Patient traumatic attachment experiences are recapitulated in medical care if the physician overlooks or misunderstands the power and influence inherent in the physician-patient relationship. Arnd-Caddigan [51, p. 296], for example, writes:
". . . subjects revealed that caregivers in childhood did not believe that the subjects were abused. The subjects had the parallel experience that physicians, counselors, and/or therapists did not believe that the subjects' somatic symptoms were real. Likewise, subjects had the experiences that caregivers held the subjects responsible for their abuse, and thought that the subjects behaved inappropriately in response to their past. The subjects also felt that doctors, counselors, and therapists, among others, told patients that they were responsible for their somatic symptoms and were inappropriate in their response to the symptoms."
Understanding attachment dynamics helps physicians attune to the needs of their patients and prevents the tragic recapitulation of mistrust and rejection in physician-patient interactions. Utilization and Containment are attachment therapy tools helpful to developing and sustaining good working relationships with somatically preoccupied patients. The goals of these strategies are to help patients take full advantage of primary health care services and to contain or prevent challenging interpersonal dynamics that arise in the physician-patient relationship and which can undermine effective patient care. Utilization and containment techniques promote patient emotional and physical healing and provide patients the opportunity to generalize this experiential learning to other interpersonal relationships.
When applied together utilization and containment support the patient fully accessing healthcare resources while preventing destructive tendencies that undermine treatment. A paradox is inherent in the strategies because utilization accepts and even encourages attachment behaviors whereas containment reinforces limiting and placing boundaries on attachment behaviors. While this paradox seems counterintuitive it actually forms the basis for an emotionally healing relationship with the somatically preoccupied patient. The utilization-containment paradigm is synonymous with successful child rearing where the parent encourages attachment with the child while simultaneously supporting the child's need to separate and individuate. Similarly, the patient learns safety and trust in the relationship with the doctor while gaining confidence and self-efficacy to act autonomously without threat of punishment.
The significant power and influence inherent in the physician role will elicit both hope and fear for patients with a trauma history. By accepting and recognizing this significance the physician can utilize it in communications with the patient. Consider the following physician statements:
Physician statement 2
"It's very important to me that my patients have input into their treatment. How can I help you feel included in the treatment plan?"
Statement 1 elicits guilt and shame for the somatically preoccupied patient because the statement clearly designates the physician as the predominant figure in the relationship. Beyond this obvious repercussion there is an important unspoken subtext in which the physician's statement means "I know better for you then you do." To a patient with a history of attachment trauma the subtext will feel similar to past relationships and be experienced as an infringement on safety and security in the relationship. The patient's past included powerful others forcing collusion in activities (i.e. sexual abuse) that violated trust and healthy attachment relationships. If the physician is unaware of this subtext there is the risk of unknowingly recapitulating trauma in the physician-patient relationship.
Statement 2 invites the patient to join with the physician in developing a treatment plan, validates the patient's ability to make good decisions, and offers help that can be accepted or rejected but in either case leaves open the possibility of additional discussion. In no way however does statement 2 undermine the physician's professionalism or expertise and good professional boundaries are maintained. Statement 2 strengthens the physician's role because it acknowledges the physician as the leader of the team who has the sound professional judgement to include patients in personal health care decision-making. But there is also an important subtext in statement 2 that is not verbally communicated to the patient. The subtext confirms that the patient is important to the physician, that the physician values having a trusting and collaborative relationship with the patient, and that the patient will not be forced into doing something for which they are uncomfortable and which would recapitulate trauma.
The example exemplifies how the use of language is critical to healing and that by effectively utilizing language, problems in relationships with patients can be reduced. If a physician pursues communications with a patient along the lines of Statement 1 it is foreseeable that the patient will resist recommendations and suggestions and be non-compliant in treatment. In the attachment paradigm non-compliance may actually be the patient's effort to be autonomous and self-efficacious. Physician authoritarian comment therefore become the source of patient resistance and non-compliance because the patient is determined to maintain an individuated self and not be controlled or abused.
