Psychodynamic psychotherapy in serious physical illness: A systematic literature review of approaches and techniques for the treatment of existential distress and mental disorders

Individuals with life-limiting physical illness experience lower mental health due to existential distress (e.g., demoralization, death anxiety) and mental disorders (e.g., depression, anxiety). Psychodynamic psychotherapy may be helpful in alleviating such distress by focusing patients' unconscious emotional and relational motivations. There is yet limited knowledge on the application of psychodynamic psychotherapies in this population. We systematically searched electronic databases and analyzed results using meta-ethnography. Of 15,112 identified records, we included 31 qualitative studies applying psychodynamic psychotherapies (n = 69, mean age: 49.3 [SD = 16.9)], 56% female). Psychodynamic treatment in this population can be beneficial when considering modification of the treatment setting to the illness reality, balancing needs for autonomy and separation in light of helplessness and death anxiety, and careful integration of supportive interventions and conflict-oriented interventions (e.g., exploring relational issues that interfere with mourning illness-related loss). We discuss future directions for the development and evaluation of treatments specific to serious physical illness.

Comparing Surgeon Approaches to Patient-Centered Cancer Care Using Vignette Methodology

BACKGROUND

We sought to characterize surgeon perceptions of patient attachment-related behaviors relative to patient-centered approaches during treatment decision-making within the clinical encounter.

METHODS

An online survey including clinical vignettes was sent to board-certified surgeons to assess their approach to patient-centered treatment decision-making. Within these vignettes, patient behaviors associated with attachment styles (secure vs 3 insecure subtypes: avoidant, anxious, and fearful) were fixed and patient factors (age, race, occupation, and gender) were randomized. Analysis included repeated measures mixed-effects linear regression.

RESULTS

Among the 208 respondents, the majority were male (65.4%) and White/Caucasian (84.5%) with an average age of 51.6 years (SD = 9.9). Most surgeons had been in practice for more than 10 years (66.8%) and treated adult patients (77.4%). Surgical specializations included breast (27.2%), HPB (35.0%), and broad-based/general (21.8%). Patient race, age, and gender did not impact surgeons' patient-centered approach to treatment decision-making (all ps > 0.05). However, when the "patient" had a white collar occupation and were securely attached, surgeons reported a greater likeliness to spend equal time presenting all treatment options (p = 0.02 and p < 0.001, respectively) and believe the patient wanted an active role in decision-making (p = 0.01 and p < 0.001, respectively). Surgeons reported being least likely to agree with a patient's treatment decision (p < 0.001) and an increased likelihood of being directive (p = 0.002) when patients exhibited behaviors associated with avoidant attachment.

CONCLUSION

Attachment-related behaviors were associated with differences in surgeon approaches to patient-centered decision-making. Attachment styles may offer a framework for providers to understand patient behaviors and needs, thereby providing insight on how to tailor their approach and provide optimal patient-centered care.

Working alliance and attachment orientations in the patient-oncologist relationship

OBJECTIVE

Accumulating research suggests that the working alliance (WA) is a key component in the patient-oncologist relationship. Attachment theory provides a useful framework for understanding this alliance within the oncological setting, where patients' attachment systems are often activated. This study examined the association between attachment orientations of both dyad members (i.e., patient and oncologist) and patients' WA experience. It also probed whether this link was mediated by patients' attachment-related attitudes towards the oncologist, using a recently developed measure.

METHOD

Oncologists and their respective patients (N = 113: 103 patients, 10 oncologists) were sampled at oncological clinics. Eligible patients filled out online measures of the WA, attachment-related attitudes, and attachment orientations. The later was also completed by oncologists.

RESULTS

Structural equation modeling demonstrated that both patients' and oncologists' avoidant attachment orientation inversely predicted patients' WA experience, via patients' experience of feeling unsupported by their oncologists.

CONCLUSIONS

Findings suggest that attributes of both members of the patient-oncologist dyad are related to patients' WA experience, and that attachment-related attitudes towards oncologists occur within this relationship. Oncologists' understanding of patients' unique attachment behaviors, as well as their own such behaviors, could improve cancer patients' quality of care and illness outcomes. Results represent another step forward in fully exploring whether oncologists can serve as attachment figures for their patients.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer

OBJECTIVE

Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time.

