Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 3: The Importance of Attachment Theory in Healthcare

By Dr. Linda Uyeda (biography and disclosures) and Dr. Ashley Miller (biography and disclosures) (Members of the Child and Youth Mental Health and Substance Use Community of Practice and the Working Group on Adverse Childhood Experiences)

Linda Uyeda: Disclosures: Engaged in public speaking and has received honoraria. Mitigating potential bias: The information provided about attachment theory and the recommendations outlined are referenced clearly to show where the evidence was obtained.

Ashley Miller: Disclosures: Dr. Miller is the co-author of What to Say to Kids When Nothing Seems to Work: A Practical Guide for Parents and Caregivers. Mitigating Potential Bias: Recommendations are consistent with attachment literature and do not relate specifically to the contents of the book.

Article 1: Cultivating secure bonds with our children during stressful times

Article 2: Parenting during a pandemic

“Evidence is accumulating that human beings of all ages are happiest and able to deploy their talents to the best advantage when they are confident that, standing behind them, there are one or more trusted persons who will come to their aid should difficulties arise.” ~ John Bowlby

What I did before

Early in my career, I puzzled over why some patients who desperately needed care rejected it while others kept calling in distress despite minimal pathology. Then, there were the patients who not only presented in crisis, but seemed to criticize my every attempt to help them through it.

At work and in my personal life, I saw that when under stress, different people use different tactics within relationships: some would lash out and fight back, while some withdrew and became quiet, and still others would pause and then approach the problem with curiosity and openness. Around that same time, I also tentatively began the difficult journey of developing insight into my own behaviour when I am under pressure and stressed out. I started learning that the road map for how humans behave in relationships is predictable and it can help us to understand both our patients and ourselves. It became increasingly clear that attachment affects everyone.

What changed my practice

As I worked with children and families, I studied more about attachment theory. As mentioned in our first article of this series, attachment theory postulates that all mammals are hardwired to signal their primary caregivers when hurt, sick, or scared. As I treated patients of all ages and became a mother myself, I realized how attachment impacts much more than the parent-child relationship: it can truly inform every aspect of personal life and professional practice. And the more I learned, the more I recognized that to better understand and serve my patients, it would help to better understand my own attachment patterns first.

Attachment across the lifespan:

Attachment theory began with the study of the infant-parent dyad, but it has grown, with research now encompassing adolescence¹, adult romantic relationships², workplace relationships³ and even the relationship between providers and patients⁴. This also opened my eyes to the importance of healthy, adult friendships and romantic relationships in stabilizing mental health and well-being. Well before the pandemic, former U.S. Surgeon General Dr. Vivek Murthy called loneliness a “public health crisis”⁵ and the Harvard Study of Adult Development⁶ has shown that people with stronger relationships and social connection are happier, healthier, and even live longer.

Attachment in healthcare:

The ingredients needed to create a happy workplace also largely reflect the principles of secure attachment. Across all levels within organizations (from executives and administration to physicians, nurses, and healthcare workers), if people do not feel “safe, seen, soothed, and secure” they are more likely to make errors, breach safety protocols, and struggle working together as a team⁷. If the ultimate goal is to provide excellence in patient outcomes, evidence is showing us that those caring for patients need to feel included, valued, and supported.

What I do now

For myself:

1. I seek to understand my own attachment history. Learning about attachment theory has allowed me to look inward and heal the hurts of my childhood. I have compassion and forgiveness for the generation above me and I understand they could not give me what they weren’t given from their parents. Through this challenging work, I grew to understand that many of the beliefs I held as an adult were formed when I was very young and, while they may have served me as a child, they don’t need to drive my behaviour today. I also recognize that I am half the equation in any physician-patient encounter and I reflect on my own reactions when frustrated with a particular situation.
2. I try to be mindful throughout the day. While having a regular mindfulness practice may be ideal, it does not necessarily mean I have to sit for hours a day in deep contemplation. If I’m able to fit in a 5–10-minute practice at lunch time I can still feel its benefits. Or, if I only have a few minutes as I’m waiting for my computer to boot up, I can take some deep breaths to settle my nervous system after rushing into work. The ultimate goal is for the practice of mindfulness to become incorporated into my daily life, not just while I’m sitting on the mat.
3. I turn to others for support and treat myself with compassion. In order to be a secure base for our patients, children, and partners, we need to keep our own “emotional cup” as full as possible. This means when I start to notice my kids acting out, I ask myself what they may need, but also ask what I need. Maybe it’s a walk at the beach, to work a little less, or to connect more with my friends and family. I call and text friends daily and go for socially distanced walks. I have my own small physician peer-supervision/support group. When I lack the strength to face the day, I call a friend. My problem may still be there, but I regain the strength to handle it. I am always amazed how the emotional climate in my household and my office improves when I attend to my own needs first.
4. I realize the only thing I have control over is me. One of the most powerful lessons I have learned over the past decade is that I am responsible for my part in all of the relationships around me⁸. While it’s tempting to blame others for things I don’t like in my environment, I know that I am solely responsible for how I respond to what is happening. This valuable, and sometimes painful, lesson has been extremely beneficial to my long-term relationships.

