Support Care Cancer (2015) 23:87–94 DOI 10.1007/s00520-014-2329-6
ORIGINAL ARTICLE
Caregivers’ attachment patterns and their interactions with cancer patients’ patterns Eleni Tsilika & Efi Parpa & Anna Zygogianni & Vassilios Kouloulias & Kyriaki Mystakidou
Received: 15 October 2013 / Accepted: 22 June 2014 / Published online: 3 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To provide a brief review of the empirical literature regarding the attachment style of the cancer patients’ caregivers as well as the link between attachment, caregiving, and care-receiving behaviors are defined. Methods An extensive systematic electronic review (Medline, PsycINFO, and Attachment Theory Website (ATW)) and subsequent examination of reference lists were carried out to retrieve published articles up to 2011, using attachment and cancer in combination with caregiver, spouse, dyad, and family as the key words. The titles, abstracts, or full articles, if necessary, were reviewed to determine whether the articles met the eligibility criteria. Results Eighty-seven studies have been identified, including research articles, books, and chapters in books. Conclusions The attachment style of a caregiver can influence how they respond to a patient’s needs. Studies have found that attachment anxiety or avoidance is more likely to interfere with effective and sensitive caregiving.
Keywords Attachment . Caregivers . Spouses . Cancer patients . Dyad . Family
E. Tsilika : E. Parpa : K. Mystakidou (*) Pain Relief and Palliative Care Unit, Department of Radiology, Areteion Hospital, School of Medicine, University of Athens, 27 Korinthias St., 115 26 Athens, Greece e-mail: [email protected]
Search strategy
E. Tsilika e-mail: [email protected] E. Parpa e-mail: [email protected] A. Zygogianni School of Medicine, Thessaly University, Volos, Greece e-mail: [email protected]
Introduction Despite medical advances, cancer not only affects the patients but also their family members. Often, friends or family members have to assume a caregiving role to a loved one with cancer for the duration of their treatment. Caregivers not only have to cope with the diagnosis and uncertainty of cancer but also have responsibilities [1–4]. The recent trend toward longer survival and toward ambulatory and home care has increased the number of informal family caregivers and may have amplified their burden [5, 6].
Methods
Identification of relevant studies began with systematic searches of the electronic databases (PubMed, PsycINFO, and Attachment Theory Website (ATW)) with the last search being up to 2011. The search terms used were attachment and cancer in combination with caregiver, spouse, dyad, and family. Searches were limited to studies published in the English language. Hand searching was completed according to the reference lists of all eligible studies to identify relevant studies. Selection strategy
V. Kouloulias Radiotherapy Unit, Department of Radiology, Attikon University Hospital, School of Medicine, Kapodistrian University of Athens, 1 Rimini St., Haidari, 12462 Athens, Greece e-mail: [email protected]
The title and abstract of each study were reviewed independently by two investigators to retrieve the full-text articles. Then, the investigators compared the papers and discrepancies
88
resolved by consensus. Inclusion criteria were as follows: (i) adult patients (≥18), (ii) a cancer diagnosis, and (iii) spouses were identified as caregivers. On the other hand, populations with comorbid dementia, studies using solely qualitative methods, reviews, commentaries, case reports, systematic reviews and meta-analyses were excluded. Ethical approval has been obtained for the study where required.
Results We identified 8,126 titles from MEDLINE, PsyINFO, and ATW. Eight thousand thirty-nine titles were excluded after reviewing and applying the inclusion criteria. Hence, 87 titles (articles and books) were eligible for systematic review. The flowchart is shown in Fig. 1. Attachment background John Bowlby [7–11] proposed that attachment bonds involve two behavioral systems, an attachment system and a caregiving system. Individuals come into the world equipped with an attachment behavioral system that can be activated when in distress and serves a major evolutionary function of protection and survival [7, 12]. Although there are normative developmental changes in the expression of the attachment system across the life span, the basic function of the attachment system remains constant [13]. Adults and children benefit from having someone looking out for them and who is available to help if needed. Intimate relationships play a critical role in promoting health and well-being in adulthood, while relationship disruption is associated with a wide range of adverse health outcomes. In addition, the attachment theory argues that the caregiving system is another safety-regulating system aiming to reduce the risk of a close other coming to harm [7, 8, 11]. Initially, research was based on a three-category typology of attachment styles in infancy by Ainsworth, Blehar, Waters, and Wall [14]—secure, anxious, and avoidant—and a conceptualization of similar adult styles in the domain of romantic relationships by Hazan and Shaver [15]. These variations in attachment pattern are believed to arise because attachment figures vary in how responsive they are in times of need. Adults commonly develop variations in their attachment tendencies, such that greater or lesser amounts of these three qualities are manifested in a given relationship [16, 17]. According to the attachment theory, individual differences in attachment histories result in a specific attachment orientation within close relationships, which tend to be organized around two main attachment dimensions [15, 18]: anxiety and avoidance. Attachment anxiety reflects the degree of worry that a relationship partner will not be available in times of need. Attachment avoidance reflects the extent of distrust of a
Support Care Cancer (2015) 23:87–94
relationship partner’s goodwill and seeking of independence and emotional distance. Attachment is a theory of socioemotional development that emphasizes the salience of human relations within an evolutionary–ethological context of adaptation and species survival. Bowlby [9, 11] proposed an attachment system that evolved to regulate the sense of security and protection through activation of the independent biological system of attachment. Because of the urgent need to protect oneself from imminent threats, activation of the attachment system inhibits activation of other behavioral systems and hence interferes with many nonattachment activities, including caregiving. Under conditions of threat, adults generally turn to others for support, rather than thinking first about providing support to others. Only when they feel reasonably secure themselves can people easily direct attention to others’ needs and provide support. In threatening situations, possessing greater attachment security may allow people to provide more effective care for others because the sense of security is closely related to optimistic beliefs and feelings of self-efficacy when coping with a partner’s distress [19]. Bowlby [9] postulated that the attachment system is also activated during times of fatigue, pain, and sickness, which typically initiates proximity-seeking behaviors to a stronger, wise, or protective figure. In adulthood, this proximityseeking behavior could be directed to a spouse, friend, therapist/support group, or physician. Attachment is conceptualized as a behavioral control system rooted in neurophysiological processes within the central nervous system [9, 11, 20]. A concept of the attachment theory is internal working models. These are mental representations organized from childhood that provide explanations for continuity: These structures guide perception and expectations, affect and behaviors, physiological responses, and cognition [9]. The premise that early experiences lead to different attachment styles, and thus differing internal models, has been supported by research [14]. The fact that there are different patterns of attachment suggests that there may be related differences in motivation for caregiving. Threats, feelings of conditional acceptance, and unsatisfied attachment needs may lead to more controlled motives for caregiving [21]. For such individuals, caregiving may be an escape from guilt. The distance entailed in avoidant attachment may deactivate compassionate responses to the partner’s needs [22, 23] This might lead avoidant persons to report lower motives of all types for caregiving, rather than specifically undermining autonomous motivations for caregiving. Attachment security with respect to the spouse, reflects comfort with being close and interdependent, has been related consistently to endorsing autonomous reasons for providing care, finding more benefit in caregiving, and finding life satisfaction. Attachment anxiety with respect to the spouse,
Support Care Cancer (2015) 23:87–94 Fig. 1 Process of literature search and review
89 Databases
Other Sources
PubMed: 6818
Books: 23
PsycINFO: 1285 Records dublicates: 38
Records after duplicates removed (n= 8088)
Records screened (n= 8088)
Records excluded (n=3036)
Full text articles assessed for eligibility (n= 5052)
Articles excluded (n=4965) reviews commentaries case reports meta-analyses solely qualitative method co-morbid dementias
Studies included (n=87) Papers from PubMed
29
Papers from PsycINFO 35 Books
reflects a hypervigilant focus on relationship threats, feelings of conditional acceptance, and desires for union with the other person, has been related to introjected motives for caregiving and to greater depression. Anxious attachment has also been related to lower life satisfaction. Mikulincer and Shaver [19] indicated that most of the studies published to date propose that anxious attachment involves hyperactivation of the attachment system, whereas avoidant attachment involves deactivation of the attachment system. In response to the plight of their spouses, these individuals are at risk to become emotionally overwhelmed [19]
23
by heightened fear of death and heightened accessibility of death-related thoughts [24, 25]. The attachment theory [10] has suggested that the nature of one’s earliest attachments predicts how one would react to loss. Couples with good marital functioning show lower levels of psychological distress [26] and consequently may buffer the impact of terminal disease [27]. Anxiously attached individuals are prone to chronic and complicated grief after bereavement [28–30] due to their fear of abandonment [31]. Therefore, such individuals might have a stronger tendency to experience depression when facing their spouses’ cancer
90
