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Attachment Theory and Primary Care: Jumping off the Porch Hand in Hand

Posted By Stephen Mitchell, Tuesday, December 9, 2014

My son, Leeds, looks at me with a spark of daring in his eyes and instinctively lifts his hand in search of mine. The ten-fingered connection is made and simultaneously he throws his body off the front porch.  He lands safely on the grassy terrain below and scampers off to the next adventure. Leeds likes to jump off of any object that rises two feet or more above the ground, any object as long as I am near offering a hand to stabilize his free falling body. When I am physically close and attentive to his needs as a budding daredevil, my son feels safe and willing to explore new things.  These moments bolster his belief that he can trust his decisions and trust I will be available to help him if needed.

A fundamental tenet of attachment theory is that a caregiver who is physically close and emotionally responsive to their child’s needs helps them believe and feel that relationships are safe1. Safety and trust facilitate the formation of an attachment bond between an attachment figure and child. An attachment figure is a person with whom a child can develop a “warm, intimate, and continuous relationship.”2

Safety and trust facilitate the formation of attachment bonds

Bartholomew and Horowitzrecognized that attachment processes continue into adulthood and developed a four-category model of adult attachment.  The four categories of adult attachment are: secure, dismissing, preoccupied, and fearful4. Each category describes how an individual perceives self and other, based on early attachment experiences.  Part of healthy self-development is the experience of making decisions, holding beliefs, and feeling certain emotions that are acknowledged and validated by others.  When this happens we come to believe that we exist. Daniel Siegeldescribes this as “feeling felt.” We feel that the other person across from us gets us and is open to us being our self. 


This is the experience Leeds hopefully had when he jumped off our porch. He felt a spirit of daring, decided to jump off the porch, and looked to me to validate his decision by taking his hand and helping (granted if I felt his decision was unsafe I would have intervened, but even in intervening I am still acknowledging him and trying to work towards a shared understanding of how to act).

Caring for patients in a primary care setting is at its core a relational endeavor. Thus, a theory about how interpersonal styles of relating develop from childhood to adulthood and influence perceptions of self and other, seems pertinent in an integrated care setting. Just as caregivers function as attachment figures for children, doctors can be seen as attachment figures for patients. Patients will relate to their doctor in the same ways they learned to interact with attachment figures. Understanding patient’s relational styles informs patient care. 

Four-Category Model of Adult Attachment

A securely attached adult has a positive view of self and other. This leads to a sense of self-worth and belief that others can be trusted.6 Dismissing adults have a positive view of self and negative view of others that originates from repeated experiences of rejection.7 Preoccupied adults have a negative view of self and positive view of others due to experiences of inconsistent levels of responsiveness from caregivers. This inconsistency results in a tendency to be “excessively vigilant of attachment relationships and emotionally dependent on others’ approval…often to the point of being ‘clingy.’”8
Fearfully attached adults experienced caregiving that was harsh, abusive, and frightening. Thus, fearfully attached adults have a negative view of self and others9.

Attachment and Integrated Care

Dr. Herbert Walker was my primary care doctor growing up. He was kind, smiled when he saw me, and when I sat on the examining room table I felt like I mattered. My feelings of “being felt” in Dr. Walker’s presence helped me believe in his medical advice and prescriptions. I spent ten years of my life attaching to Dr. Walker and as I write this I feel a strong affinity for him. 

Doctors are attachment figures. How patients respond to medical advice directly correlates to how strong their bond is with their doctor. If a patient feels safe with their doctor then they just might listen to what he or she says. For example, a “warm hand-off” from a trusted doctor can soften a patient’s anxiety about seeing a therapist like me. Doctors that are trusted by their patients are also able to broach hard topics with patients. So, a man who is struggling with depression and increasing his alcohol intake may more readily listen to his doctor when he expresses concern about his behavior. If the patient did not feel safe with his doctor he may feel threatened by his inquiries about his drinking and tune the doctor out. A safe relationship allows challenging issues to be addressed.

Awareness of a patient’s style of relating can help doctors facilitate building safe relationships. Research has shown that preoccupied patients are prone to report more symptoms compared to other attachment styles10. The higher rates of somatization could be an explanation for high-utilizers’ frequent emergency room visits and outpatient visits. Perhaps a preoccupied patient is transferring the anxiety they feel about inconsistent levels of responsiveness from caregivers to the healthcare community

Dismissing patients report higher rates of non-adherence to medication regimens, dietary restrictions, and exercise plans.11 This is a reasonable finding considering dismissive patients tend to be self-reliant.  Trusting a doctor and their recommendations is a challenge for these patients. 

Understanding a patient’s style of relating can be useful in crafting interpersonal interactions that soothe anxieties and increase overall wellness. Perhaps a preoccupied patient could have more frequent nurse visits for routine health maintenance. Frequent visits may assuage the patient’s fear of inconsistent care and actually reduce doctor visits by strengthening their relationship with doctors and clinic staff.     

Dismissing patients might benefit from routine calls from a doctor to check-in on adherence to medication, diet plans, or exercise routines. These calls could help establish a feeling of close and responsive attention to the patient’s needs. They do not require the patient to come into the clinic but help them know the doctor is thinking about them and concerned about their health. 

Each of these small interventions requires more personal contact from a doctor. There may be more work upfront but as trust grows the patient’s anxiety will decrease likely leading to a healthier patient. Dr. Walker understood that if he wanted a patient to jump off the porch with him they needed to trust him first. The integrated world would do well to heed his example.


[1] Bowlby, J.  (1982).  Attachment (2nd ed. Vol. 1).  New York: BasicBooks. 

[2] Bowlby, J.  (1973).  Separation: Anxiety and Anger (Vol. 2).  New York: BasicBooks. 

[3] Bartholomew, K.  & Horowitz, L.  (1991).  Attachment styles among young adults: A test of a four-category model.  Journal of Personality and Social

Psychology, 61(2), 226-244. 

[4] Ibid 

[5] Siegel, D. J.  (2012).  The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are (2nd ed).  New York: Guilford.

[6] Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E.  (2002). Attachment theory: A model for health care utilization and somatization.  Psychosomatic Medicine, 64, 660-667.  doi: 10.1097/01.PSY.0000021948.90613.76 

[7] (Ciechanowski et al. 2002; Bartholomew& Horowitz, 1991) 

[8] Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E.  (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64, 660-667.  doi: 10.1097/01.PSY.0000021948.90613.76 

[9] Ibid 

[10] Bennet, J. K., Fuertes, J. N., Keitel, M., & Phillips, R.  (2011).  The role ofpatient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment.  Patent Education and Counseling, 85, 53-59.  doi: 10.1016/j.pec.2010.08.005

[11] Ibid


Stephen Mitchell, Mdiv, MA, LPC is a doctoral student in Saint Louis University’s Medical Family Therapy Program.  He currently is a Medical Family Therapy Fellow at St. Mary’s Family Medicine Residency in Grand Junction, CO.  He is a Licensed Professional Counselor in both Missouri and Colorado and spends most of his days listening to patient’s stories, writing a dissertation, and wishing he had his own DIY Network series.  His research interests are loss and grief particularly in regards to infertility, miscarriage, pregnancy, and birth.  Additionally, he is interested in the connection between attachment and leadership development in pastors and doctors.  His son, Leeds, has not sustained any grave injuries jumping off of stuff in the last two weeks. 

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