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Reciprocal Empathy and Working Alliance in Terminal Oncological Illness: The Crucial Role of Patients’ Attachment Style a

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Vincenzo Calvo PhD , Arianna Palmieri PhD , Sara Marinelli MSc , a

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Francesca Bianco MSc & Johann R. Kleinbub MSc a

Department of Philosophy, Sociology, Pedagogy and Applied Psychology, University of Padova, Padova, Italy Accepted author version posted online: 02 Jul 2014.Published online: 11 Sep 2014.

Click for updates To cite this article: Vincenzo Calvo PhD, Arianna Palmieri PhD, Sara Marinelli MSc, Francesca Bianco MSc & Johann R. Kleinbub MSc (2014) Reciprocal Empathy and Working Alliance in Terminal Oncological Illness: The Crucial Role of Patients’ Attachment Style, Journal of Psychosocial Oncology, 32:5, 517-534, DOI: 10.1080/07347332.2014.936651 To link to this article: http://dx.doi.org/10.1080/07347332.2014.936651

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Journal of Psychosocial Oncology, 32:517–534, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0734-7332 print / 1540-7586 online DOI: 10.1080/07347332.2014.936651

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Reciprocal Empathy and Working Alliance in Terminal Oncological Illness: The Crucial Role of Patients’ Attachment Style VINCENZO CALVO, PhD, ARIANNA PALMIERI, PhD, SARA MARINELLI, MSc, FRANCESCA BIANCO, MSc, and JOHANN R. KLEINBUB, MSc Department of Philosophy, Sociology, Pedagogy and Applied Psychology, University of Padova, Padova, Italy

Security of attachment is described as an inner resource that may also facilitate the adaptation of individuals during critical life adversity, even when facing end-stage illness and death. This study assessed the relation between attachment styles, patient–caregiver reciprocal empathy, and patient–physician working alliance, in the terminal phase of an oncological disease. We hypothesized that the attachment security of patients, as measured by the Relationship Questionnaire (RQ), is related to the reciprocal empathy with the caregiver, as measured by the Perception of Partner Empathy (PPE) questionnaire, and to the working alliance with the physician, as measured by the Working Alliance Inventory–Short Form (WAI-S). Thirty-seven end-stage cancer patients, their caregivers, and physicians participated in the study. The PPE and WAI-S were administered twice: immediately after the hospice recovery and a week later. Results showed a significant improvement in patient–caregiver empathy and in patient–physician alliance after a week at the hospice. Findings indicated that the patients’ attachment style influenced their perception of reciprocal empathy with the caregiver and the working alliance with the physician. Patients with a secure attachment had a greater capacity to show empathic closeness with their caregivers and enjoyed a better working alliance with their physicians. Caregivers’ attachment security, otherwise, did not show the same influence on empathy and alliance. Findings support the

Address correspondence to Vincenzo Calvo, PhD, Department of Philosophy, Sociology, Pedagogy and Applied Psychology, University of Padova, via Venezia 8, Padova, Italy. E-mail: [email protected] 517

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hypothesis that patients’ attachment security plays a crucial role in the relation with their own caregiver and with the physician, even at the terminal phase. Theoretical and clinical implications of these findings are explored in the discussion.

