and independence. The staff will address the patient by his surname and title. During his appointment, it is advised to sit down when he is recumbent. When scheduling his follow up, the staff will make an effort to be flexible with dates and will offer options of appointment tracking systems, The Nurse Practitioner • September 2014 45
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Connecting with chronically ill patients to improve treatment adherence
Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes7,8,20,25,29-33 Design
Findings
Conclusion/ recommendations
Limitations
AACN level of evidence
Insecurely attached patients reported less trust in and satisfaction with their clinician, and more general distress than securely attached patients, 3 and 9 months after diagnosis
Attachment theory provides framework to interpret differences in patients’ trust, satisfaction, and distress, and may help clinicians to respond so that patients feel secure, likely improving outcomes
Possible selection bias (treating practitioner enrolled subjects)
B
Fearful and dismissingavoidant individuals mask their distress caused by pain experience
Fearful and dismissingavoidant attachment orientations are risk factors for chronic pain and related complications
Potential bias from convenience sample
C
(1) Anxious-preoccupied attachment correlated with higher subjective pain. (2) Avoidant-dismissive attachment correlated with lower subjective pain. (3) Social presence decreased autonomic responses to pain in all individuals
Social presence and perceived empathy may interact with individual differences in attachment style to influence one’s pain perception
Limited generalizability of findings to a clinical population
B
Being a patient creates a need for attachment to a caregiver. This need is fundamental and is activated in adults when sick or scared
Continuity of care with a regular practitioner should be sought in sicker and worried patients
Did not examine provider attachment styles
C
Insecure attachment is likely a risk factor for stress and mental health problems in medical students and practitioners
(1) Understanding of practitioner’s attachment style may help in counseling to avoid burnout. (2) Awareness of practitioner’s own attachment style may improve interactions with patients
Search strategy not clearly described; no objective appraisal of the level of evidence
C
Holwerda, 2013, The Netherlands31 Empirical–longitudinal group comparison, N = 130. Recently diagnosed cancer patients ages 30-75 years (mean 59 years, 70% female)
Andrews, 2011, Australia32 Quasi-experimental, correlational, N = 82 Single, mostly Australian university students, ages 17-84 years (mean 24 years, 56% male) Sambo, 2010, England33 Quasi-experimental, N = 30 Healthy adult participants ages 21-50 years (mean 29 years, 66% female)
Frederiksen, 2010, Denmark29 Qualitative, N = 22 18-82 years (10 women and 12 men), in which 12 saw their regular general practitioner (GP) and 10 saw an unfamiliar GP Adshead, 2010, England30 Narrative review
Continued
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Connecting with chronically ill patients to improve treatment adherence
Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes7,8,20,25,29-33 (Continued) Design
Findings
Conclusion/ recommendations
Limitations
AACN level of evidence
Dismissive-avoidant attachment is associated with difficulties in therapeutic alliance
Attachment theory is a valuable framework for understanding dismissive-avoidant diabetic individuals’ interactions with clinicians
(1) Possible selection bias due to small sample size (2) Cross-sectional study–not possible to infer causal relationships
C
Clinicians may improve outcomes by recognizing patients’ attachment patterns
Tailored approaches toward insecurely attached individuals can be used to improve clinical relationship and medical adherence
Limited treatment approaches
C
Attachment theory provides an useful model for understanding the ways individuals feel and react when stressed by illness
Tailored approaches to insecurely attached patients may improve interpersonal relationships and therapeutic alliance
Limited recommendations for research
E
Tailored approaches to insecurely attached patients with diabetes may improve therapeutic alliance and treatment adherence
(1) Causal relationships among glycosylated hemoglobin levels, attachment style and quality of communication cannot be definitively determined. (2) Limited generalizability due to homogenous population
