The interpersonal experience of health care through the eyes of patients with diabetes

Abstract

Patients with chronic illness often face challenges navigating the US health care system because of the system's lack of coordination and continuity. Patients with more difficulty relying on others and with reluctance in engaging frequently or in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and a perceived “wall” between providers and patients were frustrating for most study patients. Patients with fearful and dismissing attachment style reported that these aspects of the health care system often interfered with their ability to partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to improve patient-centered care and customer service are discussed.

Introduction

Chronic illness care is optimally carried out in a collaborative process with active follow-up and tracking of outcomes and adherence by providers and the health care system. Patients, in turn, become knowledgeable about their conditions, share in decision making, receive education and disease self-management support, and are provided with optimal medication management in a sustained, consistent and timely fashion (Katon et al., 1997; Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997). Such a partnership between patients and providers facilitates adoption of guideline and evidence-based treatments, increases patient-centered interactions (Ciechanowski, Wagner et al., 2004; Neumeyer-Gromen, Lampert, Stark, & Kallischnigg, 2004; Stewart, 1995), and contributes to optimal management of complex illnesses with complicated self-care and treatment regimens such as diabetes.

Despite promising changes in chronic disease management in today's health system, the prevailing delivery model may not support such a collaborative process because of system-wide fragmentation. As the recent Institute of Medicine Crossing the Quality Chasm report describes, contemporary health care delivery is characterized by frequent handoffs between providers, infrequent clinical follow-up, reliance on in-person physician visits with limited web-based or phone contact, lack of support for behavioral change, and lack of time and resources for patient self-management training (2001). While the current health system is frustrating for many patients with chronic conditions (1997), the capacity for a patient to successfully navigate this system and experience patient-centered care may be especially challenging for patients with specific interpersonal characteristics.

The “Chasm” report recognizes the importance of individual differences in preferences and approaches in working with health care professionals (2001). Patients with more reluctance depending on physicians and health care teams may have greater difficulty receiving high-quality health care and achieving optimal outcomes in a fragmented health system. Such patients may be more sensitive to the lack of shared decision making and pervasive lack of coordination and continuity of routine health care compared to patients who are more comfortable in the traditional patient–physician role. There has not been a well-established theoretical approach to understanding and working with individual differences in patients’ preferences for interacting with providers within the health care system. Attachment theory—a model that recognizes that all individuals have underlying cognitive-emotional schemas guiding their perceptions and behaviors in interpersonal relationships—provides a promising conceptual framework with which to practically approach individual differences in preferences for receiving health care (2001; Dozier, Cue, & Barnett, 1994).

In developing attachment theory, John Bowlby proposed that all individuals psychologically incorporate prior experiences with caregivers, forming enduring mental representations of caregiving that persist into adulthood called “internal working models” (Bowlby, 1977). Such models are learned ways of interacting in relationships throughout life, particularly at vulnerable times (e.g. managing one's disease or symptomatic and functional challenges of illness). These models influence whether individuals deem themselves worthy of care (model of self) and whether others are perceived as trustworthy to provide care (model of other). Studies demonstrate high stability and continuity of attachment models between infancy and adolescence (Hamilton, 2000) and infancy and adulthood (Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). Based on empirical research in infants, children and adults over the past three decades, social psychologists (Griffin & Bartholomew, 1994) have identified four patterns of attachment behaviors in adults: secure, preoccupied, dismissing and fearful. These four attachment styles can be considered conceptually distinct dimensions and individuals may be characterized interpersonally by varying degrees of each. Clinically and descriptively, however, it is often more useful to conceptualize individuals in terms of their predominant attachment style so as to better understand developmental and behavioral characteristics of each style.

Adults who have predominantly secure attachment style are generally believed to have experienced consistently responsive (Ainsworth, Blehar, Waters, & Wall, 1978) early caregiving (in the process developing a positive model of self and other; Fig. 1) and are generally comfortable depending on and being readily comforted by others. Adults with predominantly preoccupied attachment style are posited to have experienced inconsistently responsive caregiving (Bartholomew, 1990) and in an effort to ensure proximity to caregivers, they use strategies in which the attachment behavioral system is “hyperactivated” through exaggeration of behaviors attracting support (Mikulincer, Shaver, & Pereg, 2003). They are generally emotionally dependent on others’ approval (positive model of other), often to the point of being “clingy,” but generally have poor self-worth (negative model of self).

