ARTICLE:
Using attachment theory to understand and support health care workers under stress
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Using attachment theory to understand and support health care workers under stress
Jonathan Hunter, MD, and
Robert Maunder, MD
https//doi.org/10.37964/cr24704
Attachment theory aids our understanding of fundamental aspects of interpersonal relationships and stress response. As such, it can add to our understanding and support of health care workers in stressful circumstances. This paper introduces attachment theory and summarizes the current evidence that relates attachment to aspects of employment– specifically absenteeism, burnout, and leadership. Suggestions are also made for using attachment principles in management.
KEY WORDS: attachment theory, workplace stress, physician leadership, burnout, absenteeism, management
What is attachment theory?
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Attachment is an interpersonal behavioural system, selected because of its value for increased reproductive success, that serves to maintain safety for a primate infant born before it can independently care for itself. This allows time for further brain development. This initial period of immaturity and vulnerability is one in which the primary caregiver and infant need to be closely allied and connected to ensure survival of the infant. Children develop a particular pattern of responsiveness to their primary caregiver’s behavioural and emotional responses to their temperament, emphasizing infant behaviours that maintain contact and safety and de-emphasizing less reliable strategies. The outcome of this behavioural shaping is such that infants can be categorized into one of several attachment subtypes.3 In adulthood, the same subtypes can also be detected and are denoted attachment “styles,” although they are referred to with different labels in the adult attachment literature. The terms we will use are secure, preoccupied, dismissing, fearful, and disorganized. Top
Attachment subtypes are variations of normal, not psychopathological states. They are the outcome of the tailoring of expectations and behaviour to the fit between the primary caregiver and the infant. Behaviour shaped in infancy may not be the best fit for interpersonal relationships as one matures, so some aspects of one’s attachment style may create a strain in adult interpersonal relationships. When the individual is not stressed, behaviour is not determined by their attachment style, because attachment behaviour is “state dependent,” i.e., it is only manifest at times of attachment stress, such as interpersonal strain.3 The purpose of this paper is to clarify the extent to which attachment style manifests in the workplace, what impact it might have, and how appreciating and addressing attachment can advantage physician leaders in managing their teams.
Although it is rare to see pure states in human behaviour, it is helpful to understand prototypic descriptions of attachment subtypes. This is most easily done by invoking two perspectives: the person’s belief in themselves (confidence) and their belief in others (trust).
Although individuals with a “secure” attachment style are unlikely to present with difficulty in interpersonal working relationships, understanding this style provides a helpful contrast to the following insecure types. The secure person has both adequate self-confidence and adequate belief in the responsiveness of others. Their confidence allows them to function independently, and their trust in other people leads to effective group behaviour. The stress response of secure individuals is not easily triggered, but is responsive when required and returns rapidly to baseline, meaning these people respond to stressful events with a proportional reaction, without prolonged distress.4 Top
All other attachment subtypes are “insecure.” The person who is low in self-confidence and emphasizes trust of others has “preoccupied” insecure attachment. This denotes a preoccupation with proximity to another person in order to feel safe. To obtain and maintain the presence of the other person, such people “hyper-signal” attachment needs. In infants, this signaling consists of crying or clinging, but in adults it often manifests as interpersonal neediness that is difficult to soothe. Preoccupied people frequently feel stressed by their perception of being inadequately connected, and their stress response is often activated, which makes it poorly adaptive to specific circumstances. They tend to be experienced as needy or fragile and, when most distressed, can drive people away, rather than recruit support.4
At the other end of the spectrum is the person who has more self-confidence than trust in others. Such people fall into the “dismissing” subtype, as they dismiss the need to have other people close to them. More positively described as “self-reliant,” they will elect to work on their own and may experience interpersonal relationships as threatening because of their experience of being shamed or humiliated for interpersonal need in their developmental years. Such people may not come across as overly friendly to co-workers, but will typically be identified as capable of carrying out tasks on their own.4 Top
Some people have had sufficiently difficult developmental years that they have neither confidence in themselves nor trust in others. They are described as “fearful” and present interpersonally as scared, angry, or painfully shy. They have distress based on their low self-confidence and fears of inadequacy, but also believe that, if they appeal for help, they will be ridiculed or abandoned. The behavioural solution for this is to retreat and, in employment circumstances, such individuals often end up doing routine repetitive tasks that do not demand response to novel circumstances or interpersonal communication. They essentially feel perpetually stressed.4
Finally, people who have had a traumatic upbringing may also have low confidence and poor trust in others, but rather than settling into one preferred behavioural modus operandi, they are better understood as “disorganized.” They feel consistently under threat and vacillate between withdrawal/defence and attack/surrender. Interpersonally, they are experienced as chaotic workers in a group and they evoke strong, typically rejecting, interpersonal reactions.4 Top
The literature on the impact of attachment styles in primary care doctor–patient and psychotherapeutic relationships is now substantial.5-7 The insights provided by this have been helpful in understanding how to structure communication or interactions to reduce the stress created by patients’ attachment insecurity and make medical recommendations more likely to be adhered to, with less conflict between patient and provider. For instance, for the preoccupied patient, regularly scheduling appointments, independent of crises, creates better structured, less fragmented care and an overall reduction in the intensity of distress. For the dismissing individual, however, allowing them to approach the health care worker in their own way, on their own time, respecting their need for independence, is a better strategy.