C
Morris, 2009, England25 Quasi-experimental, correlational, N = 48 Patients with diabetes (54% male, mean age 56 years, 42% with type 1 diabetes, 58% with type 2 diabetes, mean of 16 years since diagnosis)
Thompson, 2003, United States7 Integrative review
Hunter, 2001, Canada8 Theoretical
Ciechanowski, 2001, United States20 Quasi-experimental, correlational, N = 367 Patients with diabetes (mean age 61 years, 56% female, 14 with type 1 diabetes, 353 with type 2 diabetes)
Dismissive-avoidant attachment is associated with poorer treatment adherence in patients with diabetes
such as phone calls or mailed appointment reminders. These actions will likely enhance Mr. R’s sense of control, need for space and independence, and ultimately improve the therapeutic alliance and his treatment adherence. ■ Limitations and further research Based on the levels of evidence, research in the area of patient attachments styles and clinical outcomes is evolving from primarily theoretical reports to quasi-experimental studies in www.tnpj.com
patient populations. However, the reviewed studies were primarily descriptive/theoretical works, and the few intervention studies were cross sectional in nature, involving mainly patients with diabetes. Nevertheless, the empirical studies indicated a strong correlation between tailored approaches and improved therapeutic alliances. Therefore, longitudinal quasi-experimental or experimental designs would be warranted among patient populations coping with a variety of chronic health conditions. This area of research would also The Nurse Practitioner • September 2014 47
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Connecting with chronically ill patients to improve treatment adherence
benefit from patient-centered participatory designs and further qualitative studies regarding patient and provider experiences. Finally, it must be stressed that although there is a growing body of research on clinically relevant problems associated with insecure adult attachment styles, the DSM-V (like the DSM-IV) defines attachment disorders only within the scope of childhood diagnoses, as the result of social neglect or other situations that limit a young child’s opportunity to form selective attachment.35 ■ Patient-centered treatment Treatment nonadherence has an enormous impact on society as well as on families and individuals. NPs are uniquely poised to decrease healthcare costs through a reduction in patient hospitalization and chronic illness complications with terminal consequences. Establishment of therapeutic alliance is a key factor involved in this process. Understanding patients’ attachment orientations allows NPs to focus on successful communication which, in turn, allows them to effectively collaborate with patients to ensure the best-possible patientcentered treatment.36 It has been the goal of this article to present attachment theory as a means for understanding the particular ways individuals may mediate stress when facing a chronic disease and how primary care NPs, through effective relationships with patients, may help them to manage that distress, thereby promoting adherence to recommended therapies and better healthcare outcomes. REFERENCES 1. World Health Organization. Chronic Conditions. http://www.who.int/topics/ chronic_diseases/en. 2. Kaplan JE, Keeley RD, Engel M, Emsermann C, Brody D. Aspects of patient and clinician language predict adherence to antidepressant medication. J Am Board Fam Med. 2013;26(4):409-420. 3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5): 487-497. 4. Tarn DM, Mattimore TJ, Bell DS, Kravitz RL, Wenger NS. Provider views about responsibility for medication adherence and content of physicianolder patient discussions. J Am Geriatr Soc. 2012;60(6):1019-1026. 5. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;(2): CD000011. 6. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530. 7. Thompson D, Ciechanowski PS. Attaching a new understanding to the patient-physician relationship in family practice. J Am Board Fam Pract. 2003;16(3):219-226. 8. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry. 2001;23(4):177-182. 9. Thomas PM. Dissociation and internal models of protection: Psychotherapy with child abuse survivors. Psychotherapy: Theory, Research, Practice, Training. 2005;42(1):20-36. 10. Bowlby J. Attachment and Loss: Vol. 1. Attachment. London: Hogarth Press; 1969.
13. Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum; 1978. 14. Slade A. The development and organization of attachment: implications for psychoanalysis. J Am Psychoanal Assoc. 2000;48(4):1147-1174. 15. Bowlby J. The Making and Breaking of Affectional Bonds. London: Routledge; 1979. 16. Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol. 1991;61(2):226-244. 17. Bartholomew K. Avoidance of intimacy: an attachment perspective. J Soc Pers Relat. 1990;7(2):147-178. 18. Bowlby J. The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. An expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976. Br J Psychiatry. 1977;130:201-210. 19. Bartholomew K. From childhood to adult relationships: Attachment theory and research. In: Duck S. Understanding Relationship Processes 2: Learning About Relationships. Beverly Hills: Sage Publications; 1993:30-62. 20. Ciechanowski PS, Katon WJ, Russo JE, Walker EA. The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry. 2001;158(1):29-35. 21. Mikulincer M, Shaver PR. Adult attachment and affect regulation. In: Cassidy J, Shaver PR, eds. Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford; 2008:503-531. 22. Bakermans-Kranenburg MJ, van Ijzendoorn MH. The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups. Attach Hum Dev. 2009;11(3): 223-263. 23. McWilliams LA, Bailey SJ. Associations between adult attachment ratings and health conditions: evidence from the National Comorbidity Survey Replication. Health Psychol. 2010;29(4):446-453. 24. Ciechanowski P, Russo J, Katon WJ, et al. Relationship styles and mortality in patients with diabetes. Diabetes Care. 2010;33(3):539-544. 25. Morris L, Berry K, Wearden AJ, Jackson N, Dornan T, Davies R. Attachment style and alliance in patients with diabetes and healthcare professionals. Psychol Health Med. 2009;14(5):585-590. 26. Levy KN, Ellison WD, Scott LN, Bernecker SL. Attachment style. J Clin Psychol. 2011;67(2):193-203. 27. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546-553. 28. Armola RR, Bourgault AM, Halm MA, et al. AACN levels of evidence: what’s new? Crit Care Nurse. 2009;29(4):70-73. 29. Frederiksen HB, Kragstrup J, Dehlholm-Lambertsen B. Attachment in the doctor-patient relationship in general practice: a qualitative study. Scand J Prim Health Care. 2010;28(3):185-190. 30. Adshead G. Becoming a caregiver: attachment theory and poorly performing doctors. Med Educ. 2010;44(2):125-131. 31. Holwerda N, Sanderman R, Pool G, et al. Do patients trust their physician? The role of attachment style in the patient-physician relationship within one year after a cancer diagnosis. Acta Oncol. 2013;52(1):110-117. 32. Andrews NE, Meredith PJ, Strong J. Adult attachment and reports of pain in experimentally-induced pain. Eur J Pain. 2011;15(5):523-530. 33. Sambo CF, Howard M, Kopelman M, Williams S, Fotopoulou A. Knowing you care: effects of perceived empathy and attachment style on pain perception. Pain. 2010;151(3):687-693. 34. Varshney U, Vetter R. Medication adherence for patients with mental illness. Conf Proc IEEE Eng Med Biol Soc. 2012;2012:2182-2185. 35. American Psychiatric Association. Highlight of Changes from DSM-IV-TR to DSM-5. http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20 to%20dsm-5.pdf. 36. Hooper LM, Tomek S, Newman CR. Using attachment theory in medical settings: implications for primary care physicians. J Ment Health. 2012;21(1):23-37. Giovana G. Silva is an adult and geriatric nurse practitioner and Martha K. Swartz is a professor and associate dean at Yale University School of Nursing, West Haven, Conn. Sheila L. Molony is a directory of quality improvement at Connecticut Community Care, Inc., Wethersfield, Conn.
11. Bowlby J. Attachment and Loss: Vol. 2. Separation: Anxiety and Anger. London: Hogarth Press; 1973.
The authors have disclosed that they have no financial relationships related to this article.