The remaining two styles, dismissing and fearful attachment styles, are characterized by strategies in which the attachment behavioral system is “deactivated” (Mikulincer et al., 2003 ), i.e. there may be avoidance of support-seeking behaviors or denial or minimization of emotions and cognitions associated with attachment needs. Adults with predominantly dismissing attachment style are believed to have experienced early caregiving that was largely emotionally unresponsive. As a result, they develop strategies from an early age in which they become “compulsively self-reliant” (Bowlby, 1977) (positive model of self) and uncomfortable trusting others (negative model of other). Individuals with dismissing attachment style are described as lacking in emotional self-disclosure and as emotionally cool or aloof (Bartholomew, 1990). They distract themselves from emotions at times of upset and they actively avoid seeking out support. Because of their high interpersonal self-reliance, they may also have moderate to high self-confidence. While downplaying the importance of relationships they often stress the importance of independence, freedom and achievement.

Individuals with predominantly fearful attachment style may initially desire social contact (i.e., not highly self-reliant), but this desire is inhibited by fear of rejection. These individuals are proposed to have had overly critical, harsh or rejecting caregiving (negative model of self and other) and as adults demonstrate interpersonal approach-avoidance behavior stemming from a fear of intimacy (Bartholomew, 1990). Interpersonally, they appear as hesitant, vulnerable, shy, self-conscious or as having a low self-confidence (Bartholomew, 1990). When confronted with problems or upsetting matters, they are emotionally reactive, but do not actively deal with their distress or seek support. They can acknowledge feeling bad but avoid self-disclosure or appearing upset in front of others because of fear of rejection. Individuals with fearful attachment style may have a few close relationships that typically take years to establish and have difficulty breaking off such relationships because of fear of ever finding another relationship.

Previous studies in community, college and medical populations have explored how adult attachment processes may interpersonally influence stress, coping and health-related outcomes. For example, in student samples it has been confirmed that in stressful situations, compared to individuals with secure attachment styles, individuals with dismissing attachment style demonstrate less self-disclosure and reciprocity (Mikulincer & Nachshon, 1991) and individuals with fearful attachment style demonstrate less collaboration (Lopez et al., 1997). In a study of expectant parents, parents with secure attachment style were more willing to seek out therapy for mental health problems and were more satisfied with care compared to parents with insecure attachment styles (Riggs, 2001). In another study, patients with dismissing attachment style were least likely to seek out support in the form of psychotherapy (Riggs, Jacobovitz, & Hazen, 2002).

In medical populations, similar coping approaches have also been found. Among patients with breast cancer, chronic leg ulcers and alopecia those with dismissing attachment style more often used denial coping compared to patients with secure attachment style (Schmidt, Nachtigall, Wuethrich-Martone, & Strauss, 2002). In HIV positive patients, secure attachment style was associated with less perceived global stress in the prior month compared to patients with insecure attachment style (Koopman et al., 2000).

Previous studies have explored the potential influence of attachment styles on treatment adherence and outcomes in patients with diabetes. For example, studies have demonstrated poorer diabetes self-care, insulin and hypoglycemic medication adherence and higher glucose levels in diabetic patients with fearful and dismissing attachment style as compared to patients with secure attachment style (Ciechanowski, Russo et al., 2004; Ciechanowski, Hirsch, & Katon, 2002; Ciechanowski, Katon, Russo, & Walker, 2001; Turan, Osar, Turan, Ilkova, & Damci, 2003).

In this paper, we present the results of a qualitative investigation of the experiences of patients with type 2 diabetes in their interactions with the health care system in managing diabetes, while taking into account their general capacity to rely on others based on attachment theory. We hypothesized that compared to patients with secure attachment style, those with dismissing and fearful attachment style would be: (1) less satisfied with interactions with health care providers; (2) less trusting of health care providers and (3) less able to collaborate in health care settings.