Attachment Theory and Poorly Performing Doctors

The attachment theory from the sixties of the previous century is still used e.g. in psychotherapy but also in research such as shown in a recent post on:How do social relationships function online. Is attachment theory also useful in medical education, does it explain the poor performance by some doctors? After all doctors are required to engage attachment relationships with their patients. It’s part of their job. In professional health care the relationship as caregiver is part of the working relationship.

This interesting question whether attachment theory is useful in medical education and poor performing doctors when under stress is discussed in a recent article and commentaries in Medical Education. The article is a review of published studies and texts about attachment theory and caregivers.

For a more extensive review of the different attachment styles read this post. In this article a distinction is made between positive and negative attachment styles. In normal populations, 58% of individuals are securely attached and 42% insecurely. Those with insecure attachment styles experience attachment past and present in a less positive way. They find attachment relationships stressful, they’re anxious and defensive about negative emotions. They either dismiss these negative emotions or are occupied with them leading to ambivalence between seeing the other as wonderful or dreadful.

The insecure group (42%) are divided into a dismissing group (23%), the members of which emphasise their independence from others and their invulnerability, and a preoccupied group (19%) representing people who are caught up in their attachment relationships, both past and present. Another subgroup (18%) includes people who appear to have unresolved emotions regarding traumatic experiences or bereavements.

What has this got to do with medical education and doctors?
Since 40% of the normal populations is insecure attached it seems reasonable that in medical education and practicing doctors a similar proportion is insecurely attached. This may be a vulnerability and lead to problems in periods of stress. Moreover, it’s not uncommon to think that some doctors might have chosen a medical career in order to ‘make good some early family unhappiness or illness’ which could also lead to insecure attachment. Unfortunately attachment styles and medical students or doctors hasn’t been studied. In a study in medical students 59% of the students rated themselves as securely attached, no news there. This comparable frequency with the normal population undermines the suggestion that more individuals with insecure attachment have chosen the medical study. Studies of doctors with mental health problems have revealed high levels of unhappy early childhood. There is also a link between insecure attachment and personality disorders, a condition also identified in doctors.

From this circumstantial evidence the author suggests that insecure attachment as sometimes useful in long and extensive period of exposure to stress may be less appropriate when working in a team or experiencing also more demands as caregivers at home may stretch the dismissing coping to the limit resulting in e.g. burn out.

Insecure attachment especially dismissing attachment styles may lead to reluctance in acknowledging that the doctor or med students is stressed and experiencing emotional problems. This might also lead to a reluctance in seeking help for themselves.

This dismissing attitude and lack of self reflection especially in med students could lead to a cynical detached attitude. It could encourage doctors to detach from human distress and it could “dehumanize” the patient as a way of coping.

Secure attachment is also important in the relationship between doctor and the students they supervise.

If they are hostile, rejecting or neglectful, trainee attachment to professional identity will be insecure or may (in insecure students) stir up unresolved attachment issues from childhood. This mechanism may go some way to explaining why poor relationships with consultants are described by some juniors as a key source of workplace stress.

In this article enough suggestions about how insecure attachment as vulnerability (not pathology) can lead to problems when experiencing stress are made. Further research is needed to gather information on the attachment problem in med students and doctors, is insecure attachment more prevalent in doctors with work stress and behavioral problems, how do secure and insecure attached students develop during medical education, what kind of interventions will help when insecure attachment leads to psychological problems?

Many questions for research I would think. What do you think about the concept of insecure attachment and psychological symptoms when under stress, and it’s implications for further research?
Adshead, G. (2010). Becoming a caregiver: attachment theory and poorly performing doctors Medical Education, 44 (2), 125-131 DOI: 10.1111/j.1365-2923.2009.03556.x