The influence of adult attachment styles and emotional intelligence

Report
The influence of adult attachment styles and
emotional intelligence in clinical communication:
data from clinicians and patients
Ian Fletcher, Division of Health Research,
Lancaster University, UK
Acknowledgements
 Medical students, Foundation Year doctors
 Investigators: Helen O’Sullivan, Rachel Hick, Peter Leadbetter, Gemma
Cherry
Background communication
Stimulus – awareness that identification of depression and
anxiety in patients by hospital consultants and GPs was poor
Primary care
• Michael Balint 1950’s in the UK began GP study groups focus
the doctor-patient relationship
• Byrne & Long (1976) ‘Doctors talking to patients’
• David Goldberg 1960s to 1980s – specific skills to facilitate
patient centred interviewing
Cancer
• Peter Maguire 1970s to 2005 – communication skills research
and training in oncology
Communication present day
• Communication skills training widespread in many countries
• Communication skills are assessed in medical training
throughout the UK
• Training in communication skills:
– assumes doctors help by exploring and overtly discussing
fears and emotions of patients/families
– encourages doctors to do this
– talk about biomedical issues often seen as preventing
emotional discussion and ignoring emotion
• Patient satisfaction, Shared decision making etc.
Attachment origin
• John Bowlby, Mary Ainsworth 1960s to 1980s
developed Attachment theory
• Focus early childhood experiences with main
caregiver
• Child develops ‘internal working models’
– how to develop relationships with other people, and
expected responses from others
• Assumption internal working models will become
the default in times of stress, are relatively stable
by late teens early 20s
Attachment approaches
• Two differing approaches towards attachment
– Developmental psychology, Social psychology
• Developmental, semi-structured interviews, focus
childhood
• Social, self report, focus on romantic and/or close
relationships
Adult attachment
• Early measures typically categorised people into 1
of 4 categories
– secure, preoccupied, fearful, dismissing
• Preoccupied, fearful, dismissing usually collapsed
to insecure, hence much literature refers to ‘secure’
and ‘insecure’ attachment
• Categorize and/or score on 2 dimensions ‘anxiety’
and ‘avoidance’
– Anxiety/dependency on others
– Avoidance of intimacy
Adult attachment
The Four-Category Model of Adult Attachment
Bartholomew and Horowitz (1992)
Attachment & communication
• Internal models of interaction and inter-personal
relationships across relationships in general
• Model for understanding ways individuals feel, react
and communicate when stressed by illness
• Attachment, has been hypothesised to play a role
in doctor-patient relationships
• There is evidence to suggest doctors’ attachment
style influences their responses to patients’ clinical
presentations
• This series of studies focused on medical students’
and junior doctors attachment styles and their
clinical communication
Methods – medical students
• Liverpool Medical School – 300 medical students
• 4yrs undergraduate training, then additional 3 years
• Summative exams in each undergraduate year
• OSCEs (Observed Structured Clinical Examinations)
• Clinical communication incorporated into exams
• Typically clinical communication OSCEs 10mins
• Aware of the general topic area i.e. psychiatry,
gynaecology etc.
•
All students videoed in one OSCE station,
consent to view/code video
Outcome measures examiner
• Examiners individual ratings OSCE station
• Behaviours identified by researchers e.g. empathy, NVB
(Non-verbal behaviour), eye contact, open questions
etc.
