Project and content management for Contemporary Authors volumes
WORK TITLE: Love, Fear, and Health
WORK NOTES: with Jonathan Hunter
PSEUDONYM(S):
BIRTHDATE:
WEBSITE: http://www.maunderings.ca/
CITY: Toronto
STATE: ON
COUNTRY: Canada
NATIONALITY:
http://www.maunderings.ca/?page_id=82 * http://www.psychiatry.utoronto.ca/people/dr-robert-g-maunder/ * http://www.lunenfeld.ca/researchers/maunder *
RESEARCHER NOTES:
PERSONAL
Male.
EDUCATION:University of Toronto, M.D., 1984.
ADDRESS
CAREER
Physician, psychiatrist, educator, writer, and editor. University of Toronto, Toronto, Ontario, Canada, professor of psychiatry and member of the Institute of Medical Science; Mount Sinai Hospital, Toronto, Ontario, Canada, head of research for the Department of Psychiatry.
AWARDS:
Recipient of research grants, including grants from the Canadian Institutes of Health Research, the Heart and Stroke Foundation (Ontario), the Crohn’s and Colitis Foundation of Canada, and the Collaborative Mental Healthcare Network of the Ontario College of Family Physicians.
WRITINGS
Contributor to professional journals. Serves on the editorial board of General Hospital Psychiatry.
SIDELIGHTS
Robert Maunder is a psychiatrist and professor of psychiatry whose research focuses on stress, resilience, and the interpersonal determinants of health. He served as the lead researcher and author on a series of papers documenting the impact of childhood adversity and of extraordinary workplace stress, from SARS to critical incidents, on health care workers. In his clinical work, Maunder deals with the psychiatric aspects of living with inflammatory bowel disease, hepatitis C, and other serious chronic illnesses.
A contributor to professional journals, Maunder is also coeditor with Paula Ravitz of Psychotherapy Essentials to Go: Achieving Psychotherapy Effectiveness and coauthor with fellow psychiatrist Jonathan Hunter of Improving Patient Treatment with Attachment Theory: A Guide for Primary Care Practitioners and Specialists. Maunder and Hunter are also coauthors of Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care. The book provides a clinically focused discussion of how human attachment issues influence an individual’s disease risk and health. It also examines the interactions patients have with their health care providers and how these interactions can affect outcomes. “This is an excellent introduction to a way of understanding problematic interactions in healthcare, providing a clear map and approach for clinicians,” wrote Barry Gilbert in a review for the Faculty of Medicine, University of Toronto Web site.
Divided into three sections, Love, Fear, and Health begins with a look at health and health care in relation to attachment. Maunder and Hunter explain the psychological aspects of attachment, noting attachment is what helps make people feel safe and secure. In introducing attachment theory, they note that the theory focuses on normal people as opposed to being a theory in the realm of abnormal psychology. The section includes a closer look at exactly what health care is and features a chapter examining the human biological response to stress.
The second part of Love, Fear, and Health delves deeper into attachment theory and the research that underlies the theory. It further explores exactly what attachment is, how attachment helps shape the brain, and attachment’s relationship to health issues from depression to obesity and alcoholism. The section ends with a look at problems within the patient-health provider relationship.
The book’s final section examines health care that is informed by a better understanding of attachment theory. Maunder and Hunter discuss how health care providers can adapt when faced with patients who have attachment anxiety, attachment avoidance, or fearful attachment issues. The overall focus is on how to meet the needs of patients with various attachment issues. The final chapter takes a wider perspective on attachment and health and the importance of having patients feel secure and safe at times of high stress in order to bolster better outcomes. The book includes thirty pages of notes and an extensive bibliography.
Love, Fear, and Health “is an excellent contribution to the literature on human attachment as it relates to health issues,” wrote M.C. Matteis in Choice: Current Reviews for Academic Libraries. Literary Review of Canada Online contributor Keith Oatley remarked: “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.”
BIOCRIT
PERIODICALS
Choice: Current Reviews for Academic Libraries, June, 2016, M.C. Matteis, review of Love, Fear, and Health: How Our Attachments to Others Shape Health and Health Care, p. 1501.
ONLINE
Department of Psychiatry, University of Toronto Web site, http://www.psychiatry.utoronto.ca/ (June 2, 2017), author faculty profile.
Faculty of Medicine, University of Toronto Web site, http://medicine.utoronto.ca/ (December 22, 2015), Barry Gilbert, “How Attachment Patterns Affect Care: A Review of Love, Fear and Health.”