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KEYWORDS caregiver

attachment, cancer, empathy, working alliance,

Independently from the many physical symptoms characterizing an endstage oncological condition, intense psychological distress and suffering is commonly found in these patients and in their caregivers, who are very often spouses (Nijboer et al., 1998; Pitceathly & Maguire, 2003). Although the cancer stage diagnosis and clinical symptoms may be similar in these patients, there appears, nevertheless, to be considerable individual variation in the level of distress that is experienced. Psychosocial factors appear to be linked to these differences, and recent studies (Braun, Mikulincer, Rydall, Walsh, & Rodin, 2007; Gauthier et al., 2012; Hunter, Davis, & Tunstall, 2006; McLean, Walton, Matthew, & Jones, 2011; Porter et al., 2012) suggested that the patient’s attachment style (affectional bond or tie between an individual and an attachment figure, generally a caregiver) is particularly salient in this context. Attachment theory, in fact, postulates that experiences in early-childhood relationships create internal working models and attachment styles that systematically affect close relationships throughout an individual’s lifetime (Bowlby, 1973, 1980; Mikulincer & Shaver, 2007). Four specific categorical attachment styles have been identified in adults (Bartholomew & Horowitz, 1991): one is a secure style and the other three—dismissing-avoidant, ambivalent or preoccupied, and fearful avoidant—are insecure ones. According to this theory, persons with a secure attachment style are adults who are able to manage discomforting situations in a constructive way without being overwhelmed by negative emotions (Kobak & Sceery, 1988; Mikulincer, Florian, & Weller, 1993; Shaver & Hazan, 1993) and are capable of turning to others for practical and psychological support (Kobak & Sceery, 1988). In general terms, security of attachment could be seen as an internal resource that facilitates management of stress and fear by promoting the individuals’ adaptation and helping them to handle these emotions in a more positive way throughout the lifetime (Florian & Mikulincer, 1998). Adults with a secure attachment have had the opportunity to form positive, warm, sensitive attachments during their lifetimes permitting them to develop a strong sense of internal security that acts as an inner resource for managing life’s adversities (Florian & Mikulincer, 1998). According to Mikulincer et al. (1993), persons with a secure attachment seem to be able to react to extremely adverse situations in a more positive way with respect to insecure persons. They are, moreover, able to rely on others for emotional

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and practical support and show relatively low levels of post-traumatic stress (Gauthier et al., 2012; Mikulincer et al., 1993). Attachment theory postulates that individuals with insecure attachment have usually experienced and/or perceived significant attachment figure unavailability during their early life. This developmental unavailability

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compounds the distress aroused by actual dangers and threats, and triggers a cascade of mental and behavioral processes that can jeopardize emotional well-being, personal adjustment, and relationship satisfaction and stability. This painful series of events forces a person to adopt a secondary attachment strategy (hyperactivation, deactivation), or a combination of the two. (Mikulincer & Shaver, 2007, p. 39)

Hyperactivating strategies are the key features of the anxious (i.e., ambivalent or preoccupied) attachment style, and their main goal is to get the attachment figure to provide more protection, support, or closeness. These strategies encompass relational overdependence; extreme demands for attention and care; attempts to minimize cognitive, emotional, and physical distance from a partner; and clinging or controlling attachment figure’s behavior (Mikulincer & Shaver, 2007). In contrast, deactivating strategies are the most salient characteristics of individuals with avoidant attachment. Avoidant people display two main relational goals: (1) gaining their affective purposes while maintaining distance, control, and self-reliance and (2) avoiding, ignoring, or denying emotional needs, dependence, and intimacy (Mikulincer & Shaver, 2007). Deactivating (i.e., avoidant) strategies include denial of attachment needs, “compulsive self-reliance,” and dismissal of threats and of the need for attachment figure availability (Mikulincer & Shaver, 2007). Some individuals, intensely insecure, are unable to develop an organized attachment style, choosing between hyperactivating and deactivating strategies. Such people were classically defined as “fearful avoidant” by Bartholomew and Horowitz (1991). They may enact hyperactivating and deactivating strategies in an incoherent, confused, and chaotic manner (Bartholomew & Horowitz, 1991). Fearful avoidant people cope stressful perceived events by withdrawing and distancing themselves from relationship partners, like dismissingly avoidant individuals; at the same time, they continue to experience anxiety, ambivalence, and desire for the attachment figure’s love and support, like anxious individuals. Theoretically, fearful avoidance is the consequence of the failure to achieve any of the goals of the major attachment strategies: safety and security following proximity seeking (the secure strategy), defensive deactivation of the attachment system (the avoidant strategy), or intense and chronic activation of the attachment system until security enhancing proximity is attained (the anxious strategy) (Mikulincer & Shaver, 2007).