and potential loss of their partners. On the other hand, avoidant marital relationships may enhance couple estrangement resulting in an extreme impact for the bereaved spouse caregiver [32]. Therefore, attachment security may impact psychosocial distress in couples where one is facing terminal cancer. Marital distress may be exaggerated within insecure attachment bonds and influence both caregiving and care receiving [33]. Many studies suggest that either anxious or avoidant attachment may contribute to depression, hopelessness, and anxiety [34–36]. Adult attachment styles Although the original attachment classifications have been described for toddlers up to 20 months, there have been several attempts to classify attachment relationships in older children and in the adult population [37]. Individuals with greater attachment security tend to provide care and support that is sensitive, cooperative, and warm [38, 39]. In contrast, more insecurely attached individuals are less likely to provide effective and sensitive support and care [40]. Avoidant attachment is associated with a relative lack of caregiving proximity and sensitivity, less empathic compassion [21, 23, 41], and more controlling caregiving [42]. Mikulincer and Shaver [31] suggested that individuals with an anxious attachment orientation identify with the suffering due to the exaggerated closeness that they feel to the other. In addition, they tend to desperately long for closeness and intimacy, but they tend to provide support and care that are more self-focused than sensitive to a partner’s needs [43]. Moreover, in these caregivers, there is a strong need to be involved with their own difficulties in affect regulation [31]. They are also likely to feel overwhelmed by distress and therefore to provide care compulsively [42]. It has been postulated that the attachment figures of individuals scoring high on attachment anxiety scales in infancy and childhood tended to be unpredictable and inconsistent [44]. The fear of abandonment and the unsatisfied need for closeness that such individuals experienced during their earlier developmental years may shape the care that they currently provide to others [45, 46]. Such individuals may lack the capacity for empathic understanding, particularly when they are distressed [31], although they may tend to identify with their partner’s distress [15] and to engage in compulsive caregiving in order to manage their own distress. The caregiving system The aim of the caregiving system is more likely to be achieved when a person is secure enough to allow for a focus on someone else’s needs. The ability to help others is a consequence of having witnessed and benefited from good caregiving on the part of one’s own attachment figures, which
Support Care Cancer (2015) 23:87–94
promotes the sense of security as a resource and provides models of good caregiving [47]. Caregiving includes a broad array of behaviors that complement a partner’s attachment behavior and may include help or assistance, comfort, reassurance, and support of a partner’s autonomous activities and personal growth [47]. According to Bowlby [7, 8], the caregiving system is designed to provide protection and support to others who are either chronically dependent or temporarily in need. It is altruistic in nature, aiming at the alleviation of others’ distress, although the caregiving system evolved because it increased the inclusive fitness of individuals by making it more possible that children and adults with whom the individual shares genes would survive and reproduce [48]. Family caregivers, particularly spouses, often assume the cancer caregiver role with little advance notice and little or no opportunity to decline this role. The quality of the caregiver’s existing relationship with the patient may strongly influence the degree to which caregivers voluntarily engage in and endorse the caregiving role. Such dynamics may also affect the extent to which the caregivers adjust psychologically to cancer. Caregiving may be constrained by gender role expectations [49]. In many cultures, women are expected to be the family caregivers. Therefore, providing care may simply reflect doing what women are “supposed” to do. With this expectation and socialization process, women evaluate interpersonal relationships as a more important value that relates significantly to their psychological adjustment [50]. Female caregivers’ adjustment is more likely to be influenced by relationship quality or attachment styles as well as the extent to which they internalize the value of providing care than male caregivers’. This high expectation may result in more burden and lower self-esteem from caregiving for female caregivers [51, 52]. Thus, gender may also influence the dynamics of attachment and caregiving motivation. Spouse caregivers of cancer patients have been found to be adversely affected by the illness in physical and psychological areas [53, 54]. Individual differences in attachment have been related to psychological adjustment to general stress [19, 55] and to certain kinds of caregiving stress [51]. Caregiver’s and patient’s attachment pattern interactions The caregiving process is dyadic in nature and therefore may be affected by the attachment orientation of the care recipient, as well as that of the caregiver. The care recipients’ capacity to communicate their needs and their willingness to accept the care and support that is offered may be an important factor influencing caregivers’ ways of support provision [31]. There is increasing attention in the literature to the complex nature of caregiver–patient interactions and to individual differences in the way support is given and received [56, 57].
Support Care Cancer (2015) 23:87–94
Past studies have found significant associations between marital dissatisfaction and psychological distress among spouse caregivers of cancer patients [58, 59]. However, no study has examined the extent to which caregivers’ marital satisfaction contributes to their distress, independent of their attachment orientation in the cancer context. Collins and Feeney [47] found that perceptions of caregiving within couple relationships were influenced by both marital satisfaction and attachment orientations. Giving care to more securely attached patients might be easier and more rewarding and might induce more sensitive and proximate patterns of caregiving than caring for less securely attached patients. Caregivers are more likely to have difficulties in providing sensitive and cooperative care to partners with anxious or avoidant attachment patterns [31]. Patients scoring higher on avoidant attachment scales, who prefer to rely on themselves and to withdraw from interpersonal dependency and emotional closeness, would be more likely to reject their partners’ caregiving efforts and frustrate their partners’ to provide support and care. Patients scoring higher on attachment anxiety scales, who desperately desire love and closeness but doubt their ability to be loved and accepted, would be more likely to be overly dependent and demanding and feel dissatisfied with care, regardless of the amount received. As a result, they may burden their partner and create high levels of caregiving distress [60]. Pistole [61] describes a “demand-withdrawal” pattern, in which the emotional demands and exaggerated requests for closeness and support from individuals relatively high on attachment anxiety orientation might lead to caregivers’ withdrawal and rejection, which is the opposite of what these individuals long for. Therefore, in response to the frustration that caring for more avoidant or anxiously attached patients can elicit, caregivers might offer more controlling and less sensitive patterns of caregiving to these insecure patients. Only a few studies have examined the contribution of caregivers’ attachment orientation to the process of support provision to cancer patients. Some of these studies have examined the contribution of caregivers’ attachment orientation to their caregiving distress and depressive symptoms [34, 60]. Higher caregivers’ attachment anxiety and avoidance have been associated with more depression; they are at risk to have heightened fear of death, and they are prone to chronic grief and bereavement. Avoidant caregivers tend to distance themselves from their patients. However, avoidant strategies are not effective in threatening illnesses and result in depression [34]. Caregivers’ motivation to provide care and find benefits in support provision has also been studied [60]. More specifically, securely attached caregivers feel the comfort in being close to others, and this motivates them to autonomously help their patients. On the other hand, anxiously attached individuals focus on threats, and their unsatisfied attachment needs may lead to more controlled motives for providing help
91
and support [62]. Finally, avoidant caregivers may deactivate compassionate responses to the patient’s needs and report lower motives for caregiving [22]. It is undeniable that the attachment theory has had a profound impact on the field of developmental psychology. Nevertheless, most of the empirical work reviewed above is from industrialized countries, predominantly Western cultures. There is growing interest in attachment processes in countries with Eastern cultures. However, this research has not yet been published in English-language journals. The recent focus on context (including inter- and intracultural differences) reflects new directions that are important for the theory’s evolution. Attachment theory is attracting renewed interest and is being applied to individual psychotherapy, couples, family, and short-term dynamic therapy [63, 64]. Emotionally focus therapy (EFT) is one of the most empirically validated types of couple’s therapy [65]. Emotionally focus therapy for couples (EFTC) gives a central place to attachment theory in understanding the nature of the couple relationship; however, it rather surprisingly seems to draw in limited ways upon the attachment theory’s richness in its description of, and prescriptions for, the process of couple therapy [66]. Nevertheless, there is significant research on this approach, and it has been found that 70–75 % of couples move from distress to recovery and that 90 % show significant improvements [67]. Although the connections between relationships and health are well established, less is known about the interpersonal processes through which relationships influence health outcomes, despite a call for this type of research more than 20 years ago [68], but cutting-edge research in relationship science typically has not been integrated into health psychology. Adult attachment theory emphasizes that relationships are dynamic and reciprocal. Many couple intervention studies include both partners but assess outcomes for patients only [69]. Even in those health studies assessing actor and partner effects, it is rare for researchers to examine how characteristics of one partner when examined in combination with those of the other partner might produce unique outcomes [70]. Researchers must examine how the patient’s attachment style, their partner’s attachment style, and the interaction between the two predict outcomes for patients and for caregivers. Men and women differ when coping with chronic disease in the context of their relationships [70]. Women, relative to men, evaluate interpersonal relationships as a more important value that relates significantly to their psychological adjustment [50]. In other words, female caregivers’ adjustment is more likely to be influenced by relationship quality or attachment styles as well as the extent to which they internalize the value of providing care to their ill spouses than male caregivers’ [52]. In a recent study on lung cancer patients’ concerns, women tended to report a significantly larger number of concerns than men [71]. Few studies that have examined
92