12. Bowlby J. Attachment and Loss: Vol. 3. Loss, Sadness and Depression. London: Hogarth Press; 1980.
DOI-10.1097/01.NPR.0000452975.53934.3d
48 The Nurse Practitioner • Vol. 39, No. 9
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42 The Nurse Practitioner • Vol. 39, No. 9
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Illustration by Don Bishop / Getty Images ©
C
Connecting with chronically ill patients to improve treatment adherence
When a patient is confronted with a debilitating disease, his or her style of coping with stress may contribute to a nonproductive clinical relationship with the healthcare practitioner. Practitioners may feel frustrated and confused by patients who are under or over concerned about their health status as well as those who are over dependent on the practitioner’s opinion.7,8 As a result of this pattern, essential and positive patient-practitioner relationships are not formed, which may lead to poor quality of care. This article presents an integrative review of the literature that assesses the relationships occurring among the following variables: the patient’s style in coping with a long-term health condition; the patient-practitioner therapeutic alliance; and treatment adherence among chronically ill adults in primary care settings. The review of empirical and theoretical studies will be grounded in Bowlby’s attachment theory and will result in evidence-based recommendations for tailored strategies aimed to improve therapeutic alliance and treatment adherence. ■ Theoretical framework Conceptualized by Bowlby in the 1950s, attachment theory is considered a widely accepted and validated approach in developmental psychology.9 According to Bowlby, infants depend on close interaction with their mothers or other attachment figures for protection and survival.10-12 Disruption or inability to form attachments can create vulnerability in one’s sense of self and in one’s capacity to regulate, contain, and modulate affective experience.13,14 Attachment needs and behaviors (seeking proximity to an attachment figure) are held throughout the life span and can be activated by illness events.10,15 Based on Bowlby’s work, attachment theorists have been able to identify attachment orientations in adolescents and adults. A model of adult attachment orientation developed by Bartholomew and Horowitz reveals four attachment types: secure, anxious-preoccupied, dismissive-avoidant, and fearful (see Bartholomew’s model of adult attachment).16 Adults with secure attachment are believed to have received consistently responsive caregiving in early childhood, thus developing positive views of self and others along with the tendency to feel comfortable when depending on or being comforted by others. Persons with anxious-preoccupied attachment are believed to have received inconsistently responsive caregiving, and thus may become excessively aware of attachment relationships and emotionally dependent on the approval of others while also developing poor self-esteem.17 Adults with dismissive-avoidant attachment are believed to have received consistently emotionally unresponsive caregiving, becoming compulsively self-reliant and uncomfortable in situations of close or trusting interactions.12,18 Finally, adults with fearful attachment are believed to have had excessively critical or harsh rejecting caregiving, resulting in a desire for social www.tnpj.com
contact that is inhibited by fear of rejection. These individuals often demonstrate approach-avoidance behavior patterns that arise from a fear of intimacy.19,20 ■ Attachment orientations and stress model of coping behaviors Mikulincer and Shaver further developed a useful model that illustrates how differences in attachment orientations affect emotional regulation and stress coping strategies.21 This model sheds light on how an individual may cope with physical illness. In this model, activation of the attachment system is triggered by a threatening situation or illness. Securely attached individuals invoke positive mental images of attachment figures to cope with the stress and experience a sense of security, relief, and positive emotional regulation. Anxious-preoccupied individuals may, under distress, react with anxiety and seek intense/frequent close proximity to an attachment figure.13 In contrast, a dismissive-avoidant individual may be self-reliant and avoid seeking proximity with an attachment figure.21 Fearful individuals may also act in a disorganized manner.21 A meta-analysis by Bakermans-Kranenburg found that between 31% and 74% of adult subjects exhibit dismissiveavoidant or anxious-preoccupied attachment orientations.22 Attachment insecurity has also been linked to the development of chronic illnesses, mortality, poor therapeutic alliance, and treatment nonadherence.7,23-26 ■ Methodology In this integrative review, the authors seek to systematically review three topics as they relate to health: attachment theory, treatment nonadherence in chronically ill patients, and patient-practitioner relationships. The CINAHL, Ovid Medline, and Ovid PsycINFO databases were searched in the spring of 2013 using the terms attachment theory, chronic disease, patient compliance, physician-patient relations, and nurse-patient relations. Subsequently, ancestry searching of the retrieved