Social Science & Medicine 63 (2006) 3067–3079
The interpersonal experience of health care through the eyes of
patients with diabetes
$
Paul Ciechanowski
, Wayne J. Katon
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 356560, 1959 NE Pacific,
Seattle, WA 98195-6560, USA
Available online 25 September 2006
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.
r
2006 Elsevier Ltd. All rights reserved.
Keywords: Diabetes; Attachment style; Trust; Patient–provider relationship; Patient centered; Customer service; USA
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 sus-
tained, consistent and timely fashion (
Von Korff, Gruman, Schaefer, Curry, &
). Such a partnership between patients
and providers facilitates adoption of guideline and
evidence-based treatments, increases patient-cen-
tered interactions (
&
), and contributes
ARTICLE IN PRESS
www.elsevier.com/locate/socscimed
0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
doi:
10.1016/j.socscimed.2006.08.002
$
Supported by grant K23 DK60652-01 (National Institute of
Digestive and Diabetes and Kidney Diseases).
Corresponding author. Tel.: +1 206 543 8848.
E-mail addresses:
wkaton@u.washington.edu (W.J. Katon)
.
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 collabora-
tive 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 frustrat-
ing 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 physi-
cians 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 comfor-
table 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;
In developing attachment theory, John Bowlby
proposed that all individuals psychologically incor-
porate prior experiences with caregivers, forming
enduring mental representations of caregiving that
persist into adulthood called ‘‘internal working
models’’ (
). 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 (
)
and infancy and adulthood (
Treboux, Crowell, & Albersheim, 2000
). Based on
empirical research in infants, children and adults
over the past three decades, social psychologists
(
) 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 char-
acterized 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 charac-
teristics of each style.
Adults who have predominantly secure attach-
ment style are generally believed to have experi-
enced consistently responsive (
) early caregiving (in the
process
developing
a
positive
model
of
self
and other;
) 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 (
) and in an effort to ensure proximity to
caregivers, they use strategies in which the attach-
ment behavioral system is ‘‘hyperactivated’’ through
exaggeration of behaviors attracting support (
kulincer, 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 (nega-
tive model of self).
The remaining two styles, dismissing and fearful
attachment styles, are characterized by strategies in
which the attachment behavioral system is ‘‘deacti-
vated’’ (
), 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 emo-
tionally unresponsive. As a result, they develop
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strategies from an early age in which they become
‘‘compulsively self-reliant’’ (
) (positive
model of self) and uncomfortable trusting others
(negative model of other). Individuals with dismiss-
ing attachment style are described as lacking in
emotional self-disclosure and as emotionally cool or
aloof (
). They distract them-
selves 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 downplay-
ing the importance of relationships they often stress
the importance of independence, freedom and
achievement.
Individuals with predominantly fearful attach-
ment 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 caregiv-
ing (negative model of self and other) and as adults
demonstrate
interpersonal
approach-avoidance
behavior stemming from a fear of intimacy
(
). Interpersonally, they appear
as hesitant, vulnerable, shy, self-conscious or as
having a low self-confidence (
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 (
) and individuals with fearful attachment style
demonstrate less collaboration (
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 (
). In another
study, patients with dismissing attachment style
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Fig. 1. Attachment style categories and model of self and other. Adapted from
Bartholomew & Hororwitz (1991)
P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
3069
were least likely to seek out support in the form of
psychotherapy (
Riggs, Jacobovitz, & Hazen, 2002
).
In medical populations, similar coping ap-
proaches 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 (
thrich-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
(
).
Previous studies have explored the potential
influence of attachment styles on treatment adher-
ence 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 attach-
ment style (
Ciechanowski, Russo et al., 2004
;
Ciechanowski, Hirsch, & Katon, 2002
ki, Katon, Russo, & Walker, 2001
;
).
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.
