Not Following Doctor’s Orders? Caregivers May Be to Blame

Getting patients to do what they are supposed to do is not always easy, as psychiatrists and other types of physicians well know. But why do certain patients balk at following a doctor’s orders? Could it be that they are tough, self-sufficient types who think, “Hey, I don’t need you!,” sort of the “John Wayne cowboys” of the patient world?

Could be.

A study conducted by Paul Ciechanowski, M.D., an assistant professor of psychiatry at the University of Washington in Seattle, and his colleagues suggests that this might indeed be the case. The study was reported in this month’s American Journal of Psychiatry.

It all started back in the 1950s with British psychiatrist John Bowlby. He theorized that, even taking people’s inherited temperaments into consideration, the experiences that they have with caregivers early in life influence the way they interact with caregivers later. What’s more, research over the past several decades has shown that there are distinct patterns of interpersonal interactions based on early caregiving. There are people who received consistently responsive early caregiving and who are thus comfortable depending on others—that is, individuals with a secure attachment style. There are people who had overly critical or harshly rejecting early caregiving and who, while desiring social contact, are afraid of rejection, that is, people with a fearful attachment style. There are people who experienced inconsistently responsive early caregiving and who are thus overly dependent on the approval of others, often to the point of being “clingy”—that is, individuals with a preoccupied attachment style. And finally, there are people who experienced consistently unresponsive early caregiving and who are thus uncomfortable being close to or trusting others—that is, people with a dismissing attachment style.

Certainly there are various reasons why patients may not comply with medical treatment: a lack of understanding of the condition and how it should be handled, no health insurance, transportation problems, and so forth. Nonetheless, Ciechanowski and his coworkers suspected that there is something over and beyond such reasons that accounts for noncompliance in many patients. They suspected that these patients might have developed a dismissing attachment style early in life that later significantly influenced the doctor-patient relationship. In other words, these patients might be the tough, dismissing types who think they can go it alone.

The researchers decided to test their hypothesis on diabetic patients rather than patients with, say, depression, in part because they would have a way of biologically measuring compliance. They recruited 367 patients who were being treated at a health maintenance organization in the Puget Sound, Wash., area for either type 1 or type 2 diabetes. The patients filled out various questionnaires that provided information about psychological attachment style, quality of communication with their physicians, diabetes severity, whether they were depressed, and whether they were following doctor’s orders regarding diabetes treatment.

The investigators were also able to obtain from the HMO automated, objective measures of patient adherence to treatment, such as glycosylated hemoglobin levels (a measure of glucose level over a three- or four-month period) and whether patients refilled oral hypoglycemics as they should have.

Using all this information, and adjusting for demographic and clinical variables such as age, education, severity of diabetes, presence or absence of depression, and so forth, the investigators then attempted to determine whether patients’ psychological attachment styles could be linked to how well they followed their doctor’s orders. The answer was yes.

Those patients with a dismissing attachment style were found to have significantly higher glycosylated hemoglobin levels than those with other types of attachment styles. When the quality of patient-doctor communication was taken into account, the magnitude of this association was even greater among patients with a dismissing style. And when the researchers zeroed in only on those subjects who were being treated with oral hypoglycemics, they found that those who had a dismissing attachment style and rated their communication with their doctors as poor had twice as many lapses in oral hypoglycemic compliance as those with other attachment styles.

Thus, the researchers believe that their hypothesis has been validated, that a dismissing attachment style acquired earlier in life is a major reason why their subjects did not adhere to doctor’s orders. They also contend that a dismissing attachment style can explain why patients with conditions other than diabetes, including psychiatric conditions, often do not follow doctors’ orders.

Do those who balk at doctor’s orders do so because of a dismissing attachment style learned early in life? “It is a significant factor; we strongly believe that,” Ciechanowski said in an interview.

“People have tried to measure the doctor-patient relationship to better understand adherence and self-care in chronic illness,” he explained. “There has been a lot of emphasis on provider behavior. But I think the crux of our research is that we have systematically explored what the patient brings to the relationship—how the patient perceives the provider. So in other words, a provider can complete all the medical education and have a great bedside manner and do everything possible to try to keep the person in treatment, but with a certain proportion of patients, it seems not to matter what the provider does. Some patients just can’t collaborate, and that has a lot to do with their early caregiving. We think that the patient-provider relationship is a recapitulation of prior caregiving relationships. Individuals will perceive and behave in patient-provider relationships as they did in all prior caregiving relationships, from childhood and adolescence into adulthood.”

In an editorial accompanying the report in the American Journal of Psychiatry, Glen Gabbard, M.D., the Callaway Distinguished Professor at the Menninger Clinic in Topeka, Kan., writes: “Ciechanowski et al. used an ingeniously creative approach to examine the nemesis of both medical and psychiatric practice—noncompliance—[and] the investigators applied adult attachment theory in an attempt to better understand the anatomy of this noncompliance. . . .”

So does Gabbard believe that there is truly something to this theory as far as patient noncompliance goes?

Indeed. “Attachment theory is finally getting the attention it deserves in our field,” he states. ▪