Attachment Style as Part of Patient-Provider Relationships and Pain Coping

Attachment theory aims to explain differences in individuals’ perceptions of belonging, security, and protection in relationships. Bowlby and colleagues believed that internal working models of self and others develop in early childhood through relationships with caregivers.¹˒² This first relationship then sets the expectations for future relationships, that is, expectations about whether our emotional and physiological needs will be reliably met across the lifespan. Importantly, a person’s attachment style has been found to impact how they view pain, catastrophizing, functionality, and coping.³⁻⁶ In fact, prior research has concluded that individuals with insecure attachment styles require different things in their relationships with healthcare providers in order to maximize treatment adherence and outcomes. For example, select insecure attachment styles may require more frequent contact with providers.

This article will review the types of attachment styles and their impact on chronic pain management, including why clinicians need to use an attachment lens to assess and tailor their treatment plans for patients.

Early caregivers are referred to as attachment figures who can either be attuned and meet an infant’s emotional and physical needs, or be misattuned and unable to meet some or all of the infant’s needs. As a result, the infant grows up to expect relationships to be secure, insecure, or unsure about relationships.

People living with chronic pain all have working internal models of how they anticipate relationships to emerge, including relationships with doctors, and whether their needs are likely to be met.

Secure

Attachment styles are categorized as secure or insecure. Securely attached individuals felt safe and valued by early childhood caregiver(s). As a result, they feel secure enough to explore the world and trust that their needs will be reliably met. Consequently, securely attached individuals are able to cope with distress and regulate their emotions. Secure attachment prevalence rates in the US have been found to be approximately 56% to 59%.⁷˒⁸

Insecure

There are three types of insecure attachment styles:

• avoidant, also known as dismissive or anxious-avoidant

• anxious, also known as preoccupied or anxious-ambivalent

• disorganized, also known as fearful-avoidant

These styles are considered insecure because the individual has developed an internal relational framework based on early caregiving patterns where their needs were not adequately met. These attachment behaviors are initially functional, but then become guiding frameworks for all future relationships. Approximately 36% to 44% of individuals report an insecure attachment style.⁷˒⁸

Adverse Impacts of Attachment Styles

Attachment style has been found to impact emotional regulation⁹⁻¹¹ and distress tolerance.¹² Disorganized attachment styles have been hypothesized as the most at-risk of poor treatment outcomes, whereas preoccupied styles have been identified at higher rates in those with chronic widespread pain.³ In addition, those with preoccupied attachment were more likely to report more pain sites and a higher level of disability compared to those with secure attachment.³

Research has demonstrated that people form interpersonal relationship attachments with healthcare providers.¹³ Bowlby et al assert that provider relationships can offer a new attachment experience and alter previous internal working models for patients.¹⁴ To facilitate this, clinicians need to assess their patients’ attachment styles. The first step in using the attachment lens with patients with chronic pain is to understand the patient’s expectations about the provider-patient relationship as well as the treatment process and outcome.

Assessment

The attachment style interview,¹⁵ the adult attachment scale,¹⁶ and the relationship questionnaire¹⁷ can be used to assess attachment style. However, these questionnaires take time to administer and score, which can be difficult in an overloaded healthcare system. More accessible assessment includes unstructured interview questions. For example, providers can assess a patient’s observed comfort sharing information with healthcare providers and expectations about whether they perceive providers and others of importance as there for them when needed. Further, it’s helpful to observe whether patients present as overly dependent on others (preoccupied) or excessively independent (avoidant).

Lastly, it is helpful to assess emotional regulation. For example, if a patient has difficulty with emotional regulation, whether they appear overly dependent or conversely hyper-independent with a lack of trust, this likely indicates an insecure or disorganized attachment style.

Tailored Treatment

Once attachment is assessed, the patient-provider relationship can be used as an opportunity to modify patients’ insecure and disorganized attachment styles. If that is not possible given resources and the scope of the provider’s role, then it is important to consider referring the patient to an adjunct provider who will be able to work with them more regularly. For example, the clinician can refer the patient to a behavioral health provider, such as a health psychologist, or to specific interventions, such as mindfulness-based stress reduction programs, which have been shown to help support attachment repair.¹² Specifically, preoccupied patients will need more support, reassurance, and regular contact. Those with avoidant attachment will need time to develop trust. Therefore, contact and engagement should slowly increase over time for those with avoidant styles.¹⁸

Humans learn early on if the world predictably meets their emotional and physical needs. As adults, they live securely or insecurely attached to those around them – including their healthcare providers. Consequently, the identification of a patient’s attachment style using available questionnaires can guide the provider-patient relationship and treatment plan. Observation and unstructured intake questions can further help to reveal patients’ attachment styles if there is little time for a structured assessment method.