Study design
Subjects and settings
Twenty-seven patients with type 2 diabetes
attending the University of Washington Diabetes
Care Center in Seattle, Washington were recruited
to the study. This tertiary care clinic provides
diabetic health care for 3000 patients and is staffed
by eight physicians, two nurse practitioners and two
nutritionists. Patients were identified from clinic
rosters and had initially responded to a self-report
questionnaire
from
the
Diabetes
Care
Study
(N ¼ 395 type 2 diabetes patients) which assessed
demographic data, clinical characteristics, self-care
adherence and attachment styles of patients attend-
ing this clinic within the prior 2 years. Response
rate to this questionnaire was 58%. To guide
selection of a patient subgroup for recruitment to
the qualitative study, purposive sampling (
) was used to achieve maximum variation in
gender, age, race/ethnicity and in attachment styles
directly or inversely associated with trust and ability
to rely on others. To optimally explore health
care experiences among patients with low levels of
trust, we intended to recruit approximately twice as
many patients within each of dismissing and
fearful attachment style groups as within the secure
attachment style group.
We also aimed to ensure maximum variation in
glucose control among study patient based on
glycosylated hemoglobin (Hb
A1c
). Hb
A1c
is accepted
as the best measure of recent glycemic control (last
120 days) and is used to guide clinical management
(
). Lowering Hb
A1c
has been
associated with a reduction of microvascular and
macrovascular diabetic complications and the Amer-
ican Diabetes Association recommends developing
or adjusting the management plan to achieve normal
(4–6%) or near-normal (
o7%) Hb
A1c
values (2005).
To measure Hb
A1c
, the University of Washington
Diabetes Care Center laboratory uses a Bayer
DCA2000, which is certified by the National
Glycohemoglobin Standardization Program as hav-
ing documented traceability to the Diabetes Control
and Complications Trial reference method.
Attachment style determination
Participants completed the Relationship Ques-
tionnaire (RQ) (
),
created by Bartholomew and colleagues based on
Bowlby’s attachment theory (
), which
measures respondent attachment style. This mea-
sure demonstrates convergent and discriminant
validity with other self-report and interview ratings
(
). Since preoccupied
attachment style has not been consistently asso-
ciated with diabetes treatment adherence or adverse
outcomes compared to secure, dismissing and
fearful attachment styles (
), an a priori decision was made not to include
this attachment style group in this study.
Items assessing each attachment style consist of
paragraphs describing each style (
). Respon-
dents are asked to think of all past and current close
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relationships when completing the questionnaire
and to choose the style suiting them best.
Semi-structured interviews
Each patient was enrolled for 3 months. In-
person interviews took place at the University of
Washington Medical Center. Interviews usually
occurred on the day of a scheduled Diabetes Care
Center appointment and were tape-recorded with
patients’ consent and transcribed in full. The study
protocol was reviewed and approved by the Uni-
versity of Washington institutional review board.
All participants gave written informed consent.
Semi-structured interviews were conducted by
the first author (PC). A repeat interview design
facilitated the development of trust and rapport
(
), particularly around issues pa-
tients might have initial reluctance to discuss. Two
in-person interviews lasting 30–50 min were con-
ducted 3 months apart, interspersed with an inter-
view conducted by telephone. In-person interviews
enquired about various aspects of patients’ perspec-
tives of diabetes care and health care, including the
patient–provider relationship. Telephone interviews
were shorter in duration and addressed recent
intervening clinic visits that patients attended at
the Diabetes Care Center.
Interview topics included: (1) assessment of the
patients’ understanding of diabetes and related
complications; (2) a review of all prior and current
health care relationships related to diabetes treat-
ment; (3) discussion of health visit frequency, modes
of contact with providers and perceived quality of
prior and current patient–provider relationships;
(4) assessment of diabetes self-management; (5)
discussion of patients’ attachment style character-
istics; (6) patients’ perceptions of how family may
help with or hinder diabetes self-management.
Patients’ prior interviews were reviewed and
additional questions were added to subsequent
interviews to address issues raised by a patient in
a previous interview, or in response to emerging
themes that arose from the interview with the same
patient or with other patients.
Analysis
We used a constant comparative approach in
which contemporaneous data collection and the-
matic analysis of interview data took place (
). All interviews were audiotaped,
transcribed and managed using QSR N6 Version 6.0
(QSR International Pty Ltd.). Themes related to
health care experiences were derived from data
rather than being imposed in the analysis, though
the interviewer was not blinded to patients’ attach-
ment style categories. Emerging themes, issues and
hypotheses from earlier interviews informed subse-
quent interviews in an iterative process (
Strauss &
). Data were organized into initial and
higher level codes and clustered across transcripts to
derive primary interpretative themes.