Literary Review of Canada Online, http://reviewcanada.ca/ (May 10, 2017), Keith Oatley, review of Love, Fear and Health.
Robert Maunder and Jon Hunter Website, http://www.maunderings.ca (June 2, 2017).
Robert Maunder has been a psychiatrist at Mount Sinai Hospital in Toronto for over 20 years and is a professor of psychiatry at the University of Toronto. His research and medical practice is focused on the areas where psychological and social aspects of life overlap with health and serious diseases - which it turns out is most of medicine!
Jon Hunter is Associate Professor in the Department of Psychiatry at the University of Toronto, where he heads the Division of Consultation-Liaison Psychiatry. CL Psychiatry addresses the psychiatric needs of medically and surgically ill patients. He is also the Head of Psychosocial Services in the Marvelle Koffler Breast Centre at Mount Sinai Hospital, Toronto. He is a founding member of the Collaborative Mental Healthcare Network of the Ontario College of Family Physicians, which links family practitioners in the community with mental health care mentors for advice about managing psychiatric concerns in a timely fashion. He participates in grants funded by NCIC, the National Institutes of Health, the Canadian Institutes of Health Research, and the Change Foundation, and is an award-winning clinical teacher.
Dr. Hunter’s clinical practice centers on the psychiatric and psychotherapeutic care of cancer patients. Research interests include psychological management of chemotherapy side-effects, group psychotherapy in women at high risk for breast cancer, the role of early life experience and attachment in adaptation to disease, and the importance of mentalizing in treatment.
Reach him: jon.hunter@sinaihealthsystem.ca
UofT Psychiatry Robert Maunder Lecture 09182014 - Web-32 (2)
Bob Maunder is Professor in the Department of Psychiatry at the University of Toronto and Head of Research for the Department of Psychiatry at Mount Sinai Hospital, Toronto. He is a member of the Institute of Medical Science at the University of Toronto and serves on the editorial board of General Hospital Psychiatry. Dr. Maunder’s research has been funded by the Canadian Institutes of Health Research, the Heart and Stroke Foundation (Ontario), the Crohn’s and Colitis Foundation of Canada and the Collaborative Mental Healthcare Network of the Ontario College of Family Physicians. His research is focused on stress, resilience and the interpersonal determinants of health. He was the lead researcher and author on a series of papers documenting the impact of childhood adversity and of extraordinary workplace stress, from SARS to critical incidents, on healthcare workers.
Dr. Maunder’s clinical work concerns psychiatric aspects of living with inflammatory bowel disease, hepatitis C and other chronic illnesses.
Reach him: robert.maunder@sinaihealthsytem.ca
Dr. Robert Maunder
Full Professor
Division One: Consultation/Liaison Psychiatry
Division Two: Adult Psychiatry and Health Systems
Contact Information
Address:
Mount Sinai Hospital
600 University Avenue
Toronto, ON M5G 1X5
Room: Ste. 915
Telephone:
416-586-4800 x3200
E-Mail:
robert.maunder@sinaihealthsystem.ca
Profile
Robert Maunder is the Head of Research in Mount Sinai Hospital’s Department of Psychiatry and provides psychiatric care for persons with serious medical illness. His research collaboration explores psychosocial aspects of health and disease. There are links to teaching videos on attachment and health (made by Bob Maunder and Jon Hunter) below.
Research Interests
Dr. Maunder has been the principal investigator of studies investigating the impact of close interpersonal relationships (attachment relationships) on stress and on the course of medical illness in ulcerative colitis and heart failure.
He has also done extensive research on stress and resilience in healthcare workers. This has included studying the long-term impact of working during the SARS outbreak on hospital workers and the impact of critical incidents on paramedics.
His research has been supported by the Canadian Insitutes of Health, the Heart and Stroke Foundation, the Crohn's and Colitis Foundation of Canada and other agencies.
OTHER LINKS:
YouTube
Intro Into Adult Attachment
How to Manage Anxiety
Symptoms, healthcare utilization and worry
How We Get to Be This Way (part 1)
How We Get to Be This Way (part 2)
Health Happens Between Us: A Rant
Other Links
http://www.attachmentandhealth.com/
Dr. Robert G. Maunder
SENIOR CLINICIAN SCIENTIST
Can the way in which we relate to others seriously affect our health? Can understanding those attachments help health care providers treat us better? Dr. Robert Maunder, in collaboration with Dr. Jonathan Hunter, studies how interpersonal interactions influence health, through the lens of attachment theory.