distress in couples coping with cancer included a comparison group [72, 73]. These studies revealed higher levels of distress among women in couples coping with cancer, regardless of whether they were the individuals with cancer or the partners. In a mixed group of cancer patients, female patients have reported more spousal withdrawal than did male patients [74]. Manne et al. (1997) found that for female cancer patients, a higher level of perceived spousal support was associated with lower distress and greater well-being, while for male patients, there was no relationship between perceived spousal support and well-being or distress. Indeed, male cancer patients were more psychologically responsive to spouses’ negative rather than supportive behavior [74]. Leiber et al. [75] found that husbands and wives seek to gain and maintain proximity when their relationship is threatened by cancer. Friedman et al. [76] found that those with the highest levels of psychological and marital adjustment also reported levels of cohesion higher than published norms. In addition, no women desired less closeness, while 34 % desired increased closeness. These studies offer support for the attachment theory notion that the diagnosis of cancer may propel couples to engage in attachment behavior [77]. Couples coping with cancer are faced with a new reality in their relationship. While cognitive aspects of working models, such as accessibility and perspective taking when possessed by wives, appear to help couples cope, these same cognitive features in husbands had mixed associations with outcome. Perhaps attachment security in husbands and wives is a function of different cognitive features. Avoidant attachment in either gender was consistently related to poorer adjustment, but husbands’ anxious attachment was, in some situations, more positively related to adjustment than was secure attachment. Couples coping with cancer may need to make adjustments in their self and partner schemas. Their scripts or expectations for their relationship may need to incorporate the changes due to cancer and its treatment. Couples who have limited positive memories or are unable to discuss their problems may require intervention to help them acknowledge their fears and the changes that the illnesses bring [77]. There is a need for an investigation of how attachment together with relationship mediators and outcomes might shape health behavior. Health research on cancer patients has examined the link between relationship processes and outcomes and affective states. Nevertheless, most research has not utilized theories from relationship science to generate hypotheses. Couple-focused interventions might benefit from a focus on reducing avoidance of discussion of issues and pressuring one another to “talk” about cancer-related stressors and work at enhancing constructive communication and problem resolution. In a study of breast cancer patients, they felt greater intimacy on days when their spouses reported providing support, and spouses showed a parallel pattern [78]. In
Support Care Cancer (2015) 23:87–94
general, partner responsiveness and support [79] appear important to relationship functioning in couples coping with cancer. Meredith and colleagues [80] proposed an integrative attachment framework of chronic pain. Insecurely attached individuals may react to pain by using interpersonal strategies that lead to greater conflict in their relationships [81], which, in turn, may influence adjustment outcomes [80]. A recent study found that less securely attached women responded more negatively to experimentally induced pain when they were with an anxiously attached partner [82]. Little work has examined how individual differences in attachment might influence how individuals provide care to older family members or outcomes for both the caregivers and older adults, despite that this caregiving situation likely activates the attachment system [83]. A recent study illustrates that attachment avoidance predicted higher caregiver burden and lower willingness to provide future care [84]. Caregiving is also inherently an interpersonal phenomenon involving complex interaction patterns between a caregiver and care recipient, highlighting the need for greater dyadic approaches in some areas of caregiving research. As Martire et al. [69] note, however, most researchers have not assessed outcomes for both the patient and partner, and given the reciprocal effects of dyadic processes, interventions might be improved by considering both partners’ perspectives. In addition, couple interventions typically do not take into account individual differences, but each partner brings specific relationship orientations such as an attachment style and related expectations and beliefs about the relationship to the situation. It is estimated that approximately 55–65 % of adults are secure, 22–30 % avoidant, and 15–20 % ambivalent, with some evidence that avoidant styles are more prevalent in older adult samples [83]. Thus, it is very likely that a couple’s intervention will include at least one insecurely attached person. This is important because an intervention that is effective for one pair who both have secure attachment styles may not work well for another. Utilizing attachment styles underlines the importance of tailoring interventions to take into account the match between relationship partners in how secure, anxious, or avoidant they each are. Interventions can consider other relationship-related individual differences such as relationship goals. Canevello and Crocker report work showing that compassionate relationship goals motivate people to be more responsive to a close other who, in turn, is more responsive to them [85]. An important consideration for future research is that couples vary in the way they reflect reciprocal and dynamic processes between them.
Conflict of interest There is no conflict of interest. The authors have full control of all primary data and agree to allow the journal to review the data if requested.
Support Care Cancer (2015) 23:87–94
References 1. Eldredge DH, Nail LM, Maziarz RT, Hansen LK, Ewing D, Archbold PG (2006) Explaining family caregiver role strain following autologous blood and marrow transplantation. J Psychosoc Oncol 24(3):53–74 2. Meehan KR, Fitzmaurice T, Root L, Kimts E, Patchett L, Hill J (2006) The financial requirements and time commitments of caregivers for autologous stem cell transplant recipients. J Support Oncol 4:187–190 3. Wilson ME, Eilers J, Heermann JA, Million R (2009) The experience of spouses as informal caregivers for recipients of hematopoietic stem cell transplants. CancerNurs 32:15–23 4. Given BA, Given CW, Kozachik S (2001) Family support in advanced cancer. CA Cancer J Clin 51:213–231 5. Glajchen M (2004) The emerging role and needs of family caregivers in cancer care. J Support Oncol 2:145–155 6. Cain R, Maclean M, Sellick S (2004) Giving support and getting help: informal caregivers’ experiences with palliative care services. Palliat Support Care 2:265–272 7. Bowlby J (1969) Attachment (vol. 1). Basic Books, New York 8. Bowlby J (1982) Attachment and loss. Vol. 1: attachment, 2nd edn. Basic Books, New York 9. Bowlby J (1973) Attachment and loss. Vol 2. Basic Books, New York 10. Bowlby J (1980) Attachment and loss. Volume III: loss: sadness and depression. Basic Books, New York 11. Bowlby J (1988) A secure base. Basic Books, New York 12. Bretherton I (1987) New perspectives on attachment relations: security, communication, and internal working models. In: Osofsky J (ed) Handbook of infant development, 2nd edn. Wiley, New York 13. Hazan C, Zeifman D (1999) Pair-bonds as attachments: evaluating the evidence. In: Cassidy J, Shaver PR (eds) Handbook of attachment theory and research. Guilford, New York, pp 336–354 14. Ainsworth M, Blehar MC, Waters E, Wall S (1978) Patterns of attachment: assessed in the strange situation and at home. Erlbaum, Hillsdale 15. Hazan C, Shaver PR (1987) Romantic love conceptualized as an attachment process. J Pers Soc Psychol 2:511–524 16. Baldwin MW, Keelan JP, Fehr B, Enns V, Koh-Rangarajoo E (1996) Social cognitive conceptualization of attachment working models: availability and accessibility effects. J Pers Soc Psychol 71: 94–104 17. La Guardia JG, Ryan RM, Couchman CE, Deci EL (2000) Within – person variation in security of attachment. A self-determination theory perspective on attachment, need fulfilment, and well-being. J Pers Soc Psychol 79:367–384 18. Brennan KA, Clark CL, Shaver PR (1998) Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS (eds) In attachment theory and close relationships. Guilford Press, New York, pp 46–76 19. Mikulincer M, Shaver PR (2003) The attachment behavioral system in adulthood: activation, psychodynamics, and interpersonal processes. In: Zanna MP (ed) Advances in experimental social psychology (vol. 35). Academic Press, San Diego, pp 53–152 20. Ainsworth M (1989) Attachments beyond infancy. Am Psychol 44: 709–716 21. Mikulincer M, Gillath O, Halevy V, Avihou N, Avidom S, Eshkoli N (2001) Attachment theory and reactions to others’ needs: evidence that activation of the sense of attachment security promotes empathic responses. J Pers Soc Psychol 81:1205–1224 22. Shaver PR, Mikulincer M (2002) Dialogue on adult attachment: diversity and integration. Attach Hum Dev 4:243–257 23. Westmaas JL, Silver RC (2001) The role of attachment in responses to victims of life crises. J Pers Soc Psychol 80:425–438
93 24. Mikulincer M, Florian V (2000) Exploring individual differences in reactions to mortality salience: does attachment style regulate terror management mechanisms? J Pers Soc Psychol 79:260–273 25. Mikulincer M, Florian V, Hirschberger G (2003) The existential function of close relationships: introducing death into the science of love. Personal Soc Psychol Rev 7:20–40 26. Kissane DW, Bloch S, Burns WI, McKenzie D, Posterino M (1994) Psychological morbidity in the families of patients with cancer. Psychooncology 3:47–56 27. Steinglass P (2000) Family processes and chronic illness. In: Baider L, Cooper C, De-Nour A (eds) Cancer and the family. Wiley, West Sussex, pp 3–15 28. Van Doorn C, Kasl SV, Beery LC, Jacobs SC, Prigerson HG (1998) The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis 186(9):566–573 29. Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J et al (2002) Resilience to loss and chronic grief: a prospective study from pre-loss to 18-months post loss. J Pers Soc Psychol 83:1150–1164 30. Wayment HA, Vierthaler J (2002) Attachment style and bereavement reactions. J Loss Trauma 7:129–149 31. Mikulincer M, Shaver PR (2007) Attachment in adulthood: structure, dynamics and change. Guilford Press, New York 32. Kissane DW (2003) Psychological morbidity associated with patterns of family functioning in palliative care: baseline data from the family grief therapy controlled trial. Palliat Med 17:527–537 33. McLean LM, Walton T, Matthew A, Jones JM (2011) Examination of couples’ attachment security in relation to depression and hopelessness in maritally distressed patients facing end-stage cancer and their spouse caregivers: a buffer or facilitator of psychosocial distress. Support Care Cancer 19:1539–1548 34. Braun M, Mikulincer M, Rydall A, Walsh A, Rodin G (2007) Hidden morbidity in cancer: spouse caregivers. J Clin Oncol 25:4829–4834 35. Kayser K (2005) Enhancing dyadic coping during a time of crisis: a theory-based intervention with breast cancer patients and their partners. In: Revnson TA, Kayser K, Bodenmann G (eds) Couples coping with stress: emerging perspectives on dyadic coping. American Psychological Association, Washington, pp 175–194 36. Hunter MJ, Davis PJ, Tunstall JR (2006) The influence of attachment and emotional support in end-stage cancer. Psychooncology 15(5): 431–444 37. Bartholomew K, Shaver P (1998) Measures of attachment: do they converge? In: Simpson JA, Rholes WS (eds) Attachment theory and close relationships. Guilford Press, New York, pp 25–45 38. Feeney JA, Hohaus L (2001) Attachment and spousal caregiving. Pers Relatsh 8(1):21–39 39. Feeney BC, Collins NL (2001) Predictors of caregiving in adult intimate relationships: an attachment theoretical perspective. J Pers Soc Psychol 80(6):972–994 40. Feeney JA (1996) Attachment, caregiving, and marital satisfaction. Pers Relatsh 3(4):401–416 41. Gillath O, Shaver PR, Mikulincer M (2005) An attachment theoretical approach to compassion and altruism. In: Gilbert P (ed) Compassion: conceptualisations, research and use in psychotherapy. Routledge Press, New York, pp 121–147 42. Kunce LJ, Shaver PR (1994) An attachment-theoretical approach to caregiving in romantic relationships. In: Bartholomew K, Perlman D (eds) Attachment processes in adulthood: advances in personal relationships (vol 5). Jessica Kingsley Publishers, Bristol, pp 205–237 43. Collins NL, Read SJ (1994) Cognitive representations of attachment: the structure and function of working models. In: Bartholomew K, Perlman D (eds) Attachment processes in adulthood: advances in personal relationships (vol 5). Jessica Kingsley Publishers, Bristol, pp 53–92 44. Crittenden PM, Ainsworth MDS (1989) Child maltreatment and attachment theory. In: Cicchetti D, Carlson V (eds) Child maltreatment: theory and research on the causes and consequences of child
94
45.