Results
Among 395 patients with type 2 diabetes from the
clinic-wide sample: mean age was 56.8
711.8 years
(range 19.9–85.3 years); 194 patients (49.1%) were
female; 72 patients (18.2%) belonged to a race/
ethnic minority; 329 patients (83.3%) had at least
one year of college education; 157 patients (41.8%)
had secure attachment style; 114 patients (30.3%)
had
dismissing
attachment
style;
72
patients
(19.1%) had fearful attachment style; 258 patients
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Table 1
Descriptive paragraphs of attachment styles (
Secure attachment
style
It is easy for me to become emotionally
close to others. I am comfortable
depending on them and having them
depend on me. I don’t worry about
being alone or having others not accept
me
Fearful attachment
style
I am uncomfortable getting close to
others. I want emotionally close
relationships, but I find it difficult to
trust others completely, or to depend
on them. I worry that I will be hurt if I
allow myself to become too close to
others
Dismissing
attachment style
I am comfortable without close
emotional relationships. It is very
important to me to feel independent
and self-sufficient, and I prefer not to
depend on others or to have others
depend on me
Preoccupied
attachment style
a
I want to be completely emotionally
intimate with others, but I often find
that others are reluctant to get as close
as I would like. I am uncomfortable
being without close relationships, but I
sometimes worry that others don’t
value me as much as I value them
a
Patients with preoccupied attachment style were not included
in this current study.
P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
3071
(65.3%) were taking oral hypoglycemic medica-
tions; 245 patients (62.0%) were taking insulin and
126 (32.1%) were taking both classes of medica-
tions. Mean glycosylated hemoglobin values was
7.4
71.2% (range 4.6 to 13.0%).
In the sample selected for the qualitative study,
sixteen women (59.3%) and eleven men (40.7%) with
type 2 diabetes between the ages of 27 and 79 years
(mean age 54.4
711.8 years) participated. Nine patients
(33.3%) belonged to a racial/ethnic minority and 25
(96.2%) had at least one year of college. Five patients
(18.5%) had secure attachment style, eleven patients
(40.7%) had dismissing attachment style and eleven
patients (40.7%) had fearful attachment style. Nine-
teen patients (63.2%) were taking oral hypoglycemic
medications, 19 patients (63.2%) were taking insulin
and 12 (44.4%) were taking both. Mean glycosylated
hemoglobin value was 7.9
71.2% (range 5.9–10.8%).
Development of trust
Patients with dismissing or fearful attachment
style described a long-standing general distrust or
inability to collaborate with others, often extending
to their health care providers. This is consistent with
an attachment theoretical framework in which
patients with these attachment styles develop a
‘‘negative model of other’’ based on consistently
unresponsive caregiving. Similar experiences of
long-standing distrust were not observed among
patients with secure attachment style.
Trusting blindly, saying ‘‘OK, I’ll go with
whatever you say’’, I don’t have that trust.
Patient 3774—Dismissing attachment style
Interviewer: When you do go to ask someone for
help, how does it feel?
Patient: I feel like I have to justify it. I feel like I
have to say, ‘‘OK, I’ve done this, this and this
and you’re my last resort.’’ Rather than just
feeling to the point where I can say ‘‘I need your
help’’.
Patient 3752—Fearful attachment style
When asked about their need to be independent
or their inability to rely on others, patients with
dismissing or fearful attachment style frequently
gave as reasons the ways they were responded to in
the past or prior experiences in which they were
emotionally hurt.
Patient: I can still turn around and cut you off
and walk away, because I don’t become attached.
Interviewer: You can get close to people as long
as you’re in control?
Patient: I would say 95% of the time if I lose that
control of myself, then I’ve gotten hurt.
Interviewer: I see. And what is it like if you—?
Patient: What is it like to be there?yLonely.
Patient 2069—Dismissing attachment style
This reflection on the loneliness resulting from
being repeatedly interpersonally hurt may also
speak to the need for patients with dismissing
attachment style to generally deny the importance
of relationships and avoid closeness and intimacy.