articles was performed. Studies of adults age 19 and older were included. Non-English language articles and articles before 2001 were excluded. The overall methodological approach was guided by strategies as described by Whittemore and Knafl.27 This approach allows for the inclusion of diverse methodologies in the review, which acknowledges the complexity inherent in the process and results in a more comprehensive discussion of complex phenomena. The evidence-leveling system, as described by the American Association of Critical Care Nurses (AACN), was applied to appraise the quality of the evidence generated (see AACN’s new evidence-leveling system).28 In keeping with the approach suggested by Whittemore and Knafl, the AACN system addresses a wide variety The Nurse Practitioner • September 2014 43
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Connecting with chronically ill patients to improve treatment adherence
of methodologies found within clinical studies, including qualitative research and metasyntheses. The initial search resulted in 27 citations. To further narrow the search, the following additional inclusion criterion was applied: articles that contained at least two or three of the core variables of interest in the study (attachment theory, treatment nonadherence, and patient-practitioner relationship). Of the 27 articles initially identified, 9 met the criteria for inclusion in the review (see Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes). Results highlight the linkage among attachment theory, nonadherence behavior, and the role of the patientpractitioner relationship in fostering positive outcomes. ■ Findings The studies included in this review revealed three associations among attachment orientation and the problems of poor patient-practitioner relationship and treatment nonadherence behavior: Patient-practitioner relationship. Results showed that a patient’s vulnerability may create a need for attachment to a caregiver. This need is activated in adults when they are sick or scared and become in need of a regular practitioner.29 It is also possible for practitioners’ own attachment orientations to adversely affect clinical relationships with patients, and practitioners with insecure attachment styles may have difficulty forming therapeutic alliances with patients.23,30 Stress coping behavior. Results suggest that attachment orientation may play a crucial role in how individuals cope with stress and how patients subsequently interact with their practitioners.8 Securely attached individuals seem to have better clinical relationships with their practitioners, trusting them for support during periods of crisis. Dismissiveavoidant patients may be overly self-reliant and believe that caregivers are unreliable and will let them down when the need is greatest.27,31 Anxious-preoccupied patients may be perceived by their practitioners as needy and dependent and
tend to amplify physical symptoms of chronic illness to evoke frequent care from practitioners. Patients with fearful attachment orientation often display a help-seeking yet help-rejecting behavior as the patient attempts to exert pressure on the practitioner to deliver more care that may subsequently be rejected by the patient due to a high level of mistrust toward others.8 Treatment adherence. Results showed that dismissiveavoidant patients had significantly higher glycosylated hemoglobin levels than did patients with preoccupied, secure, and fearful attachment styles among patients with diabetes.20 In addition, dismissive-avoidant subjects who perceived a poor quality of communication with their practitioner also tended to have higher levels. A theoretical study suggested strategies on how primary care practitioners may improve medical outcomes by recognizing patients’ unique attachment relationship patterns.7 ■ Discussion The attachment orientations of patients (as well as practitioners) may strongly affect the patient-practitioner relationship. Identifying these patterns may serve to indicate potential barriers to care and foster individualized care based on an awareness of how individuals may mediate stress through their attachment styles. While securely attached patients seek support and are trustful of practitioners during periods of crisis, dismissiveavoidant patients are less eager to seek help from practitioners, often reporting less trust and satisfaction in their clinical interactions and more psychological distress.7,8,31 They appear to have lower rates of treatment adherence when compared with patients with secure and anxiouspreoccupied orientations.20,25 Thus, a tailored approach that considers these patients’ attachment orientation may lead to improvement of adherence.20 Fearful individuals experience high levels of mistrust toward others. They tend to interact in a pattern of seeking
Bartholomew’s model of adult attachment Dependence (view of self)
Avoidance (view of others)
Low (positive)
High (negative)
Low (positive)
Secure Comfortable with intimacy and autonomy
Anxious-preoccupied Preoccupied with relationships
High (negative)
Dismissive-avoidant Dismissing of intimacy; Counter dependent
Fearful Fearful of intimacy; Socially avoidant
Adapted from Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol. 1991;61(2):226-244. Adapted with permission.