With others:

1. I see my relationship with patients through an attachment lens. I recognize now that many patients who downplay symptoms and hesitate to come through the door are the ones with more avoidant styles, while those who need frequent reassurance are often on the other end of the attachment spectrum (anxious or ambivalent styles). And those patients who seem to alternate between wanting my help and rejecting it, are not willingly “difficult”. These are people who have suffered from traumatic experiences or more “disorganized” patterns of attachment as young children. I try to be as consistent, predictable, and proactive as possible for patients with these patterns of relating. I remember that in my role as physician, my job is to be a “secure base” for my patients. I maintain clear boundaries; I schedule regular appointments to pre-empt crises; and I honor the need for control and choice that allows many people with insecure attachment to feel safe. At times of illness or stress, almost everyone’s “fight, flight, or freeze” response gets triggered. This is by definition what activates the human attachment system. So, whether I see patients presenting in the ER or for any other type of care during the pandemic, I assume patients and families are in a state of heightened attachment sensitivity or heightened emotional arousal.
2. I help patients strengthen their social networks. I routinely talk to my patients about how they are managing to meet their social needs. I ask specifically about their friends and family and how they are staying in touch, and for those who feel shy or embarrassed, we practice “reaching out” conversations. I prescribe connection and help patients problem solve ways to access more social support.
3. I teach conflict resolution. When couples (or any two people) argue, they tend to blame each other and see each other’s faults. The angrier they get, the clearer it feels like they’ve been purposely wronged. Our brain’s neurocircuitry leads us to view others as a threat when we’re emotionally dysregulated. So, I inquire about conflict and teach skills such as taking space to regain composure, perspective taking, and using “I statements” to express feelings instead of criticizing and blaming.

In my workplace:

1. I aim to create emotionally safe spaces at work. Enjoyable, healthy, and safe workplaces are created when we⁷:
   1. create a physically and psychologically safe environment for the people we work with so that we can work together collaboratively (safe),
   2. listen to the ideas and concerns our teammates bring forward without judgement (seen),
   3. realize that failures are going to happen. When we take the opportunity to see these as learning opportunities rather than times to chastise and blame one another, the culture changes and people become more open and ready to learn (soothed),
   4. create truly trusting relationships with those around us where we can move forward together as a team (secure).
2. I recognize that providers need support and care too. One of the most powerful lessons I have learned about how to support caregivers was from a program called Touchpoints Parenting. This program was developed by Dr. T. Barry Brazelton, an influential pediatrician from Boston, Massachusetts⁹, “Providers need support and respect of the kind we are asking them to give to parents.” During my workday, I often substitute the word ‘provider’ with ‘nurse, MOA, or health care worker’ and the word ‘parents’ for ‘patients’. This allows me to bring compassion to those I work with and lead by example.
3. I try to help my teams understand importance of attachment in healing. In order to build new neural networks and let old ones regress, new patterns of behaviour need to be experienced and reinforced. This is when trust can grow. When I am centred enough to realize that my patient’s behaviour may not be because of me, but rather a trigger from an earlier life experience, I can remove judgement and bring compassion to an otherwise heated situation. Then again, if we replace the word “patient” in the last sentence with child, partner, spouse, co-worker, employee, or friend, this approach becomes essentially universal. Such an approach requires inner work, understanding of attachment, patience, and compassion. The beauty of this new response is its great power to heal.
4. I use my voice as a professional to influence policies that will empower many. As my career has progressed, I wondered if there was a way to scale up what I was doing on an individual level in order to bring about change to a larger population. Becoming involved with the Child and Youth Mental Health and Substance Use Community of Practice and various groups within the PHSA has enabled this. Michael Unger, a Canadian resilience researcher, has shown that resilience doesn’t simply rest in the hands of the individual but grows out of key ingredients in the environment.¹⁰ If we can change the environment in which we find ourselves we make it much easier for individuals to succeed.

This new journey to healing takes time and persistence, however the rewards are many. These new approaches allow us to create space to become wiser and more compassionate with ourselves, those we work with, and those we care for.

References:

1. Allen, JP. The attachment system in adolescence. In: Cassidy J, Shaver PR, ed. Handbook of Attachment: Theory, Research, and Clinical Applications. New York, NY: Guilford Press; 2008:419–435. (Request with CPSBC or find with WorldCat)
2. Levine A, Heller R. (2010). Attached: The New Science of Adult Attachment and How It Can Help You Find – and Keep – Love. New York, NY: Penguin Publishing Group; c2010. (Request with CPSBC or find with WorldCat)
3. Hunter J, Maunder R. Using attachment theory to understand and support health care workers under stress. Can J Physician Leadersh. 2019:6(1):30-35. DOI: 10.37964/cr24704. (Request with CPSBC or view with UBC)
4. Hunter J, Maunder R. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry. 2001:23(4):177–182. DOI: 10.1016/S0163-8343(01)00141-4. (View with CPSBC or UBC)
5. Murthy V. Together: The Healing Power of Human Connection in a Sometimes Lonely World. Ney York, NY: Harper Wave; c2020. (Request with CPSBC or find with WorldCat)
6. Waldinger R. Harvard Second Generation Study. Harvard Second Generation Study. Updated 2015. (View)
7. Lucian Leape Institute. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. Boston, MA: National Patient Safety Foundation; c2013. (Request with CPSBC or find with WorldCat)
8. Wolsak D. Choose Again: Six Steps to Freedom. Napa, CA: Fearless Books; c2018. (Request with CPSBC or find with WorldCat)
9. Touchpoints Individual Level Training, Brazelton Touchpoints Center. Updated 2020. (View)
10. Ungar M. Change Your World: The Science of Resilience and the True Path to Success. Toronto, ON: Sutherland House; c2019. (Request with CPSBC or find with WorldCat)

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Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 3: The Importance of Attachment Theory in Healthcare

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