Patient: I’ve had troubles with intimacy in my
relationships. It’s been borne out in expecting
others to really be committed to taking care of
you or rising to whatever occasion and then
being mistaken often enough that you learn that
being independent is very, very important.
Interviewer: Because you’ve been failed before
when you depended on others?
Patient: Yes, including the medical situation.
Patient 1852—Fearful attachment style
When I have been close with others, it’s a great,
wonderful feeling. But then all of a sudden
something happens in the relationship to where
I’m like the animal that comes up and eats out of
your hand. And then all of a sudden you put the
other hand over to capture meyI’m gone.
Patient 2069—Dismissing attachment style
You don’t want to stand up and start asking
questions and say ‘‘Yeah, but what about this?’’
or anything. You just kind of sit back and take it
because we’ve all been raised to sit back and take
it, you know.
Patient 3752—Fearful attachment style
This last passage may speak to the perceived
harshness of early caregiving that is typically more
characteristic of patients with fearful attachment
style compared to those with dismissing attachment
style.
Implications of lack of trust in the health care setting
Fearful and dismissing attachment style
Such pervasive lack of trust may have implications
for health care utilization patterns or the quality of
interactions between patient and provider.
I would say never go for being completely
trusting because you’re the only one that can
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really know what it’s like to be in your skin. And
if you’re having some difficulties you have to
address those, and if the caregiver’s not respond-
ing, you go see someone else.
Patient 1852—Fearful attachment style
Patient: I always want to be able to do things
myself, and have the ability to do things myself.
And so sometimes it’s very difficult to ask people
for help.
Interviewer: Before you had diabetes, are you
someone that typically went to the doctor?
Patient: No. I stay away from those peopley
Interviewer: Does your current doctor ask you to
help make decisions about your diabetes care?
Patient: My doctor sometimes tricks me into that.
Patient 3438—Dismissing attachment style
In this last passage, as in prior passages of
patients with dismissing attachment style, there is a
high sensitivity to or fear of being controlled.
Ok, Dr. X, I don’t trust because I honestly feel
that attention wasn’t paid. Might have been that
day, might have been something else, but
regardless, the doctor did that in front of me so
we are not going to be able to build that trust.
Patient 1206—Fearful attachment style
Patients with fearful attachment style, on the
other hand, seem less concerned about being
controlled than about not being responded to which
is consistent with the observation that they are
highly sensitive to rejection.
Secure attachment style
Patients with secure attachment style were gen-
erally more likely to trust providers and value
an ongoing relationship, even when circumstances
were not ideal. They often cited their health care
provider’s knowledge as an important determinant
of their ability to trust their provider.
Interviewer: Did you have a lot of trust in your
provider at today’s appointment?
Patient: Going back to that rushing, if I don’t
catch my provider—I still have trust in what we
did, and I got everything asked that was on the
top of my head—but I would have liked a little
more time.
Interviewer: What makes you trust your provider?
Patient: I think my provider has a lot of practical
knowledge.
Patient 3576—Secure attachment style
Interviewer: What makes you have trust in your
provider?
Patient: My provider demonstrates knowledge in
current research or at least stuff that seems like it
is current because she says ‘‘I was reading this’’—
it’s just that knowledge base she has.
Patient 3629—Secure attachment style
Interviewer: Is an ongoing relationship with your
provider over time important for you?
Patient: I think it is. My experience has been that
frequently doctors become so busy that they
really don’t remember patients themselves per-
sonally so they need to look at their charts, which
is only appropriate.
Patient 3620—Secure attachment style
Patient perceptions of a power differential between
health care providers and patients
Perceptions in patients with dismissing and fearful
attachment styles: A ‘‘wall’’ between patient and
provider
Patients often perceived providers and the health
care system negatively. Patients with fearful or
dismissing attachment style often described a
barrier between providers (particularly physicians)
and patients. They used metaphors such as ‘‘wall’’
or ‘‘line,’’ or described attitudes or perceived body
language to characterize this divide. Often, char-
acteristics of the health care setting (e.g. rushed
environment) were viewed as contributing to their
negative experience.
