The Care in Health Care

It has long been recognized that mammals are born immature and need to be cared for by parents, but it was not until more recently that the psychological system was discovered that enabled the caregiving to take place. This system is attachment. It is especially developed in humans. It is the means by which infants stay closely connected with their mothers or other caregivers, and by which caregivers nurture and protect infants from harm. In adulthood, attachment is a basis of our long-lasting sexual relationships, of our parenting and of our closer friendships. Attachment is at the centre of Love, Fear and Health: How Our Attachments to Others Shape Health and Health Care by Robert Maunder and Jonathan Hunter, who are faculty members of the Department of Psychiatry at the University of Toronto and who work as psychiatrists at Mount Sinai Hospital. The book is about health, and about how care in the healthcare system is also related to attachment.

For several decades Maunder and Hunter have been doing research on health care, and they have translated their findings into programs of teaching and clinical work. In their book they extend this work, and make two striking proposals.

One proposal is that clinical care, as delivered by health delivery systems including the Canadian one, is based on relationships between providers and patients, and that these relationships can work better when providers know about potential attachment problems in those for whom they care.

A second proposal derives from demands on the health system made by some of its most habitual users. These users typically have chronic illnesses and, as Maunder and Hunter say, they are sometimes colloquially called “frequent flyers”; they use as much as 20 percent of all healthcare resources. This high use is based not only on genes and germs. Stress, for instance, contributes to a range of health problems and it occurs, perhaps, especially in this group. But also, say Maunder and Hunter, the frequent users of the system are “consistently characterized by two things: health care providers find interactions with them to be ‘difficult,’ and these patients are likely to have some form of mental illness, most often depression or anxiety.”

Maunder and Hunter explore how far the psychological issues of these difficult patients are relational and based on particular patterns of attachment.

Attachment between infants and their caregivers was discovered by John Bowlby and based on his work during World War Two with children who had become separated from their parents. The book that he published on this, Child Care and the Growth of Love, derived from a report he made to the World Health Organization on how development of people’s personalities was influenced by caregivers’ love in their early years. “Love,” of the kind about which Bowlby wrote, is the first word of Maunder and Hunter’s title. “Fear” is its second word; a principal function of attachment is protection from dangers that can induce fear.

Mary Ainsworth, who grew up in Canada and did research at the Institute of Child Study at the University of Toronto, moved to England and went to work with Bowlby. She conceived a test in which three different patterns of attachment were found to be common. In the test, an infant and caregiver would enter a room. Then a stranger would come in. Then the caregiver would leave, and later return. Entry of the stranger and the caregiver’s departure are fear-inducing. Maunder and Hunter illustrate one pattern as follows. When her mother returns after she has left the room, “‘Janice wants contact with her mother and runs to her with her arms open. She cries and her mother picks her up … It takes only a short time, a minute or less, for Janice to settle down’ … Janice is typical of kids with a secure pattern of attachment.”

In two other patterns children are insecure. One is like this: “‘When his mother comes back in the room, Theo looks like he might not have noticed. He ignores her at first and then offers a casual greeting, interrupted when he averts his eyes and then turns away’ … Theo’s attachment pattern is called avoidant.”

The other pattern is like this: “Astrid is easily distressed and hard to console. When her father leaves her alone, as he is instructed to do, she looks angry. When she is reunited with her father, she runs towards him crying … Her father scoops her up, but Astrid starts wriggling and looks away, all red in the face.” The authors of this book call Astrid’s pattern “resistant,” but the term used by Ainsworth and her colleagues—“ambivalent”—may be just as good.

Maunder and Hunter cite the important research of Everett Waters and his colleagues in which children’s attachment patterns were assessed at age one by the method devised by Ainsworth and her colleagues and by means of an interview 20 years later. For 72 percent of people in the study, their attachment pattern of childhood—secure versus insecure—continued into adulthood. Most of those who had a secure pattern in infancy felt secure in themselves and in relationships as adults. Those who were insecure as infants tended to feel unsafe with others in ways that continued from how they felt in infancy.

In addition to the three common patterns of attachment, for some people attachment has been damaged by the absence of a consistent caregiver in their early years, or by suffering cruelty, neglect or abuse. This is a separate group, on whom there has been a lot of research. Based on it, Maunder and Hunter make recommendations for improving child care and parenting. The authors’ main focus, however, is on patterns of insecure attachment in which people tend to feel unsafe in relationships and, in relation to others, often experience fear or its extended version, anxiety.

Anxiously insecure attachment (a version of the resistant or ambivalent pattern) is illustrated by Susan who visits a walk-in clinic with “a bloated sensation, nausea, and stomach pains.” She conveys her distress far more strongly than she conveys information about her symptoms. The doctor who sees her is confused by her incoherent narrative, and both she and Susan find the interaction unsatisfactory. The book’s authors offer a telling metaphor: it is as if a fire alarm has started up and cannot be turned off. Attention is on the alarm, rather than on whether there is a fire and, if there is a fire, on what to do about it.

Maunder and Hunter make suggestions about how to recognize patients with insecure patterns of attachment, and they offer detailed principles for interacting with them: for instance, arranging that avoidant patients can set times for appointments and control proceedings, giving extra time to resistant or ambivalent patients and concentrating on building alliances with them.

Overall, this book is an engaging one that healthcare workers of all kinds will find interesting, informative and helpful. The rest of us, who sometimes are patients, will also find this book worthwhile, and in reading it may even recognize issues in ourselves and in those we know.