Everyone does not ask for, or respond to, help in the same way. The oncology clinician may find themselves on the receiving end of some unexpected reactions when providing help, which can leave them wondering what else might be going on during their interaction.
Something that is not commonly considered is the possible influence of a patient’s attachment style. But why would a cancer patient’s early relationship with their childhood caregiver be relevant in the oncology clinic?
What is “attachment”?
Attachment is the psychological definition of an early relationship style developed with one’s care-givers (usually parents), during infancy and childhood. It is a pattern of connecting and communicating with others that usually remains stable into adulthood. Attachment first came into prominence in modern psychology from the work of Bowlby who published his work in the 1960’s and was further developed by various others.
Although attachment has much relevance in the field of psychology, particularly in relation to childhood matters, how could it help us understand the oncology patient? Why could it be useful in our interactions?
Let’s backtrack a little and understand the different types of attachment styles.
There are 4 broad types of attachment style typically recognised in psychology, (secure, anxious, avoidant, disorganised), however, they have also been differently named by some theorists.
When a child is frightened, sick, in pain, or generally needs assistance, its first response is to seek out their caregiver. It’s what happens next that can start to establish an attachment style… here are some simplified examples to clarify the basic concepts:
- Secure attachment happens when a caregiver is reliable in their attention and empathic in their response. The child feels secure in knowing they can trust their caregiver when needed, ask for help if required, can be comforted if in distress, and can go back to interacting with their environment when soothed.
- Anxious attachment happens when a caregiver is empathic in their response, however, is unreliable or unavailable when needed. The child experiences inconsistency and a lack of help when it is genuinely required. As a result, the child can feel anxious regarding the potential absence of the caregiver, overly seeking attention and reassurance from them. An example of such an interaction with a distressed child might be “The baby-sitter will look after you, Mummy’s going out now”.
- Avoidant attachment happens when a caregiver is reliable in their attention, however, is non-empathic in their response. The child experiences indifference, ridicule or punishment for seeking help. As a result, the child may avoid displaying their distress or seeking help when genuinely needed. An example of such an interaction with a distressed child might be “Don’t be silly. Big girls / boys don’t cry”.
- Disorganised attachment is often considered a mix of anxious and avoidant attachment styles, reflecting a particularly chaotic early environment. The caregiver may behave quite unpredictably, and this is later evidenced by the child’s own unpredictable behaviours.
It is generally agreed that most people in the population have a secure attachment style (55-59%), with avoidant attachment being the next most common (25%), and anxious attachment being less common (11-20%) (Hazan & Shaver, 1994; Mickelson et al. 1997). Disorganised attachment is considered to be relatively rare in the population.
Cancer and help seeking
For many adults a serious health diagnosis, such as cancer, may be first time since childhood where they might need a significant amount of help over a prolonged period. People expect to seek help and advice regarding appropriate medical tests, diagnosis, and treatments from health staff. However, a period of prolonged treatment over many months (or years) may be required as the individual undergoes a possible combination of surgery, chemotherapy, radiation and other interventions. Initially, the person may not anticipate the extent or duration of help that might be required. As time goes on, there are likely to be side-effects of treatment for which further assistance needs to be sought (e.g. pain, fatigue, nausea). A prolonged period of treatment may also entail help with a variety of other tasks – transportation, shopping, housework, cooking, dressing, showering etc. In fact, a common dilemma is that one’s previous roles (whether in employment, unpaid work, household or family duties), are suspended and the person is expected to adopt the new role of being a patient.
Clinicians usually see people who are in the situation of requiring greater levels of help than they have needed previously (due to pain, fear, feeling sick or inability to cope with current circumstances). Although this may be common for the clinician, it can be quite new for the patient. How is the person likely to react in this situation? What are their earliest memories of seeking help from others? Cancer and side effects of treatment may place the person in the position of requiring help again and again, and hence triggering habitual attachment patterns.
People with secure attachment styles would usually exhibit the expected or “the usual” response to receiving help from others. In other words, they are open to seeking appropriate help when needed, believe that others can be relied upon in difficult circumstances, and feel emotionally secure when the required assistance is given.