Sometimes you feel like there’s this line—you’re
the patient, they’re the provider and you can’t
cross over—They have this attitude. You’re
sitting there waiting in the waiting room and
they’re late to begin with and there’s nothing else
to do. And finally they come in and they’ve got
just this whole air about them that you’re
imposing on them almost because they’re behind
schedule and ‘‘Get it over with, I’ve got better
things to do’’, is how it comes across. You’re
almost afraid to speak up and say, you know,
‘‘I’ve got these questionsy’’.
Patient 3752—Fearful attachment style
In this last passage describing a clinical encounter
in a patient with fearful attachment style, themes
of perceived harshness and rejection arise. In
contrast, in the following passage from a patient
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with dismissing attachment style, a theme of being
controlled is apparent.
It’s like asking the difference between, ‘‘Have a
seat and tell me what you need or what I can do
to help you’’ and ‘‘Sit down and let’s find out
what’s wrong with you and I’ll tell you how to
get better or not’’. The ‘‘doc thing’’ to me is a
body language that says ‘‘I have the information
you need and if you follow and take this
information you’re going to get well. I’m the
doctor, you’re the patient, I have the answers
that you need and that’s the end’’.
Patient 1979—Dismissing attachment style
If a point would come in holding on to that
‘‘power doc’’ thing that some people do then I’d
be gone.
Patient 1371—Fearful attachment style
My health care provider always goes on about
how wonderfully I’m doing. I am reminded that
my provider sees people who are much, much
worse off than I am. Those people are not
relevant to me at the moment when I am sitting
in the room during my appointment!
Patient 2478—Fearful attachment style
Perceptions in patients with secure attachment style
Patients with predominantly secure attachment
style also acknowledged shortcomings of the health
care system and providers’ behavior. However, such
negative attributes did not appear to significantly
diminish trust or threaten the treatment relation-
ship.
Dr. Y is very intense, and if I’m not thinking fast
enough, is out the door before I can get every-
thing out that I might want to ask. Today, I felt
like the appointment ended before I was ready
for it to end. Sometimes I feel rushed and that my
doctor doesn’t take as much time with me as I’d
like, focusing on one thing and ignoring other
things yit is kind of frustrating for mey but it
is not a major thing.
Patient 3576—Secure attachment style
Overcoming lack of trust in the clinical setting
Patient-centered actions by providers
The attitude, clinical approach or behaviors of
providers can potentially enhance the capacity for
patients with dismissing or fearful attachment style
to trust or engage in the health care relationship.
When patients perceived that providers tried to get
to know them or that they were accepted with a
nonjudgmental attitude, they were more satisfied
and reported being more likely to engage in the
patient–provider relationship.
He doesn’t just come in, do your treatment and
leave. He kind of talks, you know, ‘‘How things
going? Tell me about yourself’’, and he has a
fabulous memory. He remembers about those
things that you tell himy I don’t know if it’s just
a really good memory, or he puts notes in the
chart, or whatever, but it’s just yyhe makes you
feel comfortable coming iny With my doctor
who I have now, I feel like I can be my weird,
twisted self and my doctor understands that.
Patient 3752—Fearful attachment style
Uh, Dr. Z, I don’t know too well yet. But I feel
comfortable in the fact that if I come with a
question, no matter what it might be, I can ask.
Patient 1743—Fearful attachment style
The benefits of a relationship built on trust—
particularly where the patient feels empowered
about diabetes self-care—can be significant.
But somehow the way she approaches her
practice of working with diabeticsyat least for
me, she has been able to communicate a sense of
‘‘I am bigger than this disease’’ and that together
as a team this can be managed. And it’s not
something that is so big and so powerful.
Patient 1371—Fearful attachment style
She finds something good no matter what.
There’s not much when you get a bad report.
She always finds some good in there. She works
on the positive and I like that instead of always
the negative, you know, like a lot of doctors do.
Patient 1156—Fearful attachment style
When providers were perceived as nonjudgmen-
tal, patients felt more comfortable acknowledging
when they had inadequate insurance coverage for
components of their treatment and were more able
to negotiate around their treatment plan.