46.
47.
48. 49. 50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61. 62.
63. 64.
65.
Support Care Cancer (2015) 23:87–94 abuse and neglect. Cambridge University Press, New York, pp 432– 463 Britton PC, Fuendeling JM (2005) The relations among varieties of adult attachment and the components of empathy. J Soc Psychol 145(5):519–530 Joireman JA, Needham TL, Cummings A (2002) Relationships between dimensions of attachment and empathy. N Am J Psychol 4(1):63–80 Collins NL, Feeney BC (2000) A safe haven: an attachment theory perspective on support seeking and care giving in intimate relationships. J Pers Soc Psychol 78:1053–1073 Hamilton WD (1964) The genetical evolution of social behavior. I and II. J Theor Biol 7:1–52 Brody EM (1990) Women in the middle: their parent-care years. Springer, New York Martire LM, Stephens MA, Townsend AL (2000) Centrality of women’s multiple roles: beneficial and detrimental consequences for psychological well-being. Psychol Aging 15:148–156 Collins C, Jones R (1997) Emotional distress and morbidity in dementia carers: a matched comparison of husbands and wives. Int J Geriatr Psychiatry 12:1168–1173 Rose-Rego SK, Strauss ME, Smyth KA (1998) Differences in the perceived well-being of wives and husbands caring for persons with Alzheimer’s disease. Gerontologist 38:224–230 Kurtz ME, Given B, Kurtz JC, Given CW (1994) The interaction of age, symptoms, and survival status on physical and mental health of patients with cancer and their families. Cancer 74(7 Suppl):2071–2078 Kurtz ME, Kurtz JC, Given CW, Given BA (2004) Depression and physical health among family caregivers of geriatric patients with cancer: a longitudinal view. Med Sci Monit 10:CR447–CR456 Kobak RR, Sceery A (1988) Attachment in late adolescence: working models, affect regulation, and representations of self and others. Child Dev 59:135–146 Manne SL, Ostroff J, Winkel G, Grana G, Fox K (2005) Partner unsupportive responses, avoidant coping, and distress among women with early stage breast cancer: patient and partner perspectives. Health Psychol 24(6):635–641 Reinhardt JP (2001) Effects of positive and negative support received and provided on adaptation to chronic visual impairment. Appl Dev Sci 5(2):76–85 Northouse LL, Mood D, Templin T, Mellon S, George T (2000) Couples’ patterns of adjustment to colon cancer. Soc Sci Med 50: 271–284 Kuijer RG, Buunk BP, Ybema JF, Wobbes TH (2002) The relation between perceived inequity, marital satisfaction and emotions among couples facing cancer. Br J Soc Psychol 41:39–56 Kim Y, Carver CS (2007) Frequency and difficulty in caregiving among spouses of individuals with cancer: effects of adult attachment and gender. Psycho-Oncology 16:714–723 Pistole CM (1994) Adult attachment styles: some thoughts on closeness-distance struggles. Fam Process 33(2):147–159 Kim Y, Carver CS, Deci EL, Kasser T (2008) Adult attachment and psychological well-being in cancer caregivers: the mediational role of spouses’ motives for caregiving. Health Psychol 27(2Suppl):S144– S154. doi:10.1037/0278-33.27.2(Suppl.).S144 Erdman P, Caffery T (2003) Attachment and family systems. Brunner-Routledge, New York Whiffen V (2003) What attachment theory can offer marital and family therapists. In: Johnson S, Whiffen V (eds) Attachment processes in couple and family therapy. Guilford, New York Johnson SM, Bradley B, Furrow J et al (2005) Becoming an emotionally focused therapist: the workbook. Routledge, New York
66. Greenberg L (2002) Emotion-focused therapy: coaching clients to work through their feelings. American Psychological Association, Washington 67. Johnson S, Sims A (2000) Attachment theory: a mape for couples therapy. In: Levy TM (ed) Handbook of attachment interventions. Academic Press, Santiego, pp 172–192 68. House JS, Landis KR, Umberson D (1988) Social relationships and health. Science 421:540–545 69. Martire LM, Helgeson VS, Saghafi EM (2010) Review and metaanalysis of couple-oriented interventions for chronic illness. Ann Behav Med 40:325–342 70. Badr H (2004) Coping in marital dyads: a contextual perspective on the role of gender and health. Pers Relatsh 11:197–211 71. Hill KM, Amir Z, Muers MF, Connolly CK, Round CE (2003) Do newly diagnosed lung cancer patients feel their concerns are being met? Eur J Cancer Care 12:35–45 72. Hagedoorn M, Buunk BP, Kuijer RG, Wobbes T, Sanderman R (2000) Couples dealing with cancer: role and gender differences regarding psychological distress and quality of life. PsychoOncology 9:232–242 73. Hinnen C, Ranchor AV, Sanderman R, Snijders TAB, Hagedoorn M, Coyne JC (2008) Course of distress in breast cancer patients, their partners and control couples: implications for psychological interventions. Ann Behav Med 36:141–148 74. Manne SL, Taylor KL, Dougherty J, Kemeny N (1997) Supportive and negative responses in the partner relationship: their association with psychological adjustment among individuals with cancer. J Behav Med 20(2):101–125 75. Leiber L, Plumb MM, Gerstenzang ML, Holland J (1976) The communication of affection between cancer patients and their spouses. Psychosom Med 38:379–389 76. Friedman L, Baer P, Nelson D, Lane M et al (1988) Women with breast cancer: perception of family functioning and adjustment to illness. Psychosom Med 50:529–540 77. Shields CG, Travis LA, Rousseau SL (2000) Marital attachment and adjustment in older couples coping with cancer. Aging Ment Health 4(3):223–233 78. Belcher AJ, Laurenceau JP, Graber EC, Cohen LH, Dasch KB, Siegel SD (2011) Daily support in couples coping with early stage breast cancer: maintaining intimacy during adversity. Health Psychol 30(6): 665–673 79. Clark MS, Lemay EP Jr, Graham SM, Pataki SP, Finkel EJ (2010) Ways of giving benefits in marriage: norm use and attachment-related variability. Psychol Sci 21:944–951 80. Meredith P, Ownsworth T, Strong J (2008) A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clin Psychol Rev 28:407–429 81. Pietromonaco PR, Greenwood D, Barrett LF (2004) Conflict in adult close relationships: an attachment perspective. In: Rholes WS, Simpson JA (eds) Adult attachment: new directions and emerging issues. Guilford Press, New York, pp 267–299 82. Wilson CL, Ruben MA (2011) A pain in her arm: romantic attachment orientations and the tourniquet task. Pers Relatsh 18:242–265 83. Magai C (2008) Attachment in middle and later life. In: Cassidy J, Shaver PR (eds) Handbook of attachment: theory, research, and clinical applications, 2nd edn. Guilford Press, New York, pp 532–551 84. Karantzas GC, Evans L, Foddy M (2010) The role of attachment in current and future parent caregiving. J Gerontol Psychol Sci 65B(5): 573–580 85. Canevello A, Crocker J (2010) Creating good relationships: responsiveness, relationship quality, and interpersonal goals. J Pers Soc Psychol 99(1):78–106
ORIGINAL ARTICLE
Caregivers’ attachment patterns and their interactions with cancer patients’ patterns Eleni Tsilika & Efi Parpa & Anna Zygogianni & Vassilios Kouloulias & Kyriaki Mystakidou
Received: 15 October 2013 / Accepted: 22 June 2014 / Published online: 3 July 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To provide a brief review of the empirical literature regarding the attachment style of the cancer patients’ caregivers as well as the link between attachment, caregiving, and care-receiving behaviors are defined. Methods An extensive systematic electronic review (Medline, PsycINFO, and Attachment Theory Website (ATW)) and subsequent examination of reference lists were carried out to retrieve published articles up to 2011, using attachment and cancer in combination with caregiver, spouse, dyad, and family as the key words. The titles, abstracts, or full articles, if necessary, were reviewed to determine whether the articles met the eligibility criteria. Results Eighty-seven studies have been identified, including research articles, books, and chapters in books. Conclusions The attachment style of a caregiver can influence how they respond to a patient’s needs. Studies have found that attachment anxiety or avoidance is more likely to interfere with effective and sensitive caregiving.