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Connecting with chronically ill patients to improve treatment adherence
and rejecting help, leading to poor patient-practitioner relationships.7,8 Like dismissive-avoidant individuals, they cope with pain by minimizing it, and such behavior patterns place them at risk for developing chronic pain.32 Anxious-preoccupied individuals seek support in a pattern that often overwhelms their clinicians, which can result in practitioners’ avoidance of such patients along with poor therapeutic alliance.7,8 They experience higher subjective pain in the presence of a low-empathetic individual.33 ■ Attachment orientation and clinical management strategies Dismissive-avoidant. NPs may support these patients’ needs for space and personal control by using a patient’s surname and title, sitting down when the patient is recumbent, and addressing the patient’s needs regarding appointment scheduling. These patients should be reassured that their need for independence will be sustained while responsive care continues unabated. Additionally, NPs could use automated appointment-tracking systems, smart-phone applications, and proactive contacts, such as e-mailed or texted appointment reminders. These considerations will likely reduce patient anxiety and enhance a sense of independence.7,8,34 Anxious-preoccupied. To enhance the patients’ sense of security, they should be assured that care will be regularly provided. Practitioners should be reliable, consistent, unflappable, and concerned about patient’s care. Finally, NPs should show up on time, stay for the agreed duration, interact preemptively, and be careful to not avoid the patient. Frequent but brief, regularly scheduled appointments may decrease the patient’s acute somatic symptoms as a care-eliciting strategy.7,8 Although some practitioners may consider 20-minute appointments “brief,” many NPs may not be able to implement such recommendation due to time constraints of a busy clinic and/or billing issues. Fearful. Because these patients often have difficulties in trusting their practitioners, NPs should be attuned to patient vulnerability and work in a collaborative, nonjudgmental way to create a more mutually trustful clinical relationship. Additionally, NPs should acknowledge the negative emotions that might arise when interacting with these patients and continue to provide active treatment. This approach challenges the patient’s view of caregivers as threatening. After some time, as the practitioner develops rapport and trust, the patient may be confronted with the pattern he or she has of seeking then rejecting help.7,8 ■ Case exemplar: A dismissive-avoidant patient Mr. R is a 37-year-old obese male with hypertension and hyperlipidemia. He has been a patient for 2 years. Since he was diagnosed with those conditions, he has not fully adwww.tnpj.com
AACN’s new evidence-leveling system Level A
Meta-analysis of multiple controlled studies or meta-synthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
Level B
Well-designed controlled studies, both randomized and nonrandomized, with results that consistently support a specific action, intervention, or treatment
Level C
Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
Level D
Peer-reviewed professional organizational standards, with clinical studies to support recommendations
Level E
Theory-based evidence from expert opinion or multiple case reports
Level M
Manufacturers’ recommendations only
Reprinted with permission from Armola RR, Bourgault AM, Halm MA, et al. AACN levels of evidence: what’s new? Crit Care Nurse. 2009;29:72-73.