And I feel comfortable saying I don’t have good
coverage for a specific treatmenty ‘‘Can we
consider something else?’’yWhereas with the
other doctor, I never would have thought about
it, because he would be, ‘‘This is what I ordered
and that’s what you’re going to be on.’’
Patient 3752—Fearful attachment style
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Even small patient-centered acts by providers
such as acknowledging being late and that the
patient has been left waiting can be experienced as
validating in patients with difficulty trusting others.
And you can’t control it obviously, but he was
very good and you know, if he was running late
he would pop his head in and ‘‘OK, I’ll be in in
10 min’’ or whatever. And get you noticed. So at
least you knew what was going on. You’re not
just sitting there, wondering.
Patient 3752—Fearful attachment style
Patients with difficulty trusting others reported
relying on body language as a way of gauging
safety in the health care relationship. Certain
examples of body language were seen as powerful
means of enhancing the quality of the health care
relationship.
Interviewer: You say you like face-to-face
visitsyWhat do you like about them?
Patient: Because I can read what the doctor is
thinking in his eyes.
Patient 2069—Dismissing attachment style
Of course, when she is sitting on the step that
pulls out on the bottom of examination table,
you can’t help to think of her as a person. Cause
she’s kind of sitting down there. And that’s
important. You know body language is really
important. She pulled that thing out, sat down.
This is two times in a row!
Patient 1371—Fearful attachment style
And the nonverbal communication: The sound
of his voice, the pitch of his body, the way he tries
to maintain his schedule, what he has to say and
how he says it when he can’t—just being human.
Someone that is just open—if you meet them
they’ll shake your hand and say hello and look at
you, you know, and take a little bit of time to see
what you’re about before they just look at your
chart and say—and judge, and just put you in
this block—‘‘Okay, you’re this’’ and not talk to
you or get your point of view about it.
Patient 1979—Dismissing attachment style
Tolerating the health care relationship: playing
games and roles
Patients with low levels of trust, particularly
patients with fearful attachment style, were often
reluctant to change providers who they did not
perceive as ideal or they played a ‘‘role’’ or a
‘‘game’’ they thought would allow them to stay in
the relationship and ultimately get what they
needed.
And what I don’t want to do is have to look for
somebody else. I hate doing that. It’s like dating
almost. I mean, I don’t want to go there. And so
I guess I’m willing to sacrifice the ‘‘Dr. Welby’’
mentality for the stress I’d have to go through to
find somebody else.
Patient 1610—Fearful attachment style
Interviewer: So, what if you don’t play the role
of the ‘‘good patient’’, what do you fear the
consequence might be?
Patient: Well, I think that they cut down the time
that they spend with you. And I felt that when I
disagreed about how to deal with my medical
situation: my provider absolutely withdrew and I
would have less time in the office.
Patient 1852—Fearful attachment style
This so-called game I have figured outy..I think
it’s particularly prevalent and obvious in the case
of specialists. But I find it with my general
practitioner as well. So over the years I’ve figured
this out and my task as a patient is to go along
with whatever protocols are set. But at the same
time, be assertive enough to get what I think I
need. Meaning, I have to play by the rules of this
game that I think I’ve figured out. But at the
same time remind the caregiver continuously that
I’m not just a statistic.
Patient 2478—Fearful attachment style
These last passages again point to the difficulty
that patients with fearful attachment style have with
rejection and the extent to which they may go to
avoid having to start again once relationships are
established.
Discussion
As has been previously reported in a large
American Hospital Association survey of 37,000
patients across the US, it is highly instructive and
revealing to see the health care system ‘‘through the
patient’s eyes’’ (1997). The prevailing health care
system was described as a ‘‘nightmare to navigate’’
and was characterized as complex, cold and
impersonal with fragmented information- or deci-
sion-sharing, and a perception that the system
blocked access, reduced quality and limited spend-
ing for care at expense of patients. The influential
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3075
Institute of Medicine Crossing the Quality Chasm
report several years later acknowledged positive
changes had occurred to rectify some of these issues,
but that many of these perceptions were still well-
founded (2001). Such reports have served as
important focal and anchor points from which to
improve the experience of health care from the
patient’s perspective.