Keywords Attachment . Caregivers . Spouses . Cancer patients . Dyad . Family
E. Tsilika : E. Parpa : K. Mystakidou (*) Pain Relief and Palliative Care Unit, Department of Radiology, Areteion Hospital, School of Medicine, University of Athens, 27 Korinthias St., 115 26 Athens, Greece e-mail: [email protected]
Search strategy
E. Tsilika e-mail: [email protected] E. Parpa e-mail: [email protected] A. Zygogianni School of Medicine, Thessaly University, Volos, Greece e-mail: [email protected]
Introduction Despite medical advances, cancer not only affects the patients but also their family members. Often, friends or family members have to assume a caregiving role to a loved one with cancer for the duration of their treatment. Caregivers not only have to cope with the diagnosis and uncertainty of cancer but also have responsibilities [1–4]. The recent trend toward longer survival and toward ambulatory and home care has increased the number of informal family caregivers and may have amplified their burden [5, 6].
Methods
Identification of relevant studies began with systematic searches of the electronic databases (PubMed, PsycINFO, and Attachment Theory Website (ATW)) with the last search being up to 2011. The search terms used were attachment and cancer in combination with caregiver, spouse, dyad, and family. Searches were limited to studies published in the English language. Hand searching was completed according to the reference lists of all eligible studies to identify relevant studies. Selection strategy
V. Kouloulias Radiotherapy Unit, Department of Radiology, Attikon University Hospital, School of Medicine, Kapodistrian University of Athens, 1 Rimini St., Haidari, 12462 Athens, Greece e-mail: [email protected]
The title and abstract of each study were reviewed independently by two investigators to retrieve the full-text articles. Then, the investigators compared the papers and discrepancies
88
resolved by consensus. Inclusion criteria were as follows: (i) adult patients (≥18), (ii) a cancer diagnosis, and (iii) spouses were identified as caregivers. On the other hand, populations with comorbid dementia, studies using solely qualitative methods, reviews, commentaries, case reports, systematic reviews and meta-analyses were excluded. Ethical approval has been obtained for the study where required.
Results We identified 8,126 titles from MEDLINE, PsyINFO, and ATW. Eight thousand thirty-nine titles were excluded after reviewing and applying the inclusion criteria. Hence, 87 titles (articles and books) were eligible for systematic review. The flowchart is shown in Fig. 1. Attachment background John Bowlby [7–11] proposed that attachment bonds involve two behavioral systems, an attachment system and a caregiving system. Individuals come into the world equipped with an attachment behavioral system that can be activated when in distress and serves a major evolutionary function of protection and survival [7, 12]. Although there are normative developmental changes in the expression of the attachment system across the life span, the basic function of the attachment system remains constant [13]. Adults and children benefit from having someone looking out for them and who is available to help if needed. Intimate relationships play a critical role in promoting health and well-being in adulthood, while relationship disruption is associated with a wide range of adverse health outcomes. In addition, the attachment theory argues that the caregiving system is another safety-regulating system aiming to reduce the risk of a close other coming to harm [7, 8, 11]. Initially, research was based on a three-category typology of attachment styles in infancy by Ainsworth, Blehar, Waters, and Wall [14]—secure, anxious, and avoidant—and a conceptualization of similar adult styles in the domain of romantic relationships by Hazan and Shaver [15]. These variations in attachment pattern are believed to arise because attachment figures vary in how responsive they are in times of need. Adults commonly develop variations in their attachment tendencies, such that greater or lesser amounts of these three qualities are manifested in a given relationship [16, 17]. According to the attachment theory, individual differences in attachment histories result in a specific attachment orientation within close relationships, which tend to be organized around two main attachment dimensions [15, 18]: anxiety and avoidance. Attachment anxiety reflects the degree of worry that a relationship partner will not be available in times of need. Attachment avoidance reflects the extent of distrust of a
Support Care Cancer (2015) 23:87–94
relationship partner’s goodwill and seeking of independence and emotional distance. Attachment is a theory of socioemotional development that emphasizes the salience of human relations within an evolutionary–ethological context of adaptation and species survival. Bowlby [9, 11] proposed an attachment system that evolved to regulate the sense of security and protection through activation of the independent biological system of attachment. Because of the urgent need to protect oneself from imminent threats, activation of the attachment system inhibits activation of other behavioral systems and hence interferes with many nonattachment activities, including caregiving. Under conditions of threat, adults generally turn to others for support, rather than thinking first about providing support to others. Only when they feel reasonably secure themselves can people easily direct attention to others’ needs and provide support. In threatening situations, possessing greater attachment security may allow people to provide more effective care for others because the sense of security is closely related to optimistic beliefs and feelings of self-efficacy when coping with a partner’s distress [19]. Bowlby [9] postulated that the attachment system is also activated during times of fatigue, pain, and sickness, which typically initiates proximity-seeking behaviors to a stronger, wise, or protective figure. In adulthood, this proximityseeking behavior could be directed to a spouse, friend, therapist/support group, or physician. Attachment is conceptualized as a behavioral control system rooted in neurophysiological processes within the central nervous system [9, 11, 20]. A concept of the attachment theory is internal working models. These are mental representations organized from childhood that provide explanations for continuity: These structures guide perception and expectations, affect and behaviors, physiological responses, and cognition [9]. The premise that early experiences lead to different attachment styles, and thus differing internal models, has been supported by research [14]. The fact that there are different patterns of attachment suggests that there may be related differences in motivation for caregiving. Threats, feelings of conditional acceptance, and unsatisfied attachment needs may lead to more controlled motives for caregiving [21]. For such individuals, caregiving may be an escape from guilt. The distance entailed in avoidant attachment may deactivate compassionate responses to the partner’s needs [22, 23] This might lead avoidant persons to report lower motives of all types for caregiving, rather than specifically undermining autonomous motivations for caregiving. Attachment security with respect to the spouse, reflects comfort with being close and interdependent, has been related consistently to endorsing autonomous reasons for providing care, finding more benefit in caregiving, and finding life satisfaction. Attachment anxiety with respect to the spouse,
Support Care Cancer (2015) 23:87–94 Fig. 1 Process of literature search and review
89 Databases
Other Sources
PubMed: 6818
Books: 23
PsycINFO: 1285 Records dublicates: 38
Records after duplicates removed (n= 8088)
Records screened (n= 8088)
Records excluded (n=3036)
Full text articles assessed for eligibility (n= 5052)
Articles excluded (n=4965) reviews commentaries case reports meta-analyses solely qualitative method co-morbid dementias
Studies included (n=87) Papers from PubMed
29
Papers from PsycINFO 35 Books
reflects a hypervigilant focus on relationship threats, feelings of conditional acceptance, and desires for union with the other person, has been related to introjected motives for caregiving and to greater depression. Anxious attachment has also been related to lower life satisfaction. Mikulincer and Shaver [19] indicated that most of the studies published to date propose that anxious attachment involves hyperactivation of the attachment system, whereas avoidant attachment involves deactivation of the attachment system. In response to the plight of their spouses, these individuals are at risk to become emotionally overwhelmed [19]
23
by heightened fear of death and heightened accessibility of death-related thoughts [24, 25]. The attachment theory [10] has suggested that the nature of one’s earliest attachments predicts how one would react to loss. Couples with good marital functioning show lower levels of psychological distress [26] and consequently may buffer the impact of terminal disease [27]. Anxiously attached individuals are prone to chronic and complicated grief after bereavement [28–30] due to their fear of abandonment [31]. Therefore, such individuals might have a stronger tendency to experience depression when facing their spouses’ cancer
90
and potential loss of their partners. On the other hand, avoidant marital relationships may enhance couple estrangement resulting in an extreme impact for the bereaved spouse caregiver [32]. Therefore, attachment security may impact psychosocial distress in couples where one is facing terminal cancer. Marital distress may be exaggerated within insecure attachment bonds and influence both caregiving and care receiving [33]. Many studies suggest that either anxious or avoidant attachment may contribute to depression, hopelessness, and anxiety [34–36]. Adult attachment styles Although the original attachment classifications have been described for toddlers up to 20 months, there have been several attempts to classify attachment relationships in older children and in the adult population [37]. Individuals with greater attachment security tend to provide care and support that is sensitive, cooperative, and warm [38, 39]. In contrast, more insecurely attached individuals are less likely to provide effective and sensitive support and care [40]. Avoidant attachment is associated with a relative lack of caregiving proximity and sensitivity, less empathic compassion [21, 23, 41], and more controlling caregiving [42]. Mikulincer and Shaver [31] suggested that individuals with an anxious attachment orientation identify with the suffering due to the exaggerated closeness that they feel to the other. In addition, they tend to desperately long for closeness and intimacy, but they tend to provide support and care that are more self-focused than sensitive to a partner’s needs [43]. Moreover, in these caregivers, there is a strong need to be involved with their own difficulties in affect regulation [31]. They are also likely to feel overwhelmed by distress and therefore to provide care compulsively [42]. It has been postulated that the attachment figures of individuals scoring high on attachment anxiety scales in infancy and childhood tended to be unpredictable and inconsistent [44]. The fear of abandonment and the unsatisfied need for closeness that such individuals experienced during their earlier developmental years may shape the care that they currently provide to others [45, 46]. Such individuals may lack the capacity for empathic understanding, particularly when they are distressed [31], although they may tend to identify with their partner’s distress [15] and to engage in compulsive caregiving in order to manage their own distress. The caregiving system The aim of the caregiving system is more likely to be achieved when a person is secure enough to allow for a focus on someone else’s needs. The ability to help others is a consequence of having witnessed and benefited from good caregiving on the part of one’s own attachment figures, which