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In general, the literature consistently describes that individuals with insecure attachment tend to rely on less effective coping methods in similar stressful situations (Kobak & Sceery, 1988; Mikulincer, 1995; Mikulincer & Florian, 1995; Mikulincer et al., 1993; Mikulincer & Orbach, 1995; Shaver & Hazan, 1993). Indeed, the capacity of emotion regulation varies specifically in connection to the individual’s attachment style, as suggested also by neural correlates studies, indicating that fearful avoidant or preoccupied individuals become highly emotional when threatened with social rejection or relationship loss, whereas dismissing-avoidant individuals tend to distance themselves or to disengage from emotional situations (Gillath, Bunge, Shaver, Wendelken, & Mikulincer, 2005). In accordance with these premises, some authors have reported that a secure attachment style can have protective effects in cancer patients as far as mood is concerned, an effect that is partially mediated by the individual’s sense of security favored by the attachment style and a better social support system (Rodin et al., 2009; Rodin et al., 2007). Porter et al. (2012) recently evaluated attachment styles in a large sample of terminal oncological patients and in their caregivers. According to their findings, a secure attachment style of the individual and the couple fostered marital well-being, a better management of anxiety and depression and, in general, a better social adaptation (Porter et al., 2012). Hunter et al. (2006) likewise confirmed the importance of attachment style in a group of terminal oncological patients and highlighted the positive effect of secure attachment when individuals are facing negative emotions characterizing the final phase of an oncological disease. The concept of empathy, which appears to be crucial in determining an altruistic, prosocial behavior, seems to be strongly connected to the individual’s attachment style. Indeed, in a number of studies, Batson (1991) demonstrated that lack of empathy can be due to a lack of a prosocial behavior toward others or to the arousal of what he calls “personal distress,” a form of self-focused agitation and discomfort that does not translate into effective helping. The relationship between empathy and attachment has not been adequately addressed in studies focusing on oncological terminality probably also because of the multidimensional nature of the empathy construct, which implies emotional contagion (Sonnby-Borgstr¨om, J¨onsson, & Svensson, 2003), emotion recognition (Losoya & Eisenberg, 2001), cognitive empathy (Frith & Frith, 2005; Preston et al., 2007), different behavioral responses such as prosocial behaviors (Eisenberg, 2007; Stocks, Lishner, & Decker, 2009), and physiological concordance (Messina, Palmieri, et al., 2013). In general terms, empathy has been described as “the capacity to know emotionally what another is experiencing from within the frame of reference of that other person, the capacity to sample the feelings of another or to put one’s self in another’s shoes” (Berger, 1987, p. 6). The loss of empathy has been found, in fact, to have an important effect on patient–caregiver

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couples in the medical context (Hsieh, Irish, Daveson, Hodges, & Piguet, 2013). Another relevant aspect linked to the centrality of the attachment style in end-stage cancer can be found in the relationship between the oncologic patient and the attending physician. Identifying the patient’s attachment style can help us evaluate individual differences in patients with regard to trust, satisfaction, and stress, as demonstrated by a recently published study by Holwerda et al. (2012). An interesting review by Hillen, de Haes, and Smets (2011) underlined how oncologic patients, who confidently entrust their care to their attending physician, seem to have less fear of disease progression and better therapeutic adherence. As stated by those authors (Hillen et al., 2011), the influence of the individual’s capacity to trust the physician has not been thoroughly studied, although it is considered a key concept for oncologic psychology. In general, the patient–physician relationship has mainly been studied in terms of the working alliance construct, which has long been examined in psychotherapy relationships and was first articulated by Greenson (1967). The working alliance is described as the most consistent and reliable predictor of outcome across modalities of psychological treatment, and some authors have defined it as the sine-qua-non condition of effective treatment in terms of patient adherence and satisfaction (Fuertes et al., 2007). There are few studies exploring attachment styles as a variable affecting the working alliance between patients and physicians. The aim of this study was to explore the relation between attachment styles, patient–caregiver reciprocal empathy, and patient–physician working alliance, in the terminal phase of an oncological disease. In view of the multidimensional nature of the empathic construct, the Perception of Partner Empathy (PPE) questionnaire (Jenick, 2003), which is expressly concerned with couple reciprocal empathy, was chosen. The patient–physician alliance was evaluated using the Working Alliance Inventory–Short Form (WAI-S; Tracey & Kokotovic, 1989). The WAI-S was administered to the patient (Client form) and the hospice physician (Therapist form). To investigate the progression of the reciprocal empathy and of the working alliance during the first period at the hospice, the WAIS-S and the PPE questionnaires were administered twice: on the 2nd day after admission to the hospice and a week later (on the 9th day after their admission), when the patients and their caregiver had become acclimated and accustomed to the new living condition at the hospice. We hypothesized that attachment security of patients and their caregivers, as measured by the Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991), can decisively influence the perception of reciprocal patient–caregiver empathy and the alliance with the physician. A better understanding of the role of attachment style in oncological terminal phase could help clinicians better tailor individualized

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psychological interventions for patients and caregivers, by taking into account the individuality and peculiarity of their relations.