In the current study, we gained valuable insight
into patients’ past and current experiences with
diabetes-related health care while taking into
account their cognitive-emotional schemas related
to trust based on attachment theory. Patients with
dismissing and fearful attachment style may be like
‘‘canaries in the coalmine’’ who more acutely see
and feel the inherent problems with chronic illness
care in the prevailing health care system. On the
other hand, having secure attachment style may
mitigate against experiencing the frustrations of the
health care experience as a reason to change
providers or quit the system.
We found that most patients in our sample
perceived the health care system as rushed, im-
personal and fragmented, regardless of their attach-
ment style. Patients with dismissing and fearful
attachment styles (negative model of other) also
reported perceiving a distinct division, or power
differential, between providers and patients that
threatened their ability to engage in the health care
system. Patients with fearful attachment style were
highly attuned to indications of rejection and
patients with dismissing attachment style were
highly sensitive to being controlled. While these
patients could identify provider behaviors or system
characteristics that jeopardized their relationship
with the health care system, they could also describe
behavioral and health care system attributes they
felt mitigated against health care system fragmenta-
tion and that potentially facilitated engagement
within the health care relationship. Many patients
with fearful attachment styles also learned that
changing providers took an emotional toll and
learned instead to play ‘‘games’’ or ‘‘roles’’ such as
‘‘the good patient’’ as a way of tolerating a
potentially difficult health care interaction (
),
which is consistent with descriptions of individuals
with fearful attachment style in the literature.
In a recent large epidemiological study of over
4000 primary care patients with diabetes (
) and in the initial
screening component of this study, 48–49% of
patients had dismissing or fearful attachment style.
From a population-based and public health per-
spective, there are many opportunities for interac-
tions between patients who have difficulty trusting
others and a health care system that is often
fragmented, impersonal, and often felt by patients
to recapitulate earlier, sometimes emotionally pain-
ful experiences. Given characteristics of the current
health care system, clinicians are left with the main
responsibility to recognize when patients have
difficulty collaborating in the health care setting
and to change their own behaviors and attitudes in
order to facilitate and nurture trust, particularly
with patients who are characteristically less trusting.
There may be limitations however, in how
accurately providers can assess who is at risk for
difficulty with collaboration since patients, when
asked about satisfaction with providers or their
health care, typically soften any criticism because
of social desirability biases. Furthermore, patients
who attempt to truthfully answer questions in a
clinical setting such as ‘‘What degree of contact do
you prefer with your provider?’’ or ‘‘Why do you
delay seeking care for your condition?’’ may have
difficulty responding because of shame, social
ARTICLE IN PRESS
Prevailing
health care system:
• Characterized by
fragmentation
Health care
provider:
• ± patient-centered
• ± potential power
differential
Patient
attachment style
and
capacity to trust
Patient health
care utilization
patterns:
• Engagement
• Reluctance to seek
care
• Leaving care
• Frequently changing
providers
• Playing a “role” or
“game” to tolerate
care
Fig. 2. Diagrammatic summary of findings.
P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
3076
desirability or because they truly do not know. By
using an indirect approach to assess patients’ trust
and ability to rely on others in the health care
setting (i.e. by asking about past and current
relationships in general and not specific to the
health care setting), we were able to avoid some of
these limitations and potentially derive better
determinants of satisfaction and health care beha-
viors than might be derived through direct ques-
tioning. This is a significant advantage of using
attachment theory-based questionnaires and is
consistent with recent health services (
) and customer service (
;
) literature that recognizes that
indirect methodologies that tap underlying cognitive
and emotional schemas may have benefits over
direct assessment, and may even be essential to
understanding and working with ‘‘irrational’’ or less
understood patient behaviors (
). As
clinicians better understand patients and their inner
emotional world, patient behaviors are experienced
as less and less ‘‘irrational’’.
Prior studies have found that patients with
dismissing and fearful attachment style had fewer
social supports, more adverse childhood experiences
(e.g. loss, neglect, abuse), and were more dissatisfied
with their providers and health care systems than
patients with secure attachment style (
;
). For such
patients, the health care system can impose signifi-
cant distress and a sense of invalidation. For patients
with difficulty interacting or trusting others at times
of need, interpersonal validation and a sense of safety
must be attained before adequate treatment adher-
ence, optimal health care utilization patterns and
effective disease self-management can be expected.