Support Care Cancer (2015) 23:87–94
promotes the sense of security as a resource and provides models of good caregiving [47]. Caregiving includes a broad array of behaviors that complement a partner’s attachment behavior and may include help or assistance, comfort, reassurance, and support of a partner’s autonomous activities and personal growth [47]. According to Bowlby [7, 8], the caregiving system is designed to provide protection and support to others who are either chronically dependent or temporarily in need. It is altruistic in nature, aiming at the alleviation of others’ distress, although the caregiving system evolved because it increased the inclusive fitness of individuals by making it more possible that children and adults with whom the individual shares genes would survive and reproduce [48]. Family caregivers, particularly spouses, often assume the cancer caregiver role with little advance notice and little or no opportunity to decline this role. The quality of the caregiver’s existing relationship with the patient may strongly influence the degree to which caregivers voluntarily engage in and endorse the caregiving role. Such dynamics may also affect the extent to which the caregivers adjust psychologically to cancer. Caregiving may be constrained by gender role expectations [49]. In many cultures, women are expected to be the family caregivers. Therefore, providing care may simply reflect doing what women are “supposed” to do. With this expectation and socialization process, women evaluate interpersonal relationships as a more important value that relates significantly to their psychological adjustment [50]. Female caregivers’ adjustment is more likely to be influenced by relationship quality or attachment styles as well as the extent to which they internalize the value of providing care than male caregivers’. This high expectation may result in more burden and lower self-esteem from caregiving for female caregivers [51, 52]. Thus, gender may also influence the dynamics of attachment and caregiving motivation. Spouse caregivers of cancer patients have been found to be adversely affected by the illness in physical and psychological areas [53, 54]. Individual differences in attachment have been related to psychological adjustment to general stress [19, 55] and to certain kinds of caregiving stress [51]. Caregiver’s and patient’s attachment pattern interactions The caregiving process is dyadic in nature and therefore may be affected by the attachment orientation of the care recipient, as well as that of the caregiver. The care recipients’ capacity to communicate their needs and their willingness to accept the care and support that is offered may be an important factor influencing caregivers’ ways of support provision [31]. There is increasing attention in the literature to the complex nature of caregiver–patient interactions and to individual differences in the way support is given and received [56, 57].
Support Care Cancer (2015) 23:87–94
Past studies have found significant associations between marital dissatisfaction and psychological distress among spouse caregivers of cancer patients [58, 59]. However, no study has examined the extent to which caregivers’ marital satisfaction contributes to their distress, independent of their attachment orientation in the cancer context. Collins and Feeney [47] found that perceptions of caregiving within couple relationships were influenced by both marital satisfaction and attachment orientations. Giving care to more securely attached patients might be easier and more rewarding and might induce more sensitive and proximate patterns of caregiving than caring for less securely attached patients. Caregivers are more likely to have difficulties in providing sensitive and cooperative care to partners with anxious or avoidant attachment patterns [31]. Patients scoring higher on avoidant attachment scales, who prefer to rely on themselves and to withdraw from interpersonal dependency and emotional closeness, would be more likely to reject their partners’ caregiving efforts and frustrate their partners’ to provide support and care. Patients scoring higher on attachment anxiety scales, who desperately desire love and closeness but doubt their ability to be loved and accepted, would be more likely to be overly dependent and demanding and feel dissatisfied with care, regardless of the amount received. As a result, they may burden their partner and create high levels of caregiving distress [60]. Pistole [61] describes a “demand-withdrawal” pattern, in which the emotional demands and exaggerated requests for closeness and support from individuals relatively high on attachment anxiety orientation might lead to caregivers’ withdrawal and rejection, which is the opposite of what these individuals long for. Therefore, in response to the frustration that caring for more avoidant or anxiously attached patients can elicit, caregivers might offer more controlling and less sensitive patterns of caregiving to these insecure patients. Only a few studies have examined the contribution of caregivers’ attachment orientation to the process of support provision to cancer patients. Some of these studies have examined the contribution of caregivers’ attachment orientation to their caregiving distress and depressive symptoms [34, 60]. Higher caregivers’ attachment anxiety and avoidance have been associated with more depression; they are at risk to have heightened fear of death, and they are prone to chronic grief and bereavement. Avoidant caregivers tend to distance themselves from their patients. However, avoidant strategies are not effective in threatening illnesses and result in depression [34]. Caregivers’ motivation to provide care and find benefits in support provision has also been studied [60]. More specifically, securely attached caregivers feel the comfort in being close to others, and this motivates them to autonomously help their patients. On the other hand, anxiously attached individuals focus on threats, and their unsatisfied attachment needs may lead to more controlled motives for providing help
91
and support [62]. Finally, avoidant caregivers may deactivate compassionate responses to the patient’s needs and report lower motives for caregiving [22]. It is undeniable that the attachment theory has had a profound impact on the field of developmental psychology. Nevertheless, most of the empirical work reviewed above is from industrialized countries, predominantly Western cultures. There is growing interest in attachment processes in countries with Eastern cultures. However, this research has not yet been published in English-language journals. The recent focus on context (including inter- and intracultural differences) reflects new directions that are important for the theory’s evolution. Attachment theory is attracting renewed interest and is being applied to individual psychotherapy, couples, family, and short-term dynamic therapy [63, 64]. Emotionally focus therapy (EFT) is one of the most empirically validated types of couple’s therapy [65]. Emotionally focus therapy for couples (EFTC) gives a central place to attachment theory in understanding the nature of the couple relationship; however, it rather surprisingly seems to draw in limited ways upon the attachment theory’s richness in its description of, and prescriptions for, the process of couple therapy [66]. Nevertheless, there is significant research on this approach, and it has been found that 70–75 % of couples move from distress to recovery and that 90 % show significant improvements [67]. Although the connections between relationships and health are well established, less is known about the interpersonal processes through which relationships influence health outcomes, despite a call for this type of research more than 20 years ago [68], but cutting-edge research in relationship science typically has not been integrated into health psychology. Adult attachment theory emphasizes that relationships are dynamic and reciprocal. Many couple intervention studies include both partners but assess outcomes for patients only [69]. Even in those health studies assessing actor and partner effects, it is rare for researchers to examine how characteristics of one partner when examined in combination with those of the other partner might produce unique outcomes [70]. Researchers must examine how the patient’s attachment style, their partner’s attachment style, and the interaction between the two predict outcomes for patients and for caregivers. Men and women differ when coping with chronic disease in the context of their relationships [70]. Women, relative to men, evaluate interpersonal relationships as a more important value that relates significantly to their psychological adjustment [50]. In other words, female caregivers’ adjustment is more likely to be influenced by relationship quality or attachment styles as well as the extent to which they internalize the value of providing care to their ill spouses than male caregivers’ [52]. In a recent study on lung cancer patients’ concerns, women tended to report a significantly larger number of concerns than men [71]. Few studies that have examined
92
distress in couples coping with cancer included a comparison group [72, 73]. These studies revealed higher levels of distress among women in couples coping with cancer, regardless of whether they were the individuals with cancer or the partners. In a mixed group of cancer patients, female patients have reported more spousal withdrawal than did male patients [74]. Manne et al. (1997) found that for female cancer patients, a higher level of perceived spousal support was associated with lower distress and greater well-being, while for male patients, there was no relationship between perceived spousal support and well-being or distress. Indeed, male cancer patients were more psychologically responsive to spouses’ negative rather than supportive behavior [74]. Leiber et al. [75] found that husbands and wives seek to gain and maintain proximity when their relationship is threatened by cancer. Friedman et al. [76] found that those with the highest levels of psychological and marital adjustment also reported levels of cohesion higher than published norms. In addition, no women desired less closeness, while 34 % desired increased closeness. These studies offer support for the attachment theory notion that the diagnosis of cancer may propel couples to engage in attachment behavior [77]. Couples coping with cancer are faced with a new reality in their relationship. While cognitive aspects of working models, such as accessibility and perspective taking when possessed by wives, appear to help couples cope, these same cognitive features in husbands had mixed associations with outcome. Perhaps attachment security in husbands and wives is a function of different cognitive features. Avoidant attachment in either gender was consistently related to poorer adjustment, but husbands’ anxious attachment was, in some situations, more positively related to adjustment than was secure attachment. Couples coping with cancer may need to make adjustments in their self and partner schemas. Their scripts or expectations for their relationship may need to incorporate the changes due to cancer and its treatment. Couples who have limited positive memories or are unable to discuss their problems may require intervention to help them acknowledge their fears and the changes that the illnesses bring [77]. There is a need for an investigation of how attachment together with relationship mediators and outcomes might shape health behavior. Health research on cancer patients has examined the link between relationship processes and outcomes and affective states. Nevertheless, most research has not utilized theories from relationship science to generate hypotheses. Couple-focused interventions might benefit from a focus on reducing avoidance of discussion of issues and pressuring one another to “talk” about cancer-related stressors and work at enhancing constructive communication and problem resolution. In a study of breast cancer patients, they felt greater intimacy on days when their spouses reported providing support, and spouses showed a parallel pattern [78]. In
