Background and Purpose: The situation leading to the death of a close relative is a unique and irrevocable experience of separation which evokes a state of emotional strain for the patient and the family. This situation therefore is an especially effective trigger of the so-called ‘attachment system’. Attachment research in recent decades has shown that already in early infancy every person develops special attachment strategies activated in cases whenever a person cannot cope on its own with dangers. Only four such patterns of attachment have been specified, namely ‘secure’, ‘insecure-avoidant’, ‘insecure-ambivalent/enmeshed’ and ‘disoriented/disorganized’. Since the dying are usually brought to the hospital by members of the family, the doctor responsible for treatment can perceive with unusual clarity the patterns of attachment within the family system, and can integrate such observation into her treatment strategy. This article suggests an attachment-informed therapy in the field of palliative medicine. It seems apparent that such approaches provided by the attachment theory for relief during the terminal phase are not only relevant in a palliative context but also applicable within the overall field of medicine and care-giving relating to terminal patients and their families. Methods: To the doctor familiar with the attachment patterns and the conditions of their formation, clinical observation easily reveals which pattern is active among the dying and the accompanying members of the family. Here, cases are used to show how these insights can be realized in the psychotherapeutic care of patients and their families on a palliative ward. For example, in a case of ‘avoidant’ attachment, denied emotions can be addressed carefully and still existent hopes for protection and support can be reinforced; in a case of so-called ‘ambivalent-enmeshed’ attachment, overly intense relationships can be disentangled, and in a case of ‘disorganized’ attachment, emotion regulation can be supported and clarity in the relationships can be promoted. Results: The clinical results show that psychotherapeutic intervention based on insights imparted by the attachment theory are of special benefit in relieving the psychological strain for the dying and their families.

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The aim of this paper is to discuss and explore the interrelation between two concepts, attachment theory and the concept of spirituality, which are important to palliative care and to founding a multivariate understanding of the patient's needs and challenges. Both concepts have been treated by research in diverse and multiform ways, but little effort has yet been made to integrate them into one theoretical framework in reference to the palliative context. In this paper, we begin an attempt to close this scientific gap theoretically. Following the lines of thought in this paper, we assume that spirituality can be conceptualized as an adequate response of a person's attachment pattern to the peculiarity of the palliative situation. Spirituality can be seen both as a recourse to securely based relationships and as an attempt to explore the ultimate unknown, the mystery of one's own death. Thus, spirituality in the palliative context corresponds to the task of attachment behavior: to transcend symbiosis while continuing bonds and thus to explore the unknown environment independently and without fear. Spiritual activity is interpreted as a human attachment behavior option that receives special quality and importance in the terminal stage of life. Implications for clinical practice and research are discussed in the final section of the paper.

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Yvon ne Pe ter sen · Lot te Köh ler · Mün chenDie Bin dungs theo rie als Ba sis psy cho the ra peu ti scher In ter ven tio nen in der Ter mi nal pha se Die von J. Bowlby (1969) ent wi ckel te und M. Ains worth so wie an de ren (Ains worth et al. 1978; Gross mann u. Gross mann 2003, 2004 zu ei ner Schu le aus ge bau te Bin dungs theo rie be sagt, ver kürzt zu sam men ge fasst, Fol gen des: Es gibt ein bio lo gisch an ge leg tes Bin dungs sys tem, dass die Jun gen ei ner Spe zi es, da run ter auch die der Spe zi es Mensch, dazu ver an lasst, im Fal le ei ner Ge fahr bei er fah re ne ren Art ge nos sen, bei Äl te ren (El tern) Schutz zu su chen. Die Be dro hung kann von au ßen kom men, z. B. durch Reiz über flu tung oder Un ge wiss heit, aber auch aus in ne ren Be findlich kei ten wie Miss be ha gen, Krank heit, Schmerz her rüh ren, wenn die se nicht aus ei ge nem Ver mö-gen be ho ben wer den kön nen. Dies ist in der frü-hen Kind heit re la tiv häu fig der Fall. Da her werden vom Säug ling be reits in den ers ten Le bensmo na ten Ver hal tens stra te gi en ent wi ckelt, um Hilfe und Schutz von der Pfle ge per son, im all ge meinen der Mut ter, zu er hal ten. Die Pfle ge per son bzw. Mut ter wird zur so ge nann ten Bin dungs person. Die Tren nung von ihr stellt die höchs te Gefahr dar, die Bin dungs ver hal ten aus löst. Das Bindungs ver hal ten zeigt sich da rin, dass Nähe zur Bin dungs per son als ei nem si che ren Hort ge sucht wird, z. B. durch Sich-Rück ver si chern, An leh nen, Klam mern, Quen geln -bei Kin dern vor al lem auch durch Schrei en -wo bei das Schrei en, durchaus ag gres siv-wü tend wir ken kann. Aus dem ge netisch vor ge ge be nen Bin dungs sys tem wer den Bindungs mus ter, die spe zi fisch auf die Per sön lichkeits zü ge der Bin dungs per son aus ge rich tet sind bzw. die se an spre chen. Das zwi schen mensch li che 1 Das ge sam te kli ni sche Ma te ri al stammt von Pe ter sen, die Darstel lung der theo re ti schen Grund la gen von Köh ler, die kli nischtheo re ti sche Aus wer tung des Fall ma te ri als wur de von bei den Au to rin nen ge mein sam er ar bei tet. Bin dung und Bin dungs ent wick lung 278 | Forum der Psychoanalyse 3 · 2005