METHODS

We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes.

RESULTS

Attachment avoidance partially mediated the relationship between death anxiety and demoralization (β = 0.07, 95% CI 0.02-0.12) and anxiety (β = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: β = -0.07, 95% CI -0.13 to -0.02, anxiety: β = -0.05, 95% CI -0.11 to -0.003).

CONCLUSIONS

Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

Patient loyalty to HIV care in an HIV facility in Eldoret, Kenya: A mediated mediation

Patient loyalty is the continuous commitment and engagement in care where patients can improve and sustain quality of life through continuous use of medical care. Identifying strengths and weaknesses in providing excellent quality care is a key measure of success of healthcare professionals and hospital management. However, few studies have examined patient loyalty from a strategic leadership perspective within HIV health care systems. The purpose of this study is to determine how patient loyalty to HIV care is influenced by multiple factors in a healthcare system environment. The study employs a mixed-methods approach guided by the complexity theory and the theory of planned behavior. A total of 444 surveys with (50 healthcare providers and 394 adult HIV-infected patients) currently on antiretroviral drugs, as well as 22 in-depth interviews with healthcare providers will be conducted. The study will be done at AMPATH Eldoret Kenya. We will use stratified proportionate and census sampling methods to select study participants for the survey while purposive and convenient sampling techniques will be used for in-depth interviews. Structured questionnaires and interviewer guides will guide data collection. Quantitative data analysis will entail hierarchical regression to test direct effects while multiple regression will test the mediation effects using the Hayes PROCESS Model No.6 in SPSS. Qualitative data analysis will be conducted using a thematic analytical method.

Understanding the use of attachment theory applied to the patient-provider relationship in cancer care: Recommendations for future research and clinical practice

Patient attachment styles may inform how patients react differently to the stress of being diagnosed with cancer, as well as how patients may desire to interact and be supported by their provider. The objectives of this study were two-fold: 1) to conduct a systematic scoping review to clarify how attachment theory is utilized and applied within the current body of research on the patient-provider relationship within cancer care, and 2) add to the existing body of literature by introducing an integrated model of patient attachment styles and patient-provider relationships for use in clinical and scholarly work. A systematic search of multiple databases including PubMed, Google Scholar, PsychInfo, and WorldCat was conducted using variations and combinations of keywords related to patient-provider relationship, attachment style, and cancer. The nine studies included in the review were published from 2011 to 2019. The majority of studies had participant samples with multiple cancer diagnoses (n = 5) and examined attachment as an independent or predictor variable (n = 6). Results suggest that a secure attachment was predictive of a better working alliance, more perceived support, less general distress, higher levels of trust and satisfaction with healthcare providers when compared to patients with an insecure attachment style. Data from the current review suggest that using an attachment theory framework can improve the understanding of the patient-provider relationship. We propose a conceptual model that aligns patient attachment style and patient-provider relationship types to be utilized in clinical practice in future research to tailor patient-centered cancer care.

Assessing emotional aspects of midwives' intrapartum care: Development of the emotional availability and responsiveness in intrapartum care scale

BACKGROUND/PROBLEM

Emotional care underpins women's positive experiences during labour andbirth but is under-researched. Applying an attachment theory approach may inform the measurement of emotional aspects of maternity care.

OBJECTIVE

To develop and validate a self - report measure for midwives to assess their emotionally attuned intrapartum care.

METHODS

A staged approach to tool development was followed. Item generation was informed by a critical review of the literature and expert review. Following a pilot test, the draft scale was psychometrically assessed. Principal component analysis with varimax rotation was used to establish construct validity. Cronbach's alpha determined internal reliability. Concurrent validity was tested with the 'empathic concern' and the 'personal distress' subscales on the Interpersonal Reactivity Index. The study was conducted with midwives (n = 705) who are members of the Australian College of Midwives.

FINDINGS

The Cronbach's alpha for the scale was 0.88. Principal component analysis revealed a one- factor solution. Significant but low correlations with Interpersonal Reactivity Index subscales of 'empathic concern' (rho = .256, p <.001) and 'personal distress' (rho = -.249, p<.001) confirmed concurrent validity.