Reframing problem behaviors into strivings for health enables constructive utilization of the patient's behavior rather than futile attempts to stop frustrating and aggravating non-compliance. Patient non-compliance is interpreted as the patient non-verbally stating, "you can't control or take advantage of me." Non-compliance therefore represents the patient's effort to meet legitimate needs for autonomy. Based on this conceptualization the central clinical question for the physician becomes, "How can I help the patient meet their needs in a way that isn't self-destructive?" rather then approaching non-compliance by asking "How can I make this patient comply with treatment?"
Despite a physician's best efforts to communicate effectively with somatically preoccupied patients disagreements and misunderstandings will inevitably occur. Containment strategies help the physician to predict, limit and manage potentially negative physician-patient interactions. Successful containment preserves the physician's interest and energy for long-term care of the patient, and prevents burn-out and potential emotional distancing from the patient. The core feature of effective containment is the use of empathic and validating responses to diffuse patient anger and rejection. Containment techniques "reality-check" the irrational beliefs and attitudes held by patients and offer new and healthier relationship experiences through immediate physician responses.
An effective containment technique is for the physician to periodically "check-in" with the patient about the quality of the physician-patient relationship. Physician inquiries about the relationship may at first feel unusual to the patient because in their past experience, particularly with health care providers, interpersonal sensitivity of this nature was rare. Similarly, the approach may feel awkward to the physician whose education may not have included process-oriented communication skills. With time the patient and doctor will likely come to respect and appreciate the opportunities to "check-in" on the quality of the physician-patient relationship because such opportunities serve to diffuse misunderstandings and miscommunications.
Effective use of containment by the physician appreciates that patient emotional outbursts stem from past dysfunctional interactions with powerful adults. If for example a patient screams at the doctor, "You never listen to me! You don't understand!" it is useful to recognize that emotion of this intensity is probably not completely grounded in the physician-patient relationship. One of the best means to address emotional negativity is for the physician to openly "name it" as a patient concern rooted in past relationships. For instance, acknowledging the patient's history of emotional pain with a statement such as "I can tell you are angry. I'm aware your relationships with physicians in the past have not always been helpful. I'd like to work with you to make our relationship different" draws attention to the fact the physician wants a good relationship with the patient and contrasts the current relationship with the patient's history of difficult relationships with physicians. The intervention is delivered in a measured and unemotional tone of voice to further diffuse and contain the patient's emotions by not meeting them with similar intensity. The response effectively models how this new relationship will regulate and manage strong affect. Strong patient emotions can become opportunities for teaching rather than something to be feared or avoided. Physician-patient interactions are utilized as elements of the healing process rather than framed as resistance or non-compliance.
If patient blaming and anger persists the physician must directly confront the behavior but this is not to imply the physician reacts out of personal frustration or anger. Responses along the lines of "You sound frustrated with me, help me better understand what that is about" contains anger by drawing attention to it and asking the patient for help in understanding the source of the unhappiness. The patient is invited to share more information so the physician can better understand. Disagreements between physicians and patients about medical care can unfortunately be a catalyst for larger problems and therefore require immediate and effective containment. Negative interactions left unattended and unresolved may eventually rupture the physician-patient relationship and result in complaints about the physician or even malpractice claims.
In the attachment theory paradigm the patient's history of relationships were marked by damaging and unresolved ruptures and the goal of the physician-patient relationship is to prevent such ruptures. In the past problems were ignored and "swept under the carpet" rather than acknowledged and worked-through. To prevent the recapitulation of problematic attachment dynamics the physician must make logical and reasonable statements to the patient such as "Let's talk about what just happened" and "I'd like to try to understand what just happened between you and me." Statements of this nature create openings for resolution rather than shutting down communication. Utilizing disruptions and containing harmful communications and behaviors allows the physician to demonstrate to the patient that the physician is caring and responsive, and models that relationships can be collaborative and non-abusive.