METHOD

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Participants Thirty-seven end-stage cancer patients admitted to a hospice participated to this study, together with each patient’s main caregiver, and their staff physicians. All the patients had a diagnosis of end-stage cancer (3 three patients had skin cancer, 3 brain cancer, 3 gastric cancer, 3 intestinal cancer, 3 prostate cancer, 5 breast cancer, 5 colon cancer, 6 pancreatic cancer, & 6 lung cancer); 17 were women (46%) and 20 men (54%); the patients’ mean age was 66.04 years (SD = 5.12). The patients were not affected with concomitant, serious conditions such as mental deficits, important medical complications, or serious states of depression or denial, as determined by a routine clinical interview. The main caregiver, the person who took care of the patient at the hospice, was in the majority of cases the spouse (24 of 37) or another member of the family (6 children, 3 cousins, 1 son-in-law). In three cases, the patient’s main caretaker was a person outside the family circle (two friends and one social worker). There were 13 women (35.14%) and 24 men (64.86%). The age range of the caregivers fell between 40 and 70 years. The medical staff, made up of four physicians (three men and one woman) who daily visited the patients, also participated in the study.

Instruments and Procedure The attachment style of the patients and their caregivers was evaluated on the second day after admittance to the hospice using the RQ (Bartholomew & Horowitz, 1991), which is a classic self-report questionnaire that proposes four brief descriptions of prototypical attachment styles (secure, dismissingavoidant, preoccupied, fearful avoidant). Patients were asked to choose a single, best-fitting attachment pattern description. Such choice provides the categorical measure of individual attachment style. According to the literature, the RQ showed adequate test–retest reliability and evidence of convergent, discriminant, and predictive validity (Ravitz, Maunder, Hunter, Sthankiya, & Lancee, 2010). The reciprocal empathy of the patient-caregiver couples was evaluated using the PPE questionnaire (Jenick, 2003) that was administered to the patients and their main caregiver. The PPE questionnaire is a 10-item subset of the Revised Barrett-Lennard Relationship Inventory (Barrett-Lennard, 1986)

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selected to assess the respondent’s perception of the degree to which he or she felt understood by the own partner. The items used in this research were the same ones utilized by Jenick (2003) and Pistrang and Barker (1992, 1995) in their cancer research and were chosen on the basis of Cramer’s factor analysis from the empathy subscale of the Revised Barrett-Lennard Inventory (Cramer, 1986). Respondents were asked to rate each item on a 6-point scale, from 1 (low empathy) to 6 (high empathy). The total empathy score of the respondents ranges from a minimum score of 10 (low empathy) to the maximum score of 60 (high empathy), and it was calculated for the patients and their own caregivers. Coefficient alpha for this scale was 0.84 (Pistrang & Barker, 1995), and 0.92 in this research. The Italian version of the Barrett-Lennard Relationship Inventory was found to be a reliable and valid measure (Messina, Sambin, & Palmieri, 2013). The alliance between the patient and physician was evaluated using the Working Alliance Inventory–Short Form (WAI-S; Tracey & Kokotovic, 1989), which was administered to the patient (Client form) and to the attending physician (Therapist form). Commonly used to evaluate the patient–physician relationship (Busseri & Tyler, 2003; Hanson, Curry, & Bandalos, 2002; Martin, Garske, & Davis, 2000), this inventory is a 12-item instrument scored on a 7-point Likert-type scale (1 = never, and 7 = always) and assesses the definition of alliance in a general sense (General Alliance or Total Score) and in three subscales, each made up of four items and considered specific aspects of the alliance (Goal, Task, and Bond). Based on Bordin’s (1979) working alliance theory, its three parts are: Goals (agreement about the goals of therapy), Tasks (agreement about the tasks of therapy), and Bond (the bond between the patient and the therapist). Research data showed that the WAI has adequate reliability and validity (Horvath & Greenberg, 1989). The PPE questionnaire and the WAI-S inventory were administered twice: once on the second day at the hospice (Time 1) and another time a week later (Time 2) to estimate the modifications in patients, caregivers, and physicians reciprocal adaptation during the initial phase of the hospice stay. The procedure was fully approved by our university ethical committee and all participants signed an informed consent.