Support Care Cancer (2015) 23:87–94
general, partner responsiveness and support [79] appear important to relationship functioning in couples coping with cancer. Meredith and colleagues [80] proposed an integrative attachment framework of chronic pain. Insecurely attached individuals may react to pain by using interpersonal strategies that lead to greater conflict in their relationships [81], which, in turn, may influence adjustment outcomes [80]. A recent study found that less securely attached women responded more negatively to experimentally induced pain when they were with an anxiously attached partner [82]. Little work has examined how individual differences in attachment might influence how individuals provide care to older family members or outcomes for both the caregivers and older adults, despite that this caregiving situation likely activates the attachment system [83]. A recent study illustrates that attachment avoidance predicted higher caregiver burden and lower willingness to provide future care [84]. Caregiving is also inherently an interpersonal phenomenon involving complex interaction patterns between a caregiver and care recipient, highlighting the need for greater dyadic approaches in some areas of caregiving research. As Martire et al. [69] note, however, most researchers have not assessed outcomes for both the patient and partner, and given the reciprocal effects of dyadic processes, interventions might be improved by considering both partners’ perspectives. In addition, couple interventions typically do not take into account individual differences, but each partner brings specific relationship orientations such as an attachment style and related expectations and beliefs about the relationship to the situation. It is estimated that approximately 55–65 % of adults are secure, 22–30 % avoidant, and 15–20 % ambivalent, with some evidence that avoidant styles are more prevalent in older adult samples [83]. Thus, it is very likely that a couple’s intervention will include at least one insecurely attached person. This is important because an intervention that is effective for one pair who both have secure attachment styles may not work well for another. Utilizing attachment styles underlines the importance of tailoring interventions to take into account the match between relationship partners in how secure, anxious, or avoidant they each are. Interventions can consider other relationship-related individual differences such as relationship goals. Canevello and Crocker report work showing that compassionate relationship goals motivate people to be more responsive to a close other who, in turn, is more responsive to them [85]. An important consideration for future research is that couples vary in the way they reflect reciprocal and dynamic processes between them.
Conflict of interest There is no conflict of interest. The authors have full control of all primary data and agree to allow the journal to review the data if requested.
Support Care Cancer (2015) 23:87–94
References 1. Eldredge DH, Nail LM, Maziarz RT, Hansen LK, Ewing D, Archbold PG (2006) Explaining family caregiver role strain following autologous blood and marrow transplantation. J Psychosoc Oncol 24(3):53–74 2. Meehan KR, Fitzmaurice T, Root L, Kimts E, Patchett L, Hill J (2006) The financial requirements and time commitments of caregivers for autologous stem cell transplant recipients. J Support Oncol 4:187–190 3. Wilson ME, Eilers J, Heermann JA, Million R (2009) The experience of spouses as informal caregivers for recipients of hematopoietic stem cell transplants. CancerNurs 32:15–23 4. Given BA, Given CW, Kozachik S (2001) Family support in advanced cancer. CA Cancer J Clin 51:213–231 5. Glajchen M (2004) The emerging role and needs of family caregivers in cancer care. J Support Oncol 2:145–155 6. Cain R, Maclean M, Sellick S (2004) Giving support and getting help: informal caregivers’ experiences with palliative care services. Palliat Support Care 2:265–272 7. Bowlby J (1969) Attachment (vol. 1). Basic Books, New York 8. Bowlby J (1982) Attachment and loss. Vol. 1: attachment, 2nd edn. Basic Books, New York 9. Bowlby J (1973) Attachment and loss. Vol 2. Basic Books, New York 10. Bowlby J (1980) Attachment and loss. Volume III: loss: sadness and depression. Basic Books, New York 11. Bowlby J (1988) A secure base. Basic Books, New York 12. Bretherton I (1987) New perspectives on attachment relations: security, communication, and internal working models. In: Osofsky J (ed) Handbook of infant development, 2nd edn. Wiley, New York 13. Hazan C, Zeifman D (1999) Pair-bonds as attachments: evaluating the evidence. In: Cassidy J, Shaver PR (eds) Handbook of attachment theory and research. Guilford, New York, pp 336–354 14. Ainsworth M, Blehar MC, Waters E, Wall S (1978) Patterns of attachment: assessed in the strange situation and at home. Erlbaum, Hillsdale 15. Hazan C, Shaver PR (1987) Romantic love conceptualized as an attachment process. J Pers Soc Psychol 2:511–524 16. Baldwin MW, Keelan JP, Fehr B, Enns V, Koh-Rangarajoo E (1996) Social cognitive conceptualization of attachment working models: availability and accessibility effects. J Pers Soc Psychol 71: 94–104 17. La Guardia JG, Ryan RM, Couchman CE, Deci EL (2000) Within – person variation in security of attachment. A self-determination theory perspective on attachment, need fulfilment, and well-being. J Pers Soc Psychol 79:367–384 18. Brennan KA, Clark CL, Shaver PR (1998) Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS (eds) In attachment theory and close relationships. Guilford Press, New York, pp 46–76 19. Mikulincer M, Shaver PR (2003) The attachment behavioral system in adulthood: activation, psychodynamics, and interpersonal processes. In: Zanna MP (ed) Advances in experimental social psychology (vol. 35). Academic Press, San Diego, pp 53–152 20. Ainsworth M (1989) Attachments beyond infancy. Am Psychol 44: 709–716 21. Mikulincer M, Gillath O, Halevy V, Avihou N, Avidom S, Eshkoli N (2001) Attachment theory and reactions to others’ needs: evidence that activation of the sense of attachment security promotes empathic responses. J Pers Soc Psychol 81:1205–1224 22. Shaver PR, Mikulincer M (2002) Dialogue on adult attachment: diversity and integration. Attach Hum Dev 4:243–257 23. Westmaas JL, Silver RC (2001) The role of attachment in responses to victims of life crises. J Pers Soc Psychol 80:425–438
93 24. Mikulincer M, Florian V (2000) Exploring individual differences in reactions to mortality salience: does attachment style regulate terror management mechanisms? J Pers Soc Psychol 79:260–273 25. Mikulincer M, Florian V, Hirschberger G (2003) The existential function of close relationships: introducing death into the science of love. Personal Soc Psychol Rev 7:20–40 26. Kissane DW, Bloch S, Burns WI, McKenzie D, Posterino M (1994) Psychological morbidity in the families of patients with cancer. Psychooncology 3:47–56 27. Steinglass P (2000) Family processes and chronic illness. In: Baider L, Cooper C, De-Nour A (eds) Cancer and the family. Wiley, West Sussex, pp 3–15 28. Van Doorn C, Kasl SV, Beery LC, Jacobs SC, Prigerson HG (1998) The influence of marital quality and attachment styles on traumatic grief and depressive symptoms. J Nerv Ment Dis 186(9):566–573 29. Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J et al (2002) Resilience to loss and chronic grief: a prospective study from pre-loss to 18-months post loss. J Pers Soc Psychol 83:1150–1164 30. Wayment HA, Vierthaler J (2002) Attachment style and bereavement reactions. J Loss Trauma 7:129–149 31. Mikulincer M, Shaver PR (2007) Attachment in adulthood: structure, dynamics and change. Guilford Press, New York 32. Kissane DW (2003) Psychological morbidity associated with patterns of family functioning in palliative care: baseline data from the family grief therapy controlled trial. Palliat Med 17:527–537 33. McLean LM, Walton T, Matthew A, Jones JM (2011) Examination of couples’ attachment security in relation to depression and hopelessness in maritally distressed patients facing end-stage cancer and their spouse caregivers: a buffer or facilitator of psychosocial distress. Support Care Cancer 19:1539–1548 34. Braun M, Mikulincer M, Rydall A, Walsh A, Rodin G (2007) Hidden morbidity in cancer: spouse caregivers. J Clin Oncol 25:4829–4834 35. Kayser K (2005) Enhancing dyadic coping during a time of crisis: a theory-based intervention with breast cancer patients and their partners. In: Revnson TA, Kayser K, Bodenmann G (eds) Couples coping with stress: emerging perspectives on dyadic coping. American Psychological Association, Washington, pp 175–194 36. Hunter MJ, Davis PJ, Tunstall JR (2006) The influence of attachment and emotional support in end-stage cancer. Psychooncology 15(5): 431–444 37. Bartholomew K, Shaver P (1998) Measures of attachment: do they converge? In: Simpson JA, Rholes WS (eds) Attachment theory and close relationships. Guilford Press, New York, pp 25–45 38. Feeney JA, Hohaus L (2001) Attachment and spousal caregiving. Pers Relatsh 8(1):21–39 39. Feeney BC, Collins NL (2001) Predictors of caregiving in adult intimate relationships: an attachment theoretical perspective. J Pers Soc Psychol 80(6):972–994 40. Feeney JA (1996) Attachment, caregiving, and marital satisfaction. Pers Relatsh 3(4):401–416 41. Gillath O, Shaver PR, Mikulincer M (2005) An attachment theoretical approach to compassion and altruism. In: Gilbert P (ed) Compassion: conceptualisations, research and use in psychotherapy. Routledge Press, New York, pp 121–147 42. Kunce LJ, Shaver PR (1994) An attachment-theoretical approach to caregiving in romantic relationships. In: Bartholomew K, Perlman D (eds) Attachment processes in adulthood: advances in personal relationships (vol 5). Jessica Kingsley Publishers, Bristol, pp 205–237 43. Collins NL, Read SJ (1994) Cognitive representations of attachment: the structure and function of working models. In: Bartholomew K, Perlman D (eds) Attachment processes in adulthood: advances in personal relationships (vol 5). Jessica Kingsley Publishers, Bristol, pp 53–92 44. Crittenden PM, Ainsworth MDS (1989) Child maltreatment and attachment theory. In: Cicchetti D, Carlson V (eds) Child maltreatment: theory and research on the causes and consequences of child
94
45.