Despite their best efforts physicians will naturally from time to time have an empathic failure with a patient. If this occurs it is essential that the episode be immediately brought up for discussion with the patient. Patients having a history of damaged attachments will not generally acknowledge that they have hurt feelings. The patient will therefore not be the one to bring up the problem and is more likely to quietly dismiss the doctor, leave treatment and move on to another practitioner. The physician who is keenly attuned to attachment dynamics with somatically preoccupied patients will observe empathic failures as they occur and acknowledge and discuss the impact on the relationship.
Other common attachment recapitulations occurring in the physician-patient relationship with somatically preoccupied patients include neediness (i.e. frequent requests for additional appointments, testing or procedures), fearfulness (i.e resistance to referral to mental health) and, of course, preoccupation with health concerns (i.e numerous new health complaints and unexplained illnesses). If a patient complains that nothing seems to be helping relieve the symptoms a physician response such as "I can see that this is very frustrating and even exhausting for you. It must seem to you that as hard as you try nothing helps" acknowledges the patient's physical pain but perhaps more importantly empathically validates that the physician understands. Validating statements counter the patient's long held beliefs of isolation and insecurity by simply affirming to the patient, "I hear you and I understand."
Routine data collected in the medical practice can be valuable to increasing physician awareness that utilization and containment strategies would be helpful with a particular patient. For example, tracking outpatient visit data, observing referral patterns, attending to patient family history information, monitoring utilization, and being alert to co-occurring psychiatric conditions are relevant to identifying patient somatic preoccupation [
5]. A family genogram, which can be quickly created in the presence of the patient, provides a point of reference for future discussions with the patient about their health history and their family history. If the genogram reveals that a parent of the patient was also somatically preoccupied the information can be helpful in understanding and treating the patient's symptoms.
In making inquires about family history of somatic preoccupation it is advisable to do so in a straightforward manner devoid judgment. The patient may be ashamed of their past and reluctant to openly discuss it. The direct approach creates a spirit of openness with the patient, reduces the shame patients feel about their past and family of origin, and models for the patient that it is acceptable to openly discuss problems with their doctor who in turn will be non-judgmental. Directness serves a number of containing functions including preserving the physician's energy for the patient and reducing the patient's anxiety and shame about past trauma.
Patients with depression and anxiety constitute up to 85% of the patients having somatic symptoms [
4]. Stressful life events including marital problems or normative transitions such as a child leaving home can contribute to "flare ups" of somatic symptoms. If over time the primary care physician discusses with the patient how stressful events precede intensification of somatic complaints it will serve to contain or reduce the patient's anxiety and depression. For example, statements such as "We know in the past changes have resulted in you having more physical symptoms – that may be something to look for as you go through this change," can be reassuring for the patient.
Barsky [
52] and Holder-Perkins et al. [
53] recommend additional strategies that are helpful utilization and containment techniques. Physicians should focus on patient care rather than cure. This strategy has the effect of reducing patient emphasis on eliminating symptoms and reinforces coping skills. Conservative diagnostic and treatment approaches are recommended and careful review of records needs to occur before ordering new tests. The conservative approach prevents the patient from getting their hopes too high when tests are ordered as well as dropping too low when test results are inconclusive. Scheduling frequent and brief follow up appointments with the patient as well as sticking to the scheduled routine will be reassuring to the patient and serve to develop trust. Validate the patient's distress, do not refute symptoms and cautiously reassure the patient without giving false hope.
Frequent shifting between practitioners disrupts the patient being able to establish a healthy attachment to one provider and will increase the patient's anxiety. Consistent follow-up by one practitioner also allows for monitoring of substance abuse or self-medication with analgesics or benzodiazepines, for which somatically preoccupied patients are at risk [
54]. Blackwell and DeMorgan [
54] suggest linking presenting symptoms with the patient's day-to-day functioning, connecting symptoms with feelings by asking questions such as "How do you feel when you are having (the symptom)?," and obtaining the precise sequence of symptoms by exploring environmental triggers. These strategies invite a greater exchange of emotional information from the patient to the physician.