Data Analysis Changes in reciprocal empathy and working alliance over time (Time 1 vs. Time 2) were analyzed using paired t tests. The effects of the attachment style of the patient and the caregiver on empathy and on the working alliance (evaluated at Time 2) were analyzed with ANOVA. The analyses were carried out considering the attachment style

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as the independent variable and the measures of empathy and of alliance (at Time 2) as the dependent variables.

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RESULTS Firstly, we investigated the progression of the reciprocal patient–caregiver empathy and the patient–physician working alliance during the first period at the hospice. The scores collected immediately after admittance (on the 2nd day, Time 1) were compared with those scored a week later (on the 9th day, Time 2) using paired t tests. These analyses identified a statistically significant increase in the empathy of the caregiver perceived by the patient, t(36) = −3.89, p < .001, as well as in the empathy of the patient perceived by the caregiver, t(36) = –3.89, p < .001. The empathy of the caregiver and that of the patient did not, however, result significantly correlated with one another, neither at Time 1, r(37) = –.02, p = .896 nor at Time 2, r(37) = −.06, p = .721. Furthermore, toward the physician, the patients showed a statistically significant increase in their General Alliance, t(36) = –4.07, p < .001, and in the Goal, t(36) = –2.12, p = .041, and Task scores, t(36) = –3.96, p < .001, but not in the Bond one, t(36) = –.92, p = .362. Similarly, the physicians increased their Working Alliance scores in the time period between the 2nd and the 9th day. In particular, the t test comparison highlighted a significant increase in the General Alliance t(36) = –5.85, p < .001, as well as in the Goal, t(36) = –4.84, p < .001, Task, t(36) = −2.70, p = .010 and Bond dimensions, t(36) = –4.62, p < .001. Table 1 outlines paired t test results. The second aim of the study was to verify if attachment style had any effect on the reciprocal empathy between patients and caregivers and on the working alliance between patients and physician. Before attempting to verify this hypothesis, we analyzed the attachment distribution of the participants, resulting from the RQ questionnaire. According to that instrument, 10 patients (27%) had a secure attachment style, 13 (35.1%) had a dismissingavoidant one, 8 (21.6%) a preoccupied one, and 6 (16.2%) a fearful avoidant one. Of the caregivers, 7 (18.9%) had a secure attachment style, 1 (2.7%) a dismissing-avoidant one, 16 (43.2%) a preoccupied one, and 13 (35.1%) a fearful avoidant one. To verify the effect of the attachment style on the working alliance, we carried out one-way ANOVAs, considering the patient’s attachment style as independent variable at four levels and measures of empathy and working alliance at Time 2 as dependent variables. ANOVAs detected significant effects when the effects of the patients’ attachment style on the caregiver’s empathy, F(3, 33) = 39.07, p < .001 and on the patient’s empathy assessed by the caregiver, F(3, 33) = 6.30, p = .002. Post hoc comparisons, using

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TABLE 1 Changes of Reciprocal Empathy and Working Alliance in the First Days After Admittance to the Hospice (Paired t Test)

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Perception of empathy Caregivers’ empathy Patients’ empathy Working alliance according to patients (WAI-S) General Alliance Goal Task Bond Working alliance according to physicians (WAI-S) General Alliance Goal Task Bond

Time 1 M (SD)

Time 2 M (SD)

Paired t Test

df

Significance (two-tailed)

35.84 (8.71) 38.22 (7.66)

38.14 (8.55) 39.73 (7.80)

−3.89 −5.19

36 36

.000 .000

67.16 22.08 22.30 22.78

(8.05) (3.28) (2.46) (2.97)

68.65 22.68 23.03 22.95

(8.78) (3.58) (2.65) (2.91)

−4.08 −2.12 −3.96 −0.92

36 36 36 36

.000 .041 .000 .362

60.73 18.19 22.78 19.76

(2.75) (1.68) (1.06) (1.30)

63.76 19.84 23.27 20.65

(2.80) (1.52) (.73) (1.18)