CONCLUSION

The Emotional Availability and Responsiveness in Intrapartum Care Scale appears to be a valid and reliable measure of emotional aspects of midwives' caregiving. An Attachment Theory approach validates women's perspectives and elucidates our understanding of the importance of emotional labour support.

Efficacy of an Attachment-Based Intervention Model on Health Indices in Children with Chronic Disease and Their Mothers

Studies have shown significant relationship between health conditions and attachment. This study aimed to examine an attachment-based intervention model named mother-child-disease triangle (MCDT) on health indices in children with chronic disease and their mothers. This randomized trial study included 22 volunteer children aged 12-18 years undergoing medical treatment for a chronic disease and their mothers. After evaluation by 28-form General Health Questionnaire (GHQ-28), inventory of parent and peer attachment (IPPA), 28-form Child Health Questionnaire (CHQ-28) and Illness Perception Questionnaire (IPQ), the mother-child dyads were paired on the basis of IPPA scores. These pairs were then randomly assigned to an experimental or control group. The experimental group received ten 90-min sessions of MCDT over a 7-week period. Meanwhile, the control group received ten simple conversational sessions as a dummy intervention. In accordance with this study's pre-test/post-test design, both groups were evaluated once again after completing their respective treatment. Multivariate analysis of covariance (MANCOVA) showed members of the experimental group to have significantly stronger attachment and better physiological and psychosocial health than those in the control group. These findings suggest that attachment-based interventions can be used to improve the effectiveness of treatment among children with chronic disease and their mothers.

Two is a perfect number: Patient–doctor relationship and patient attachment style in palliative care

We tested the association between the palliative patient’s attachment style and the patient–doctor relationship, by means of Revised Adult Attachment Scale and a self-designed, patient–doctor relationship questionnaire. The study included 110 (52 M, 58 F) cancer, hospice patients, aged 36–80 years. We observed 54 percent of secure, 18 percent of dismissive, 9 percent of preoccupied, and 19 percent of fearful styles. Securely attached patients developed significantly ( p < .05) better relationships with doctors than insecure patients. There was no difference in the quality of the patient–doctor relationship among dismissive versus preoccupied versus fearful patients. We argue that attachment theory should be applied in palliative care to improve patients’ quality of life and dying.

Can patients be 'attached' to healthcare providers? An observational study to measure attachment phenomena in patient-provider relationships

OBJECTIVES

To develop and assess the validity of measures of patients' attachment-related perceptions of experiences with healthcare providers (HCPs).

SETTING

Online survey.

PARTICIPANTS

181 people provided consent and 119 completed the survey (66%). Most participants were women (80%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Questions were developed to assess possible attachment functions served by an HCP and patients' attachment-related attitudes towards an HCP. Scales were constructed based on exploratory factor analysis. Measures of adult attachment, therapeutic alliance, perceived HCP characteristics and health utilisation were used to validate scales.

RESULTS

Possible safe haven and secure base functions served by HCPs were strongly endorsed. A model with good fit (root mean square error of approximation=0.056) yielded 3 factors: 'HCP experienced as supportive and safe' (SUPPORT, α=0.94), 'HCP experienced as aversive' (AVERSE, α=0.86) and 'more and closer contact wanted with HCP' (WANT, α=0.85). SUPPORT was correlated with positive HCP characteristics and not with attachment insecurity. AVERSE was inversely correlated with positive HCP attributes and correlated with attachment insecurity. WANT was unrelated to positive HCP attributes, but correlated with attachment insecurity. Frequency of HCP contact was related to WANT (Kruskal-Wallis=21.9, p<0.001) and SUPPORT (Kruskal-Wallis=13.2, p=0.02), but not to AVERSE (Kruskal-Wallis=1.7, p=0.89).

CONCLUSIONS

Patients attribute attachment functions of secure base and safe haven to HCPs. SUPPORT is related to positive appraisal of HCP characteristics; AVERSE is associated with discomfort in the HCP relationship that is related with perceived HCP characteristics and patients' insecure attachment; WANT is associated with unmet needs for connection with an HCP related to insecure attachment, but not to perceived HCP characteristics. These scales may be useful in studying the application of attachment theory to the HCP-patient relationship.