hered to the treatment regimen. Practitioners have been trying to establish a relationship with him and get him involved in his care, but, although somewhat pleasant, he appears emotionally distant and superficial in his interactions. He often does not return to the clinic for the scheduled appointments or return calls. Whenever he comes to see a practitioner, his BP and cholesterol levels are elevated. Although he is already showing signs of hypertension-related complications, he keeps gaining weight and continues to smoke. He often acknowledges not taking his medication consistently. The adverse reactions of long-standing hypertension and the need for him to lose weight and quit smoking have been explained to him. He agrees and states that he is going to do the necessary lifestyle changes on his own. The providers feel unconvinced and frustrated. Mr. R displays a pattern of dismissive-avoidant attachment by minimizing his illness, being self-reliant, not seeking out support, and avoiding proximity with healthcare practitioners. This behavior hinders the establishment of a relationship with the patient. Practitioners decide to tailor their approach to Mr. R by considering his attachment orientation. When dealing with dismissive-avoidant patients, it is key to enhance their sense of control and independence. The staff will address the patient by his surname and title. During his appointment, it is advised to sit down when he is recumbent. When scheduling his follow up, the staff will make an effort to be flexible with dates and will offer options of appointment tracking systems, The Nurse Practitioner • September 2014 45
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Connecting with chronically ill patients to improve treatment adherence
Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes7,8,20,25,29-33 Design
Findings
Conclusion/ recommendations
Limitations
AACN level of evidence
Insecurely attached patients reported less trust in and satisfaction with their clinician, and more general distress than securely attached patients, 3 and 9 months after diagnosis
Attachment theory provides framework to interpret differences in patients’ trust, satisfaction, and distress, and may help clinicians to respond so that patients feel secure, likely improving outcomes
Possible selection bias (treating practitioner enrolled subjects)
B
Fearful and dismissingavoidant individuals mask their distress caused by pain experience
Fearful and dismissingavoidant attachment orientations are risk factors for chronic pain and related complications
Potential bias from convenience sample
C
(1) Anxious-preoccupied attachment correlated with higher subjective pain. (2) Avoidant-dismissive attachment correlated with lower subjective pain. (3) Social presence decreased autonomic responses to pain in all individuals
Social presence and perceived empathy may interact with individual differences in attachment style to influence one’s pain perception
Limited generalizability of findings to a clinical population
B
Being a patient creates a need for attachment to a caregiver. This need is fundamental and is activated in adults when sick or scared
Continuity of care with a regular practitioner should be sought in sicker and worried patients
Did not examine provider attachment styles
C
Insecure attachment is likely a risk factor for stress and mental health problems in medical students and practitioners
(1) Understanding of practitioner’s attachment style may help in counseling to avoid burnout. (2) Awareness of practitioner’s own attachment style may improve interactions with patients
Search strategy not clearly described; no objective appraisal of the level of evidence
C
Holwerda, 2013, The Netherlands31 Empirical–longitudinal group comparison, N = 130. Recently diagnosed cancer patients ages 30-75 years (mean 59 years, 70% female)
Andrews, 2011, Australia32 Quasi-experimental, correlational, N = 82 Single, mostly Australian university students, ages 17-84 years (mean 24 years, 56% male) Sambo, 2010, England33 Quasi-experimental, N = 30 Healthy adult participants ages 21-50 years (mean 29 years, 66% female)
Frederiksen, 2010, Denmark29 Qualitative, N = 22 18-82 years (10 women and 12 men), in which 12 saw their regular general practitioner (GP) and 10 saw an unfamiliar GP Adshead, 2010, England30 Narrative review
Continued
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Connecting with chronically ill patients to improve treatment adherence
Summary of articles investigating NP/patient relationships, attachment style, and patient outcomes7,8,20,25,29-33 (Continued) Design
Findings
Conclusion/ recommendations
Limitations
AACN level of evidence
Dismissive-avoidant attachment is associated with difficulties in therapeutic alliance
Attachment theory is a valuable framework for understanding dismissive-avoidant diabetic individuals’ interactions with clinicians
(1) Possible selection bias due to small sample size (2) Cross-sectional study–not possible to infer causal relationships
C
Clinicians may improve outcomes by recognizing patients’ attachment patterns
Tailored approaches toward insecurely attached individuals can be used to improve clinical relationship and medical adherence
Limited treatment approaches
C
Attachment theory provides an useful model for understanding the ways individuals feel and react when stressed by illness