−5.85 −4.84 −2.70 −4.62

36 36 36 36

.000 .000 .010 .000

Note: WAI-S = Working Alliance Inventory–Short Form. Time 1 = the 2nd day after admittance to the hospice, Time 2 = the 9th day after admittance.

the Student-Newman-Keuls test, indicated that the patients with secure attachment styles perceived the greatest level of empathy on the part of their caregivers, followed by those with a preoccupied attachment; the dismissingavoidant and the fearful avoidant patients perceived the same, lowest level of empathy. As far as the patient’s empathy as perceived by the caregiver was concerned, post hoc comparisons uncovered that fearful avoidant, secure, and dismissing-avoidant patients showed similar levels of empathy, and all had higher scores with respect to the preoccupied ones. The ANOVA analysis revealed a significant effect linked to the patient’s attachment style on all the alliance measures evaluated by the patient. Patient’s attachment had a significant effect on patient’s General Alliance, F(3, 33) = 56.74, p < .001, Goal, F(3, 33) = 40.23, p < .001, Task, F(3, 33) = 32.25, p < .001, and Bond, F(3, 33) = 47.40, p < .001. All post hoc comparisons indicated that the secure patients had the highest scores of alliance, followed by the preoccupied patients, then by the fearfully avoidant, and finally by the dismissing-avoidant patients. The patient’s attachment style did not have a significant effect on the working alliance perceived by the physician. More in detail, patient’s attachment style did not affect General Alliance, F(3, 33) = 2.02, p = .128; Goal, F(3, 33) = 1.07, p = .375; Task, F(3, 33) = 1.00, p = .406; and Bond dimensions, F(3, 33) = 2.13, p = .115, according to the physician’s perception. The mean scores for all of the attachment styles are outlined in Table 2. The F ratios computed from the ANOVA together with the results of the

526 M SD M SD M SD M SD M SD M SD M SD M SD M SD M SD

47.50 1.08 42.80 5.75 78.80 2.15 26.40 1.17 26.10 0.57 26.30 1.06 65.10 3.41 20.50 1.90 23.60 0.70 21.00 1.41

31.62 6.69 39.31 7.26 59.08 5.47 2.51 0.697 20.46 2.03 19.77 1.79 63.77 2.65 19.67 1.86 23.23 0.83 20.62 1.26

Dismissingavoidant (n = 13)

S-N-K = Student-Newman-Keuls test. a. Post Hoc S-N-K comparisons between groups significant for p < .05. 1 = secure, 2 = dismissing-avoidant, 3 = preoccupied, 4 = fearful avoidant.

Physician’s bond alliance

Physician’s task alliance

Physician’s goal alliance

Physician’s general alliance

Patient’s bond alliance

Patient’s task alliance

Patient’s goal alliance

Caregiver’s empathy perceived by the patient Patient’s empathy perceived by the caregiver Patient’s general alliance

Measures

Secure (n = 10) 43.25 1.49 32.00 7.78 72.13 0.35 24.63 0.52 23.88 0.35 23.63 0.52 62.25 2.19 19.00 0.76 23.13 0.64 20.13 0.99

Preoccupied (n = 8)

Patient’s Attachment

29.83 1.72 45.83 2.78 67.83 3.13 22.17 1.33 22.33 1.51 23.33 1.21 63.50 2.17 19.67 1.86 23.00 0.63 20.83 0.75

Fearful avoidant (n = 6)

TABLE 2 The Effect of Patient’s Attachment on Reciprocal Empathy and Working Alliance Measures

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4, 1, 2 > 3 1>3>4>2 1>3>4>2 1>3>4>2 1 > 3, 4 > 2 ns ns ns ns