46.
47.
48. 49. 50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61. 62.
63. 64.
65.
Support Care Cancer (2015) 23:87–94 abuse and neglect. Cambridge University Press, New York, pp 432– 463 Britton PC, Fuendeling JM (2005) The relations among varieties of adult attachment and the components of empathy. J Soc Psychol 145(5):519–530 Joireman JA, Needham TL, Cummings A (2002) Relationships between dimensions of attachment and empathy. N Am J Psychol 4(1):63–80 Collins NL, Feeney BC (2000) A safe haven: an attachment theory perspective on support seeking and care giving in intimate relationships. J Pers Soc Psychol 78:1053–1073 Hamilton WD (1964) The genetical evolution of social behavior. I and II. J Theor Biol 7:1–52 Brody EM (1990) Women in the middle: their parent-care years. Springer, New York Martire LM, Stephens MA, Townsend AL (2000) Centrality of women’s multiple roles: beneficial and detrimental consequences for psychological well-being. Psychol Aging 15:148–156 Collins C, Jones R (1997) Emotional distress and morbidity in dementia carers: a matched comparison of husbands and wives. Int J Geriatr Psychiatry 12:1168–1173 Rose-Rego SK, Strauss ME, Smyth KA (1998) Differences in the perceived well-being of wives and husbands caring for persons with Alzheimer’s disease. Gerontologist 38:224–230 Kurtz ME, Given B, Kurtz JC, Given CW (1994) The interaction of age, symptoms, and survival status on physical and mental health of patients with cancer and their families. Cancer 74(7 Suppl):2071–2078 Kurtz ME, Kurtz JC, Given CW, Given BA (2004) Depression and physical health among family caregivers of geriatric patients with cancer: a longitudinal view. Med Sci Monit 10:CR447–CR456 Kobak RR, Sceery A (1988) Attachment in late adolescence: working models, affect regulation, and representations of self and others. Child Dev 59:135–146 Manne SL, Ostroff J, Winkel G, Grana G, Fox K (2005) Partner unsupportive responses, avoidant coping, and distress among women with early stage breast cancer: patient and partner perspectives. Health Psychol 24(6):635–641 Reinhardt JP (2001) Effects of positive and negative support received and provided on adaptation to chronic visual impairment. Appl Dev Sci 5(2):76–85 Northouse LL, Mood D, Templin T, Mellon S, George T (2000) Couples’ patterns of adjustment to colon cancer. Soc Sci Med 50: 271–284 Kuijer RG, Buunk BP, Ybema JF, Wobbes TH (2002) The relation between perceived inequity, marital satisfaction and emotions among couples facing cancer. Br J Soc Psychol 41:39–56 Kim Y, Carver CS (2007) Frequency and difficulty in caregiving among spouses of individuals with cancer: effects of adult attachment and gender. Psycho-Oncology 16:714–723 Pistole CM (1994) Adult attachment styles: some thoughts on closeness-distance struggles. Fam Process 33(2):147–159 Kim Y, Carver CS, Deci EL, Kasser T (2008) Adult attachment and psychological well-being in cancer caregivers: the mediational role of spouses’ motives for caregiving. Health Psychol 27(2Suppl):S144– S154. doi:10.1037/0278-33.27.2(Suppl.).S144 Erdman P, Caffery T (2003) Attachment and family systems. Brunner-Routledge, New York Whiffen V (2003) What attachment theory can offer marital and family therapists. In: Johnson S, Whiffen V (eds) Attachment processes in couple and family therapy. Guilford, New York Johnson SM, Bradley B, Furrow J et al (2005) Becoming an emotionally focused therapist: the workbook. Routledge, New York
66. Greenberg L (2002) Emotion-focused therapy: coaching clients to work through their feelings. American Psychological Association, Washington 67. Johnson S, Sims A (2000) Attachment theory: a mape for couples therapy. In: Levy TM (ed) Handbook of attachment interventions. Academic Press, Santiego, pp 172–192 68. House JS, Landis KR, Umberson D (1988) Social relationships and health. Science 421:540–545 69. Martire LM, Helgeson VS, Saghafi EM (2010) Review and metaanalysis of couple-oriented interventions for chronic illness. Ann Behav Med 40:325–342 70. Badr H (2004) Coping in marital dyads: a contextual perspective on the role of gender and health. Pers Relatsh 11:197–211 71. Hill KM, Amir Z, Muers MF, Connolly CK, Round CE (2003) Do newly diagnosed lung cancer patients feel their concerns are being met? Eur J Cancer Care 12:35–45 72. Hagedoorn M, Buunk BP, Kuijer RG, Wobbes T, Sanderman R (2000) Couples dealing with cancer: role and gender differences regarding psychological distress and quality of life. PsychoOncology 9:232–242 73. Hinnen C, Ranchor AV, Sanderman R, Snijders TAB, Hagedoorn M, Coyne JC (2008) Course of distress in breast cancer patients, their partners and control couples: implications for psychological interventions. Ann Behav Med 36:141–148 74. Manne SL, Taylor KL, Dougherty J, Kemeny N (1997) Supportive and negative responses in the partner relationship: their association with psychological adjustment among individuals with cancer. J Behav Med 20(2):101–125 75. Leiber L, Plumb MM, Gerstenzang ML, Holland J (1976) The communication of affection between cancer patients and their spouses. Psychosom Med 38:379–389 76. Friedman L, Baer P, Nelson D, Lane M et al (1988) Women with breast cancer: perception of family functioning and adjustment to illness. Psychosom Med 50:529–540 77. Shields CG, Travis LA, Rousseau SL (2000) Marital attachment and adjustment in older couples coping with cancer. Aging Ment Health 4(3):223–233 78. Belcher AJ, Laurenceau JP, Graber EC, Cohen LH, Dasch KB, Siegel SD (2011) Daily support in couples coping with early stage breast cancer: maintaining intimacy during adversity. Health Psychol 30(6): 665–673 79. Clark MS, Lemay EP Jr, Graham SM, Pataki SP, Finkel EJ (2010) Ways of giving benefits in marriage: norm use and attachment-related variability. Psychol Sci 21:944–951 80. Meredith P, Ownsworth T, Strong J (2008) A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model. Clin Psychol Rev 28:407–429 81. Pietromonaco PR, Greenwood D, Barrett LF (2004) Conflict in adult close relationships: an attachment perspective. In: Rholes WS, Simpson JA (eds) Adult attachment: new directions and emerging issues. Guilford Press, New York, pp 267–299 82. Wilson CL, Ruben MA (2011) A pain in her arm: romantic attachment orientations and the tourniquet task. Pers Relatsh 18:242–265 83. Magai C (2008) Attachment in middle and later life. In: Cassidy J, Shaver PR (eds) Handbook of attachment: theory, research, and clinical applications, 2nd edn. Guilford Press, New York, pp 532–551 84. Karantzas GC, Evans L, Foddy M (2010) The role of attachment in current and future parent caregiving. J Gerontol Psychol Sci 65B(5): 573–580 85. Canevello A, Crocker J (2010) Creating good relationships: responsiveness, relationship quality, and interpersonal goals. J Pers Soc Psychol 99(1):78–106