However, the person’s presentation and response to assistance may be quite different in people with anxious and avoidant attachment…
The individual with an anxious attachment pattern may be the type of individual who frequently seeks your attention, can become quite emotional, have difficulty leaving at the end of a consultation, asks for additional appointments, wants reassurance but doesn’t seem to be actually reassured by what you say. It can become exhausting for the clinician to know how to best assist an individual who consistently displays a pattern like this, as it appears that nothing they offer is sufficient to alleviate the individual’s distress. It can almost feel like a bottomless pit of anxiety and attention seeking.
Tips for working with suspected anxious attachment:
- Take into account the patient’s distressed emotional state. Break down information into small, clear steps. The individual may be so distressed that they cannot comprehend or retain information to use on their own. Involve supportive significant others who can assist the individual in your consultation. Carers can provide comfort and assist with soothing of distress. Written information to take home may also be helpful.
- Help the person to engage in management of their own distress. This can include both skill development and linkage to appropriate services. Skills that can assist with development of self-regulation and appropriate emotional expression include relaxation training, meditation, and artistic expression (art, music, writing, and other creative activities). Services that assist with emotional regulation and social support include exercise programs, massage, diversional therapies, yoga classes, and support groups. Reinforce the person for their efforts in these areas.
- Encourage appropriate self-reliance, while still showing that you care. Try not to feel that you need to be the “rescuer” at each presentation.
Keep in mind that such a behavioural pattern is not necessarily clear cut, and may present in a similar manner to other problems. For example, hypochondriasis could present in a similar way with seeking of frequent medical contact, asking for ongoing testing and reassurance seeking. However, this is often related to a specific health concern, and requires taking people through health-related information and checking their understanding of the situation. In hypochondriasis, reassurance seeking may be based on incorrect assumptions, misinterpretation of bodily symptoms, or catastrophic rumination about their illness (Warwick & Salkovskis, 1990), and approaches such as CBT can be efficacious (Olatunji et al. 2014).
On the other hand, the individual with avoidant attachment may display little obvious emotion in situations where emotion is typically expected by the clinician. People with avoidant attachment can be reluctant to speak about how they are feeling, and play down situations which may be quite serious. They may be quite resistant to receiving assistance, whether practical and / or emotional, when it is suggested. Interestingly, such an individual can feel quite comfortable giving help to others, but not if the assistance is directed at them. Such a situation can be frustrating for the clinician as it may be perceived as non-compliance, non-communication or a rejection of appropriate care.
Tips for working with suspected avoidant attachment:
- Whenever possible, try to maintain consistency with the same staff member (or same team) to help build up rapport and trust
- When the person states that they are fine (and you suspect otherwise) do acknowledge their resilience, but also ask if there have been any exceptions. For example, have there been any unexpected challenges?
- When offering assistance to the person, provide the rationale for doing so in a sensitive manner. For example, giving additional information on why you are making a particular recommendation, what problems it may help to avoid, what could happen if the issue is not addressed, how doing this is in their best interests, pros & cons of the situation, etc. Having a logical reason presented for their consideration may prevent perceptions of “weakness” for accepting help.
Again, the difficulty is that such a behavioural pattern is not clear cut, and may present in a similar manner to other problems such a social anxiety. In social anxiety, the individual is often keen to engage with others however feels anxious in doing so, and hence avoids communication or social contact. Social anxiety and social avoidance may be based on fears of interpersonal rejection or a lack of social skills. Effective treatment approaches to assist with social anxiety include relaxation training, social skills practice, CBT and pharmacological interventions (Rodebaugh et al., 2004).
What else can help? Attachment, self-compassion and help seeking
Another way of understanding difficulties with help seeking is by considering self-compassion. Self-compassion can be understood as the individual’s ability to soothe themselves with kindness and non-judgemental understanding when presented with setbacks or difficulty (Gilbert, 2005; Gilbert, 2009). Researchers in the field link the development of self-compassion with early childhood experiences (Gilbert, 2005; Neff & McGehee, 2010). It is thought that the ability to self-soothe develops through being comforted by attachment figures in early life. Therefore, if this experience is missing or inconsistent, the ability to self-soothe may not fully develop in the individual, hence leading to a decreased ability to be self-compassionate later in life (Gillath et al., 2005).