.000 .002 .000 .000 .000 .000 .200 .219 .374 .473

39.07 6.30 56.74

0.86

1.07

1.55

1.63

47.40

32.25

40.23

1 > 3 > 2, 4

p Value

F

Post Hoc S-N-Ka

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Student-Newman-Keuls test for the pairwise comparisons among the four attachment groups are also presented. The same type of ANOVA analyses were carried out to verify the effect of the caregiver’s attachment on the measures of empathy and alliance. The attachment of the caregiver had a significant effect only on the patient’s empathy perceived by the caregiver, F(3, 33) = 107.10, p < .001. Secure caregivers perceived the patient as more empathic with respect to unsecure caregivers. The other ANOVA analyses did not reach significance. The caregiver’s attachment did not, therefore, significantly affect the empathy of the caregiver perceived by the patient, F(3, 33) = .54, p = .660, nor the measures of alliance perceived by the patient, General Alliance, F(3, 33) = 1.01, p = .401; Goal, F(3, 33) = 1.23, p = .315; Task, F(3, 33) = 0.69, p = .566; Bond, F(3, 33) = 1.00, p = .405. Similarly, caregiver’s attachment did not show an effect on the alliance perceived by the physician, General Alliance, F(3, 33) = 2.03, p = .128; Goal, F(3, 33) = 1.07, p = .375; Task, F(3, 33) = 1.00, p = .406; Bond, F(3, 33) = 2.13, p = .115.

DISCUSSION AND CONCLUSIONS This study, which evaluated 37 terminal cancer patients and their respective caregivers and physicians, aimed to investigate whether self-reported attachment style affects two crucial psychological aspects of the disease’s terminal stage: reciprocal empathy between patient and caregiver and the quality of the working alliance instituted between the patient and the physician. The progression in the patient–caregiver reciprocal empathy and the working alliance between patient and physician was investigated on a preliminary level comparing the test results of specific instruments 2 and 9 days after participants were admitted to a hospice. Analysis of these data uncovered a statistically significant increase in the reciprocal empathy with regard to the empathy of the caregiver as perceived by the patient as well as the empathy of the patient as perceived by the caregiver. There was, likewise, a statistically significant increase in the global measure of the therapeutic alliance, as defined by the patient and the physician. Statistical analyses showed that patients’ attachment style had significant effect on patients–caregivers reciprocal empathy, as perceived by both of them. Post hoc statistical comparisons have, moreover, underlined that patients with secure attachments perceived the greatest level of empathy in their caregivers, followed by the preoccupied persons, then, with a similar score, by the dismissing-avoidant, and finally by the fearful avoidant ones. Our results are consistent with the attachment model developed by Kim Bartholomew (Bartholomew, 1990; Bartholomew & Horowitz, 1991) according to which an individual’s attachment orientation can be seen as the function of two dimensions: the person’s image of the self, dichotomized as

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positive or negative (the self as worthy of love and support or not), and the person’s image of the other, also dichotomized as positive or negative (other people are seen as trustworthy and available vs. unreliable and rejecting). Four prototype forms of attachment patterns can thus be derived from a combination of the two dimensions. The secure style characterizes patients who have a positive image of themselves and of others. The dismissing-avoidant style characterizes patients who have a positive image of themselves and a negative one of others. The preoccupied patients have a negative image of themselves and a positive image of others, and fearful avoidant individuals are characterized by a negative image of themselves and others. Consistently with this model, our research has uncovered that patients who have an attachment orientation characterized by a negative image of others (dismissing-avoidant and fearful avoidant) tend to have the most negative perception of the empathy transmitted by the caregiver. On the other side, the patients who have an attachment orientation characterized by a positive image of others (secure and preoccupied) perceived more positively the caregiver’s empathy. The attachment style of the caregiver was not found to have the same crucial role in affecting the perception of reciprocal empathy between patients and caregivers; it had a significant effect only on the patients’ empathy perceived by caregivers. More specifically, secure caregivers describe the patients as more empathic with respect to the insecure caregivers. This result suggests that caregivers characterized by attachment security may be less vulnerable during the terminal phase of the disease as they tend to perceive greater emotional reciprocity on the part of the patient. As far as the physician–patient relationship is concerned, patients’ attachment style was found to significantly affect their perception of working alliance. All post hoc statistical comparisons indicated that secure patients have the highest scores of alliance, followed by the preoccupied, then the fearful avoidant, and finally the dismissing-avoidant individuals. As already stated, these data indicate that secure attachment functions as a sort of internal resource promoting the individual’s adaptation even in the difficult context of being an end-stage patient in a hospice. In this respect, secure attachment seems to facilitate trust toward the physician, promoting a positive alliance. As could be expected, the attachment style of patients characterized by a negative image of others (Bartholomew & Horowitz, 1991) seems to have the strongest negative effect on the alliance with the physician. Patients’ attachment style does not seem to have significant effects on the working alliance as seen by the physician. In other words, physicians tend to judge their relationship with patients independently from their attachment. This might be explained by the role that the specialist is constrained to play in this type of facility. The literature reports, in fact, that physicians find becoming emotionally involved with their patients stressful due to their