One size does not fit all: for instance, the space provided for the dismissing individual would precipitate abandonment fears in the preoccupied individual. It is the specificity of response that optimizes communication. It is also useful to keep in mind that, although we assign an attachment style to an individual, the style is only activated in the context of a relationship, so actions aimed at improving these difficult interactions can usefully be undertaken by either or both parties of the dyad.
From an attachment framework, difficulties in employment that pertain to interpersonal situations can be understood as stressing the individual to the point that their “default” attachment pattern is activated, causing them to act accordingly. This is not necessarily the best fit for the here-and-now circumstances, so conflict can occur, especially if all parties in the interaction are similarly stressed. Top
The relevance of attachment style in employment
Attachment style correlates with organizational behaviour.8 In general, secure attachment is associated with less problematic job performance. Specifically, it is associated with higher job satisfaction,9 less negative spill-over from work to home,10 less reporting of hostile outbursts in the workplace,11 workers who are less prone to psychosomatic illnesses or actual physical illnesses,12 and better organizational citizenship.13
Similarly, insecure attachment, in general, has been associated with lower job satisfaction,11 greater anxiety about rejection by co-workers,9 feeling unappreciated and misunderstood,10 having more anger or distressing emotions in the workplace,14 more insomnia and physical problems,15 less instrumental help offered,16 and significantly less support-seeking or support-giving behaviour.16,17
The following summaries serve to make the point that attachment status is a useful lens for understanding behaviours that are both helpful and challenging in the workplace. Given our basic understanding that those with insecure attachments are less likely to have well-tuned stress response, one may conjecture that the subjective states of lower job satisfaction or the presence of anger or distressing emotions, as listed above, indicate vulnerability on the part of workers with insecure attachment to feeling more stressed, more often, than their secure counterparts. Top
Burnout
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Therefore, attachment insecurity appears to create vulnerability to experiencing the workplace as stressful in ways that are specific to the type of attachment insecurity and that are correlated with burnout.
Leadership
Much of the work examining leadership efficacy from an attachment theory perspective has been carried out in the context of the military. For instance, Davidovitz17 demonstrated that Israeli officer leaders who had preoccupied attachment style had lower task efficacy, whereas those with dismissing attachment style had lower emotional efficacy. Units with leaders with a dismissing attachment style were reported as being less cohesive, perhaps because of such leaders’ characteristic de-emphasis of the relevance of interpersonal relationships. Leaders with both preoccupied and dismissing attachment styles were ranked by the members of their unit as having poorer performance as leaders. Furthermore, members of units where the leader had a dismissing attachment style tended to show decreases in mental health over time. Top
Mikulincer15 also demonstrated that Israeli military recruits with secure or dismissing attachment styles were more likely to be nominated as leaders by their peers than those with preoccupied attachment style. Berson21 found that securely attached team members were more likely to emerge as leaders in experimental groups.
Ronen and Mikulincer22 reported on 85 work groups from 71 non-military organizations including 483 subordinates and 85 direct managers. They used hierarchical linear modeling analyses to show that the managers’ insecure attachment style predicted higher job burnout and lower job satisfaction among their subordinates and that the effect was mediated by ineffective caring for others on the part of the managers. Top
Furthermore, attachment orientation influences style of leadership. Secure attachment has been associated with a relational leadership style with maximal delegation and a fostering of exploration.23 Dismissing attachment in a leader is more associated with task-oriented leadership style and minimal delegation.23
Hardy and Barkham24 examined 219 employees receiving psychological treatment for stress at work. They found that preoccupied attachment style correlated significantly with reported anxiety about work performance and work relationships, whereas dismissing attachment style correlated with concern over hours of work and difficulties in relationship at home and in social life. They also demonstrated that work relationship problems associated with insecure attachment were significantly helped by psychological treatment.