Drs. Maunder and Hunter first published a model describing the paths by which insecurity in close relationships contributes to disease and illness in Psychosomatic Medicine in 2001. These paths include the influence of relationships on stress physiology and immune regulation; on behaviours that increase health risk, like smoking and unhealthy eating; on the ability to benefit from others’ support, and on interactions between patients and health care providers.
Their subsequent research has tested the predictions of this model. For example, with respect to patient-provider interactions, this work has demonstrated that attachment insecurity markedly increases the likelihood of difficult, dissatisfying interactions in high-stakes medical interactions, such as visits to the emergency department.
A new research instrument has been developed allowing research which supports the idea that under some circumstances patients “become attached” to their health care providers such that the quality of medical interactions may be driven as much by a patient’s need to feel more secure, as by efforts to investigate diagnose and treat disease.
With respect to physiology, this research has demonstrated that certain patterns of interpersonal attachment are associated with lower activity in the parasympathetic nervous system (our body’s “brake” on fight-or-flight reactions to threats).
In 2015, Drs. Maunder and Hunter integrated the growing literature in this area from the fields of neuroscience, stress physiology, social psychology, and evolutionary biology into a book to introduce these ideas and their implications to health care providers: Love, Fear and Health: How Our Attachments to Others Shape Health and Health Care (University of Toronto Press).
Dr. Maunder received an MD from the University of Toronto in 1984. He is a Professor in the Department of Psychiatry at the University of Toronto and the Head of Research in the Department of Psychiatry at Mount Sinai Hospital.
Maunder, Robert: Love, fear, and health: how our attachments to others shape health and health care
M.C. Matteis
53.10 (June 2016): p1501.
Copyright: COPYRIGHT 2016 American Library Association CHOICE
http://www.ala.org/acrl/choice/about
Maunder, Robert. Love, fear, and health: how our attachments to others shape health and health care, by Robert Maunder and Jonathan Hunter. Toronto, 2015. 332p bibl index afp ISBN 9781442617510 cloth, $75.00; ISBN 9781442615601 pbk, $30.95; ISBN 9781442668409 ebook, $30.95
(cc) 53-4396
RC455
Can. CIP
This book is an excellent contribution to the literature on human attachment as it relates to health issues. Psychiatrists Maunder and Hunter (both, Univ. of Toronto) synthesize a vast amount of theoretical information on biology, evolutionary psychology, development, interpersonal relationships, and attachment, and present it in a very readable fashion. Case studies of people grappling with attachment issues help to make the work come alive. Using this method, the authors clearly elucidate how for some individuals, the stress of illness, loss, and other life events can cause an imbalance in an already challenged attachment style. Importantly, the authors focus on the need for a humanistic health care system, on micro and macro levels. They provide needed guidance on how health care professionals can and should respond in a humanistic manner to help patients with compromised attachment styles; they also address the importance of comfortable treatment settings. The well-organized book includes 30 pages of notes and a 36-page bibliography, which will be a useful resource for students and professionals. Summing Up: *** Highly recommended. Lower-division undergraduates through professionals/practitioners in the health sciences.--M. C. Matteis, Regis College
Source Citation (MLA 8th Edition)
Matteis, M.C. "Maunder, Robert: Love, fear, and health: how our attachments to others shape health and health care." CHOICE: Current Reviews for Academic Libraries, June 2016, p. 1501. General OneFile, go.galegroup.com/ps/i.do?p=ITOF&sw=w&u=schlager&v=2.1&id=GALE%7CA454942807&it=r&asid=b5cc2f6febd21ee7b809a992da1dd716. Accessed 10 May 2017.
Gale Document Number: GALE|A454942807
The Care in Health Care
The love experienced in infancy affects us far later in the medical system.
Keith Oatley
Love, Fear and Health: How Our Attachments to Others Shape Health and Health Care
Robert Maunder and Jonathan Hunter
University of Toronto Press
332 pages, softcover
ISBN 9781442615601
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LRCv24n3 April 2016 cover RGB
April 2016
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.
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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.
Relationships between providers and patients can work better when providers know about potential attachment problems in patients.
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.
Book Reviews — Winter 2015
The Theft of MemoryMemories Lost and Found:
A Son Documents His Neurologist-Father’s Descent into Alzheimer’s
By Professor Edward Shorter
Jonathan Kozol’s engaging memoir of the growing cognitive decline and death of his father, the distinguished Boston neurologist Harry Kozol, is one of many catastrophic tales of Alzheimer’s lining bookstore shelves.
Why would you want to read this one?