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professional training but also as a defense mechanism (Buckman, 1992). An oncological disease, in particular at its terminal stage, forces the physicians to face with the pain and anguish that are linked to imminent death (K¨ublerRoss, 1988), causing them to maintain greater emotional distance. Moreover, the relational asymmetry between patient and physician in terms of reciprocal dependence may be relevant to explain this result. The physician may play a role for the end-stage patient as attachment figure; vice versa, it is much less likely that the patient may serve as attachment figure in the physician’s perspective. The most relevant finding that emerges from this study, and which needs further consideration, is that the attachment style of the patients influence in a decisive manner their own perception of the reciprocal empathy shared with the caregiver and the strength of the working alliance with the physician. On the basis of our results, the protective factor and access to greater resources observed in secure patients seem to be protective even in the face of the prospect of death. Other studies have already underlined how healthy individuals with a secure attachment style show less fear of death and a higher level of awareness with respect to insecure ones (Mikulincer, Florian, & Tolmacz, 1990). An interesting aspect emerging from our findings is that the attachment style of the patient was found to have a greater effect on the reciprocal empathy between patient—caregiver than did the attachment style of the caregiver. Some researchers have evaluated the protective role of attachment security of caregivers (Kim & Carver, 2007; Kim, Carver, Deci, & Kasser, 2008), but there is little data in the literature concerning the role of patients’ attachment with respect to the reciprocal empathy between caregivers and patients, and the working alliance relationship of end-stage patients with their physicians. Secure patients perceive their caregiver in a more empathic light with respect to insecure patients, and above all the caregiver feels that he or she is understood to a greater extent by the patient with a secure attachment style. Consistent with previous findings (Fergus, Gray, Fitch, Labrecque, & Phillips, 2002), our results suggest that we may be coming to a turning point in the conceptualization of the patient as only a care recipient and of the caretaker as only a care giver. Conceivably, fostering a sense of mutuality could have a positive effect when a person in a close relationship is ill, even if the patient’s contribution is restricted to the more subtle agential of expression of empathy. Some authors have emphasized the importance of providing support not only to the patient but also to the caregiver during the final stage of the disease (Gaston, 2004), even by the patient himself or herself (Jenick, 2003). The practical applications of this study may even envision the possibility of enhancing security, as Mikulincer and colleagues (Mikulincer & Shaver, 2005, 2007; Mikulincer, Shaver, Gillath, & Nitzberg, 2005) suggested in their

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studies. Indeed, through contextual triggers that could be present in the hospice setting, the accessibility of secure attachment representations may be activated, enhancing the sense of security. As these authors pointed out, when combined effectively and continued over an extended period of time, these may “allow human beings to achieve noble goals: freeing sentient beings from suffering” (Mikulincer et al., 2005). Principal limitations of this study include the small sample size of participants and the heterogeneity of the oncological diagnosis. Moreover, the use of the Relationships Questionnaire (Bartholomew & Horowitz, 1991) as a measure of adult attachment may raise some concerns. On one hand, it is an instrument very simple and quick to use, a clear advantage when participants are facing their critical terminal phase of life. On the other hand, it has the disadvantage that forces individuals’ choices into four discrete categories of attachment. Future researches are warranted to replicate and extend our results in larger samples, taking into account the impact of different oncological diseases and illness progression, and using several adult attachment measures to assess this construct from different theoretical perspectives. This study once again confirms the importance of the attachment style in extremely distressful situations and how it can affect relationships with important persons, such as the caregiver or the physician. In conclusion, identifying the attachment orientation of end-stage cancer patients may be useful in clinical and research settings. Attachment theory helps to explain in developmental terms what caregivers come to learn through repetitive patient–provider interactions, and why different patients require different approaches. Using this theoretical framework may help health care professionals to respond with greater sensitivity to the unique interpersonal characteristics of these patients and their caregivers.

ACKNOWLEDGEMENTS The authors are grateful to the patients and their caregivers who participated in the study and to the physicians on staff at the “via di Natale” Hospice, located in Aviano (PN), Italy.

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