Application of Attachment Theory for Psychological Support in Palliative Medicine during the Terminal Phase

Abstract

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.

Attachment Theory and Spirituality: Two Threads Converging in Palliative Care?

“…In the palliative situation, some attempts have been made to address family relationships and to facilitate communication [10, 11] or to identify determinants of depression and hopelessness in metastatic cancer patients [12] from an Attachment Theory perspective. Tan et al [13] and Petersen and Koehler [2] made the effort to apply Attachment Theory to analyze interpersonal processes in Palliative Care and identified fundamental attachment patterns in patient's behavior. Milberg et al [3] pointed out the importance of a “secure base” from a patient's and relatives' perspectives in palliative home care (a concept derived from Attachment Theory, as we shall see later).…”

“…Some papers contain case reports describing the different attachment patterns in clinical situations [2, 13]. These case reports give an idea on how individuals with different attachment representations behave when they are in palliative care.…”

“…They openly mourn their situation and express such feelings as fear, anxiety, or anger, which facilitates emotional relief and thus their working through the grieving process. Often, it is sufficient to accompany those patients merely by providing basic support, for example, by helping them in structuring their remaining time or by giving them spiritual support [2]. …”

“…In the present paper, two important concepts come into focus, both founding a multivariate understanding of the patient's needs and challenges in the palliative situation: attachment theory and the concept of spirituality. Attachment Theory is a concept that is concerned with human relationship behavior in situations of loss, separation, or helplessness and can help to understand the patient's behavior, needs, and challenges [2, 3]. The patient's spirituality in health care and research is addressed by the field of Spiritual care.…”

Attachment figures when death is approaching: a study applying attachment theory to adult patients’ and family members’ experiences during palliative home care

“…Adults often rely on a network of attachment figures, and the importance placed on different figures changes in response to ageing and normative life events [16]. For example, in older adults with grown children, there might be a role-reversal process, and the grown children may begin to serve as attachment figures [17]. It appears also that pets, God and deceased loved ones may become sources of attachment security [16, 18–23].…”