However, patients less satisfied with providers or the
health care system, who miss appointments or who
are less adherent with self-care regimens may be
perceived as ‘‘difficult patients’’ (
).
While such designations are often made in earnest in
order to improve clinical responses (
), these labels may absolve a health care system
of the need to consider whether it offers an adequate
range of responses to patients with varying inter-
personal preferences.
In our study, many patients cited the power
differential between patient and provider as a
significant deterrent to forming a collaborative
health care relationship. Literature on health service
excellence suggests that acutely ill, ‘‘horizontal’’ (i.e.
bed-ridden) patients may traditionally anticipate
that the primary locus of power and control in the
health care relationship lies in the provider (
Mayer &
). On the other hand, when patients are
less acutely ill—assuming a more ‘‘vertical’’ posi-
tion—they may expect to be treated like customers
where power and control in the relationship is
shared. It is instructive to review what business
literature has long identified as the most important
elements of exemplary customer service resulting in
customer satisfaction and loyalty to a service,
product or company (
): empowerment
of customers, provision of choice, clear communica-
tion, customer relevant education and information,
continuous access, multiple modes of access, capa-
city to receive a timely response, product/service
expertise, attentive listening to customers, and
development of a shared action plan.
Key components of recent chronic care models
(
;
)—where patients are educated about
their condition(s), activated and share in decision
making, are provided a choice in treatment, and set
goals to work on—are almost identical to the valued
elements that have been cornerstones in customer
service for decades. Given greater dissatisfaction
with health care among patients who live in a world
where they can expect and demand tailored,
customer service in their daily pursuit of other
services and products, it is not surprising, perhaps,
that medicine is finally starting to shift toward a
customer service model.
In their article on health service excellence,
recommend that clinicians make a
customer service diagnosis in addition to a clinical
diagnosis when assessing a patient. That is, clin-
icians should ask if they are meeting the unique
needs of a patient in a caring, competent, compas-
sionate and skillful way. A primary step in
delivering tailored, attuned customer service (i.e.
patient-centered care) to patients with chronic
illness may necessarily include recognizing and
conceptually understanding characteristics of a
patient’s attachment style especially with patients
less inclined to collaborate with the health care
system. By analogy, depression treatment in pri-
mary care did not improve significantly until sound
methods of recognizing and understanding the
needs of depressed patients were well delineated
(
). Once patients with problems trusting
health care providers are identified through clinical
assessment using measures of attachment style,
changes in the health care system to address
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3077
patients’ unique needs can take place. In addition
to provider education about attachment styles,
effective interventions may make use of ancillary
providers who either facilitate interactions between
providers and patients or who actually take on a
significant care management role in helping patients
with their interpersonal patterns and fears and
in getting their emotional needs met clinically.
Such approaches would likely be well received by
providers and health care systems, but perhaps most
by patients with difficulty trusting who currently
have to resort to repeatedly changing providers,
‘‘playing games’’ or choosing not to seek medical
care when they most need it.
There are several limitations in this study.
Based on prior observational studies that did not
consistently demonstrate an association between
preoccupied attachment style and diabetes self-
care behaviors and outcomes, we did not include
patients with this style in the current study. Future
qualitative studies with similar or larger sample sizes
might benefit from inclusion of patients with
preoccupied attachment style since this style is
characterized by high medical utilization, often for
medically unexplained physical symptoms (
nowski, Walker, Katon, & Russo, 2002
). Another
potential limitation is our use of a self-report
measure that has only single-item responses. Future
studies might benefit from the use of one of a
number of other attachment style questionnaires
(
Stein, Jacobs, Ferguson, Allen, & Fonagy, 1998
)
some of which may have stronger reliability and
validity. Future qualitative studies may also benefit
from use of interview assessments of attachment
categories such as the Adult Attachment Interview
(
Acknowledgements
The authors would also like to thank Lorna
Rhodes, Ph.D. for her input in the design and
interpretation of the results of this study. The
authors would also like to acknowledge the support
of Ms. Natalie Brown who served as a research
assistant on this study.
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Document Outline
- The interpersonal experience of health care through the eyes of patients with diabetes
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