Tailored approaches to insecurely attached patients may improve interpersonal relationships and therapeutic alliance
Limited recommendations for research
E
Tailored approaches to insecurely attached patients with diabetes may improve therapeutic alliance and treatment adherence
(1) Causal relationships among glycosylated hemoglobin levels, attachment style and quality of communication cannot be definitively determined. (2) Limited generalizability due to homogenous population
C
Morris, 2009, England25 Quasi-experimental, correlational, N = 48 Patients with diabetes (54% male, mean age 56 years, 42% with type 1 diabetes, 58% with type 2 diabetes, mean of 16 years since diagnosis)
Thompson, 2003, United States7 Integrative review
Hunter, 2001, Canada8 Theoretical
Ciechanowski, 2001, United States20 Quasi-experimental, correlational, N = 367 Patients with diabetes (mean age 61 years, 56% female, 14 with type 1 diabetes, 353 with type 2 diabetes)
Dismissive-avoidant attachment is associated with poorer treatment adherence in patients with diabetes
such as phone calls or mailed appointment reminders. These actions will likely enhance Mr. R’s sense of control, need for space and independence, and ultimately improve the therapeutic alliance and his treatment adherence. ■ Limitations and further research Based on the levels of evidence, research in the area of patient attachments styles and clinical outcomes is evolving from primarily theoretical reports to quasi-experimental studies in www.tnpj.com
patient populations. However, the reviewed studies were primarily descriptive/theoretical works, and the few intervention studies were cross sectional in nature, involving mainly patients with diabetes. Nevertheless, the empirical studies indicated a strong correlation between tailored approaches and improved therapeutic alliances. Therefore, longitudinal quasi-experimental or experimental designs would be warranted among patient populations coping with a variety of chronic health conditions. This area of research would also The Nurse Practitioner • September 2014 47
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Connecting with chronically ill patients to improve treatment adherence
benefit from patient-centered participatory designs and further qualitative studies regarding patient and provider experiences. Finally, it must be stressed that although there is a growing body of research on clinically relevant problems associated with insecure adult attachment styles, the DSM-V (like the DSM-IV) defines attachment disorders only within the scope of childhood diagnoses, as the result of social neglect or other situations that limit a young child’s opportunity to form selective attachment.35 ■ Patient-centered treatment Treatment nonadherence has an enormous impact on society as well as on families and individuals. NPs are uniquely poised to decrease healthcare costs through a reduction in patient hospitalization and chronic illness complications with terminal consequences. Establishment of therapeutic alliance is a key factor involved in this process. Understanding patients’ attachment orientations allows NPs to focus on successful communication which, in turn, allows them to effectively collaborate with patients to ensure the best-possible patientcentered treatment.36 It has been the goal of this article to present attachment theory as a means for understanding the particular ways individuals may mediate stress when facing a chronic disease and how primary care NPs, through effective relationships with patients, may help them to manage that distress, thereby promoting adherence to recommended therapies and better healthcare outcomes. REFERENCES 1. World Health Organization. Chronic Conditions. http://www.who.int/topics/ chronic_diseases/en. 2. Kaplan JE, Keeley RD, Engel M, Emsermann C, Brody D. Aspects of patient and clinician language predict adherence to antidepressant medication. J Am Board Fam Med. 2013;26(4):409-420. 3. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5): 487-497. 4. Tarn DM, Mattimore TJ, Bell DS, Kravitz RL, Wenger NS. Provider views about responsibility for medication adherence and content of physicianolder patient discussions. J Am Geriatr Soc. 2012;60(6):1019-1026. 5. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions for enhancing medication adherence. Cochrane Database Syst Rev. 2008;(2): CD000011. 6. Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Med Care. 2005;43(6):521-530. 7. Thompson D, Ciechanowski PS. Attaching a new understanding to the patient-physician relationship in family practice. J Am Board Fam Pract. 2003;16(3):219-226. 8. Hunter JJ, Maunder RG. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry. 2001;23(4):177-182. 9. Thomas PM. Dissociation and internal models of protection: Psychotherapy with child abuse survivors. Psychotherapy: Theory, Research, Practice, Training. 2005;42(1):20-36. 10. Bowlby J. Attachment and Loss: Vol. 1. Attachment. London: Hogarth Press; 1969.
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The authors have disclosed that they have no financial relationships related to this article.
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DOI-10.1097/01.NPR.0000452975.53934.3d
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