For one thing, this book is full of surprising developments. After almost four years in a nursing facility, the father goes home! He had kept asking to go home, and people brushed the request aside, convinced that when you check into a nursing home, you never check out again. But the father returns to live in the family’s grand apartment in the Boston area, where the mother herself has fallen ill and requires round-the-clock care. Everybody is much happier. So this kind of return home is not just the reflexive wish of a dementing mind; it’s possible.
For another thing, the father, as a staff neurologist at the Massachusetts General Hospital, had a very interesting life. He was involved in the affairs of playwright Eugene O’Neil, and the son brings out this story using his father’s records. Ditto Patty Hearst, the heiress who joined a band of radicals, and for whom Harry Kozol is summoned as an outside expert.
Jonathan Kozol essentially becomes his father’s biographer. He intercuts tales of the past — namechecking some of the world’s most distinguished doctors, such as psychiatrists Adolph Meyer and Manfred Bleuler — with more recent discussions at his father’s bedside. As the father loses memories, the son revives them.
Finally, it’s interesting to see what a difference a little bit of money (actually a lot) can make in end-of-life nursing experiences. A good deal of the book is about the various private nurses who are summoned to the father’s and the mother’s bedsides: two for the father in the nursing home, and a special bedroom at home for the mother’s caregivers. It’s clear how a couple million dollars can make gentler the passage into that good night.
—
Jonathan Kozol: Losing My Father, One Day at a Time (Toronto: McClelland and Stewart/Penguin Random House, 2015), 302pp
Edward Shorter is the Jason A. Hannah Professor of the History of Medicine in the Faculty of Medicine of the University of Toronto and Professor of Psychiatry. He co-authored Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.
Love, Fear and Health — Book CoverHow Attachment Patterns Affect Care: A Review of Love, Fear and Health
By Barry Gilbert MD FRCPC
This is an excellent introduction to a way of understanding problematic interactions in healthcare, providing a clear map and approach for clinicians. Authors Robert Maunder and Jonathan Hunter are both psychiatrists and faculty members at the University of Toronto whose careers have been spent working with patients who are medically ill. They draw from their extensive clinical experience to ground their approach in real-life encounters.
William Osler said that, “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The authors provide a way of understanding people using attachment theory that has wide application in health care, in health and in life. The book is divided into 3 sections: First, a review of health and health care in the light of attachment; second, a detailed explanation of attachment and the vast body of research underlying it; and, third, a look at relational healthcare, or healthcare informed by an understanding of attachment.
Attachment, in short, is what we need to do in order to feel secure and safe. Attachment theory is about normal people; it is not a theory of abnormal psychology. Most of the time, in the routine of daily life, it is invisible, but in stressful or threatening situations, such as being ill and requiring care, it becomes activated and much more apparent. The authors note: “Illness makes relationships matter more than normal.”
The first third of the book provides some interesting and familiar observations: unexplained symptoms take up a great deal of time in primary care, and in one study, 70% of clinical time was taken up by 13% of the patients, and these patients tended to have problematic relations with their healthcare providers (at least from the providers’ perspective). Primary care practices are full of people with multiple, unexplained symptoms; many Emergency Room visits are from people struggling with addictions. Healthcare providers often find that encounters with high users are difficult, suggesting, say the authors, that part of the problem is relational. At the opposite end of the spectrum are patients whose needs to be self-reliant are so strong that they discount symptoms, delay seeking care and have more difficulty managing chronic diseases like diabetes.
The chapter “Why Else Do We get Sick?” shows that the biology of one’s response to stress is linked to early relational experiences which become consolidated into durable attachment patterns of relating, affect regulation and behaviour. The brain is hierarchical: we have many automated patterns of thinking and feeling, such as our quick, unthinking responses to gestures or tone of voice. These unconscious patterns can be disrupted by conscious thought , but more slowly, and only with persistent effort. This is why a person watching his weight can inhibit his desire to eat cookies all day, but then lapse into old patterns of eating late at night, when he’s tired or in need of comfort. The need to feel secure is much stronger than we think and is one of the reasons it is so difficult to change maladaptive (from one perspective) health behaviours, such as smoking or overeating, when they are highly associated with maintaining a deep feeling of security. The authors cite research showing that people who have high Adverse Childhood Experiences Scores (e.g. abuse, neglect, exposure to violence) have more health problems.