• Overall communication ratings
•
summary score from 4 to 5 OSCE stations, control for
examiner bias
• Clinical information
•
relevant clinical information elicited from patient
Outcome measures VR-CoDES
• Verona Coding Definition of Emotional Sequences
To identify
1. Patient cues (hint of underlying emotion)
require exploration
2. Patient concerns (explicit mention of emotion)
require acknowledgement/exploration
3. Health provider responses, whether interviewer
gives or reduces space for further discussion
• Data, percentage of provide vs. reduce responses
from total number of responses
Prediction
• Medical students with lower attachment
anxiety and/or lower attachment avoidance
scores will have higher communication and
clinical performance OSCE scores
Study 1 – medical students
• Psychiatry OSCE - symptoms of depression and
suicidal ideation
• N=190, 165 female (65%) 67 male (35%), mean
age 22.3yrs
• Sig negative correlations attachment and OSCE
scores
• Higher attachment anxiety and avoidance lower
examiners OSCE scores
Assessment
Global impression
Attachment anxiety
Attachment avoidance
-0.19**
-0.23**
-0.19**
-0.21**
communication
Clinical competency
Study 2 – medical students
•
•
•
•
•
•
•
•
Paediatric OSCE – daughter self harming
N=37, mean age 23yrs
Coded with VR-CoDES
Inter-rater (0.87) for cues/concerns
Inter-rater (0.82) “provide space” responses
Mean nos. cues/concerns per interview 14.6
Mean proportion of provide space responses 63.3%
No significant difference in provide space responses
re student gender
Study 2 – medical students
• Sig negative correlation avoidant attachment and
students provide space responses
• The more avoidant medical students attachment,
more likely they will not explore patient emotional
cues and concerns
• Avoidant attachment influences micro-coding
assessment
Assessment
VR-CoDES proportion provide space responses
Attachment avoidance
r= -0.41*
Study 2 - junior doctors
• Phase 2: follow up 4th year into 5th year Primary
Care setting
• Video cohort (n=37) of students with ‘real’ patients
(2-6 each) in GP practice
• 138 student-patient consultations
• Attachment measures repeated
• Videoed viewed and coded with the VR-CoDES
Study 2 - junior doctors
• 1255 cues/concerns across 138 consultations
• Mean number of cues/concerns per interaction 9.1
• Large variation in number of cues given varying
conditions and length of consultation
• Mean proportion of provide space responses 60%
• No significant difference in provide space responses
based on gender
Study 2 - junior doctors
• Sig negative correlation between attachment
avoidance and attachment anxiety to proportion of
provide space responses
• The more avoidant and anxious junior doctors more
likely they will not explore patients’ emotional cues
and concerns
Assessment
VR-CoDES proportion
provide space responses
Avoidance
Anxiety
r=-0.50*
r=-041*
Emotional Intelligence (EI)
• Defined as “a type of social intelligence that involves
the ability to monitor one’s own and other’s
emotions, to discriminate among them, and to use
this information to guide one’s own thinking and
actions” Mayer & Salovey (1997)
• Doctors make judgments about when to explicitly
discuss emotion, and must also understand how
patients or their relatives will perceive their
(doctor’s) emotional and instrumental behaviours
• Hypothesised that EI is associated with interpersonal
competency, with doctors’ level of EI being an
influence on clinical communication
• EI assessments taken into consideration for entry to
Medical Schools in USA and St George’s UK
EI measure MSCEIT
• Mayer-Salovey-Caruso Emotional Intelligence Test
Area Scores
Experiential Emotional Intelligence
Strategic Emotional Intelligence
Branch
Scores
Perceiving Emotions
Facilitating Thought
Understanding Emotions
Emotional Management
Ability to perceive emotional
information, relate it to other
sensations and use it to facilitate
thought
Ability to understand emotional
information and use it for planning
and self-management
Ability to identify emotions in self
and/or others
Ability to use emotions to improve
thinking
Ability to understand complexities of
emotional
meanings/situations/transitions
Ability to manage emotions in own
life and/or others’ lives
EI – medical students
• N=186, 1st yr, 4 OSCE stations, only communication
• Sig correlations EI, attachment, OSCE
EI scores
Experiential Emotional
Intelligence (Area 1)
Strategic Emotional
Intelligence (Area 2)
Total Emotional
Intelligence
Overall OSCE score
Attachment
avoidance
-.26**
Attachment
anxiety
-.17*
OSCE score
-.29**
-.08
.20**
-.30**
-.16
.22**
-.15*
-.06
-
.14
EI – medical students
• Research question, does EI mediate relationship
between attachment and EI?
• Attachment theory, internal working models formed
in early childhood
• EI, develops throughout lifetime
• Therefore, possible greater opportunity for clinical
communication teaching and training
EI – medical students
• Structural equation modelling (SEM)
e1
e2
1
1
Strategic
Experiential
2=
R2=0.45
R 0.60
†
0.78
†
0.67
EI
R2=0.13
r1
0.22*
1
PPC
R2=0.07
†
-0.35
Avoidance
1
r2
-0.08
EI – medical students
• Attachment avoidance accounted for 13% of the
variance in students’ EI
• Attachment avoidance had no direct effect on clinical
communication
• EI sig predicted 7% of the variability in clinical
communication
• Students with higher levels of EI are probably better
able to make judgments about when to respond
appropriately, regardless of their attachment style
• However, vast majority of variance in clinical
communication was not explained by students’ EI
EI – medical students
• Repeated SEM 2nd yr students, n=296, results
strengthen
Experiential EI
Strategic EI
2
r2= .67
r = .64
.80
***
.82
***
1
e3
Total EI
r2= .07
r1
1
.33***
Overall 1OSCE
score
r2= .14
-.26
**
Attachment
avoidance
1
r2
-.12
Conclusions
• Attachment theory is a robust conceptual model
that may promote understanding of patient and
health professionals individual differences in
personal interactions
• Similar argument made be advanced for EI
• However, we need to know more about EI in
relation to medicine
• Research in social psychology has identified high
EI scores with Machiavellianism
• i.e. “The employment of cunning and duplicity in
statecraft or in general conduct” (OED)

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