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 collapsedto 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 AttachmentBartholomew 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/exploration3. 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 Attachment anxiety Attachment avoidance

Global impression

communication

-0.19** -0.23**

Clinical competency -0.19** -0.21**

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 Attachment avoidance

VR-CoDES proportion provide space responses 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 Avoidance Anxiety

VR-CoDES proportion

provide space responses

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 Ability to perceive emotional information, relate it to other sensations and use it to facilitate thought

Strategic Emotional Intelligence Ability to understand emotional information and use it for planning and self-management

Branch Scores

Perceiving Emotions Ability to identify emotions in self and/or others

Facilitating Thought Ability to use emotions to improve thinking

Understanding Emotions Ability to understand complexities of emotional meanings/situations/transitions

Emotional Management 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 Attachment avoidance

Attachment anxiety

OSCE score

Experiential Emotional Intelligence (Area 1)

-.26** -.17* .14

Strategic Emotional Intelligence (Area 2)

-.29** -.08 .20**

Total Emotional Intelligence

-.30** -.16 .22**

Overall OSCE score -.15* -.06 -

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)

1

1

1 1

0.78† 0.67

†

0.22*

-0.08

-0.35†

EI

R2=0.13

Strategic R2=0.60

Experiential R2=0.45

Avoidance

PPC R2=0.07

r1

r2

e1 e2

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

1

1

.80*** .82

***

.33***

-.12

-.26**

Total EI r2= .07

Experiential EI r2= .64

Strategic EI r2= .67

Attachment avoidance

Overall OSCE score r2= .14

r1

r2

e3 1

1

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)