In the second section, the authors give a detailed account of attachment, grounding it in biology and the evolutionary impact of prolonged dependency after birth. The attachment system, with behaviours like crying, clinging, and following, serves to keep the infant safely close to the adult. As the paediatrician and psychoanalyst Donald Winnicott observed: “There is no such thing as a baby; there is always a baby and someone.” Attachment begins and develops in the early relationship with the parent. Babies need to learn what is dangerous but also how to feel safe and secure. Most children have developed attachment patterns by the age of 12 months. The varied experiences a child can have growing up can have one of two outcomes in the adult: either a tendency towards secure attachment or towards what is called insecure attachment. Through the period of young adulthood, most people make a shift from their parents to peers, especially through romantic relationships, as their main source of feeling safe and secure.
To understand who your own attachment figures are, think of who you like to be with; think of a person you don’t like to be away from (such as when you travel); who you seek out for advice and will be with when you are feeling upset; and who provides a secure base for you, encouraging your growth and even creativity. The more functions a person meets, the stronger the attachment bond.
Attachment patterns are set early and appear to be quite stable throughout life. About 60% of adults have secure attachment patterns. The rest have insecure attachment, which divides into two main types: People with attachment (separation) anxiety become anxious and distressed when they feel too disconnected from people they feel safe with; people with attachment avoidance tend to feel smothered and uncomfortable with too much closeness. People with insecure attachment patterns have more trouble inhibiting maladaptive behaviour using “top down” thinking; they tend to have more difficulty “mentalizing”, or being able to imagine what other people might be experiencing (some recent psychotherapies teach mentalizing in hope that it will help people make more secure attachments).
The authors explain how the nature of the interaction with a patient can alert the clinician to different attachment styles. Remember that the stress of needing health care will bring out attachment behaviour — seeking a feeling of safety and security — from people. Attachment helps regulate feelings; if your relationships are calm and nurturing, you can find solace in hard times. But if your relationships are fraught with conflict, or you find it difficult to tolerate being too close to people, you may react by shutting down awareness of any emotional needs or diminishing them. Or you may turn to other sources of soothing, such as drugs, which can sometimes provide some of the same release of oxytocin — “the bonding hormone”- as closeness to an attachment figure can provide to a more securely attached person. Insecurely attached people have more trouble with powerful maladaptive responses and have more difficulty inhibiting them. An important issue for health care providers, the authors say, is that people with high attachment anxiety will often be heavy users of health care and will come to their provider looking for help to feel safe and secure; they are not primarily (at least to start) coming to identify a disease to be treated.
Authors Hunter and Maunder
One striking finding the authors describe at length is that the clinical narrative provided by a patient can be revealing pathognomonic of their attachment style. I found these descriptions accurately described my daily experience in different clinical settings. Securely attached people will give a coherent history with clear chronology and an appropriate amount of detail (they can mentalize and determine what the provider most needs to hear, and inhibit their anxiety enough to be coherent). In contrast, high attachment anxiety leads to a narrative that is disjointed, hard to follow and over inclusive of detail that confuses the listener. People with high attachment avoidance provide a narrative that is flat and remarkably devoid of detail, leaving the clinician with little information to go on. These narrative styles reflect difficulties with mentalizing the needs of the other and reflect fears/expectations of the other: that the clinician will abandon the patient if the tale is not dire enough (anxious attachment) or will be unresponsive regardless of what is said, hence little is provided or risked in the narrative (avoidant attachment).
The third section of this book is replete with clinical pearls, providing a systematic approach to meeting the different needs of people with different attachment styles in the clinical encounter. The emphasis is not on changing attachment styles — this is attempted through psychotherapy and the research on this is in its infancy — but on adapting to our patients’ different styles. While an anxiously attached patient will do best with a calm, active approach, with the care provider taking charge to a sufficient degree to allay anxiety, almost the opposite is needed for the avoidant patient, whose need for self-sufficiency must be recognized in the clinical relationship. The authors make clear that health care will be more healing and comprehensive when it takes account of what each patient needs to feel safe and secure at a time when stress brings out old established ways of seeking safety and security.
This book is well constructed, building on previous chapters as the evidence and more detail accumulates. It never strays far from its clinical roots; there is always an apt clinical example told with compassion and often humour. It is well grounded in evidence in much more comprehensive detail than I can convey here. The authors do well to compress and summarize a vast literature and make it into a fascinating story that moves from the individual to the health system at large. They end with some thoughts about how an understanding of attachment needs could inform the health systems we design in future — as understanding the attachment needs of children led to a revolution in hospital care , with parents being able to stay with their children throughout hospitalizations. There is much more we can do.
This book is written to appeal to a wide clinical audience, including physicians, nurses and other care providers. The understanding this book promotes could go far in improving the care all clinicians offer to their patients.