Furthermore, evidence suggests that those with a secure attachment style report greater levels of self-compassion than those with other attachment styles (Neff & McGehee, 2010). Low self-compassion has been found to be significantly correlated with anxious and avoidant attachment (Pepping et al., 2014; Raque-Bogdan et al., 2011). Recent research indicates that self-compassion based interventions can help to improve secure attachment styles in healthy populations (Navarro-Gil et al., 2018) https://self-compassion.org/wp-content/uploads/2018/05/Navarro.Gil_.2018.pdf
Self-compassion is a relatively new area of investigation in health psychology, however research is indicating its applicability to broad range of issues. It has been found that individuals with higher levels of self-compassion are more likely to undertake appropriate help seeking, display greater compliance with medical recommendations and use health-promoting behaviours (Terry & Leary 2011, Terry et al., 2013). Such results suggest that interventions which enhance self-compassion could be especially beneficial in health care settings. Patients who may have had particularly negative experiences regarding help seeking in early life, such as those with anxious or avoidant attachment, and subsequently encounter difficulties in the health care setting may especially benefit from self-compassion based interventions.
Let’s watch this space…
Gilbert, P., (2005). Compassion: conceptualisations, research and use in psychotherapy. New York: Routledge; US.
Gilbert, P., (2009). Introducing compassion-focused therapy. Advances in Psychiatric Treatment; 15(3):199–208. Doi: 10.1192/apt.bp.107.005264.
Gillath, O., Shaver, P., & Mikulincer, M. (2005). An attachment-theoretical approach to compassion and altruism. In P. Gilbert (Ed.), Compassion: conceptualizations, research, and use in psychotherapy. London: Brunner-Routledge.
Hazan, C., & Shaver, P., (1994). Attachment as an organizational framework for research on close relationships. Psychological Inquiry; 5:1; 1-22. DOI: 10.1207/s15327965pli0501_1
Mickelson, K., Kessler, R., & Shaver, P., (1997). Adult attachment in a nationally representative sample. Journal of Personality and Social Psychology. 73:5; 1092-1106
Navarro-Gil, M., Lopez-del-Hoya, Y., Modrego-Alacon, M., Montero-Marin, J., Van Gordon, W., Shonin, E., & Garcia-Campayo, J., (2018). Effects of Attachment-Based Compassion Therapy (ABCT) on self-compassion and attachment style in healthy people. Mindfulness. https://doi.org/10.1007/s12671-018-0896-1
Neff, K., & McGehee, P., (2010). Self-compassion and psychological resilience among adolescents and young adults. Self and Identity; 9(3):225–240. Doi: 10.1080/15298860902979307.
Olatunji, B., Kauffman, B., Meltzer, S., Davis, M., Smits, J., & Powers, M., (2014). Cognitive-behavioural therapy for hypochondriasis / health anxiety: A meta-analysis of treatment outcome and moderators. Behaviour Research and Therapy; 58:65-74.
Pepping, C., Davis, P., O’Donovan, A., & Pal, J., (2014). Individual differences in self-compassion: the role of attachment and experiences of parenting in childhood. Self and Identity; 14(1):104–117. Doi: 10.1080/15298868.2014.955050.
Raque-Bogdan, T., Ericson, S., Jackson, J., Martin, H., Bryan, N., (2011). Attachment and mental and physical health: self-compassion and mattering as mediators. Journal of Counseling Psychology; 58:272–278. Doi: 10.1037/a0023041.
Rodebaugh, T., Holaway, R., & Heinberg, R., (2004). The treatment of social anxiety disorder. Clinical Psychology Review. 24:883-908
Terry, M., & Leary, M., (2011). Self-compassion, self-regulation, and health. Self and Identity; 10: 352–362.
Terry, M., Leary, M., Mehta, S., & Henderson, K., (2013). Self-compassionate reactions to health threats. Personality and Social Psychology Bulletin; 39:911-926
Warwick, H., & Salkovskis, P., (1990). Hypochondriasis. Behaviour Research and Therapy; 28: 105-117.
Wei, M., Liao, K., Ku, T., Shaffer P., (2011) Attachment, self-compassion, empathy, and subjective well-being among college students and community adults. Journal of Personality; 79(1):191–221. Doi: 10.1111/j.1467-6494.2010.00677.x.