Absenteeism
In hospital-based health-care workers, attachment insecurity was significantly associated with impairment in overall sleep quality and physical symptomatology.25 Attachment anxiety (which contributes to preoccupied attachment) was also associated with depressive symptoms and an increased number of sick days. In 448 employees, Krpalek et al.26 found insecure attachment style to be positively associated with both absenteeism and presenteeism (present but not really working). Top
Intervention
There are no empirical data on this, but operating from the principles of attachment theory,27 several broad suggestions can be made. Top
Activation of the attachment behaviour is a response to stress, typically separation, fear, or perceived attack; thus, if the issue is not intermittent and stress related, it is unlikely to be dependent on attachment style. However, given that the main trigger for attachment behaviour is a sense of insecurity, then whatever one can do to increase felt security in an organization should keep stress-related behaviours to a minimum. Increasing open communication, predictability of work, and keeping individuals operating within their sense of competency could all contribute to a working environment that feels interpersonally safe.
Securely attached people are unlikely to present a challenge in interpersonal functioning, as the combination of confidence and trust makes them highly adaptive to changing demands or environments. When interpersonal behaviour is problematic, it could be helpful to consider that the individual has an insecure attachment style, and if so, what type. The behaviour associated with fearful and disorganized people is typically sufficiently intense that it is not difficult to detect, and tailoring of the job to the limitations of the individual may be helpful. Top
When stressed, people with preoccupied attachment style may have an amplified perception of their own incapacity (low confidence) and feel a need to recruit others to their aid (higher trust). In response to this, regular supervisory meetings to reassure them that they do not need to signal distress to engage support, but that it is readily available, may be helpful. Keeping a good fit between capacity and demands of the work task may also minimize triggers.
Those with a dismissing attachment style are less likely to complain or request accommodation, because of their self-reliance and relative lack of investment in others, creating a propensity for independent activity. Hints that this style is active include complaining that others are contributing less, or being dismissive of the constraints of co-workers. As leaders, people with a dismissing attachment style tend to dismiss the psychological state of team members and are inclined to focus only on task completion,17 which may create interpersonal tensions in the team. However, this same tendency can read as independence and strength, which are valued in many organizations. Tailoring the job to these strengths, by allowing a worker with a dismissing attachment style to focus on tasks and make decisions for themselves may minimize interpersonal friction.
Summary
An appreciation of attachment theory may help physician leaders optimize understanding of interpersonal relationships. The attachment theory perspective provides a useful lens for understanding sources of interpersonal strain in the workplace and individuals’ comfort with teamwork. Using this point of view, the workplace and the individual can work together to improve the fit between them and minimize sources of friction and difficulty. Top
Further resources
A recent article in the popular press addressed this topic: Saunders EG. The 4 “attachment styles” and how they sabotage your work–life balance. New York Times 2018;19 Dec.
Online videos introduce and summarize attachment theory: Maunder and Hunter. Intro to adult attachment, How do I become more secure? Attachment and health — symptoms, worry and healthcare use. https://www.youtube.com/watch?v=GHHCy1IHTUc
To find out your own attachment style, go to the Self-Assessment Kiosk, and do the relationship style questionnaire (Experience in Close Relationships, medical version, ECR-M16): http://bit.ly/2ccH0tx.
References
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Author attestation
Jon Hunter was the primary author. Bob Maunder participated in the conceptualization of the article, re-writes, and obtaining of applicable references.
Conflict of interest: Neither author has any conflict of interest in publishing this article. No funding was received for this work.
Authors
Jonathan Joel Hunter, MD, FRCPC, is the Pencer Family Chair in applied general psychiatry at Sinai Health Systems and a professor in the Department of Psychiatry at the University of Toronto.
Robert Gordon Maunder, MD, FRCPC, holds the chair in health and behaviour at Sinai Health System and is also a professor in the Department of Psychiatry at the University of Toronto.
Correspondence to:
Jon.Hunter@sinaihealthsystem.ca
This article has been peer reviewed.