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ARTICLE IN PRESS

Social Science & Medicine 63 (2006) 3067–3079

www.elsevier.com/locate/socscimed

The interpersonal experience of health care through the eyes of

patients with diabetes $

Paul Ciechanowski , Wayne J. Katon

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 356560, 1959 NE Paciﬁc,

Seattle, WA 98195-6560, USA

Available online 25 September 2006

Abstract

Patients with chronic illness often face challenges navigating the US health care system because of the system’s lack of

coordination and continuity. Patients with more difﬁculty relying on others and with reluctance in engaging frequently or

in-depth with providers, face even greater challenges obtaining optimal health care in this system. Using a self-report

measure of attachment style, we selected patients with varying degrees of comfort and trust in relationships. We conducted

qualitative semi-structured interviews with a purposive sample of 27 patients with type 2 diabetes attending the University

of Washington Diabetes Care Center in Seattle to explore issues of trust and collaboration in the health care setting. We

used a constant comparative approach in which contemporaneous data collection and analysis took place. A subset of

patients with fearful and dismissing attachment style reported having low levels of trust and an inability to collaborate with

others of longstanding duration. Many aspects of the current health care system, such as its rushed, impersonal nature and

a perceived ‘‘wall’’ between providers and patients were frustrating for most study patients. Patients with fearful and

dismissing attachment style reported that these aspects of the health care system often interfered with their ability to

partner with providers but also reported that patient-centered attitudes and behaviors by providers could improve their

trust and ability to engage in the health care system. Implications of using a conceptual model of attachment theory to

improve patient-centered care and customer service are discussed.

Keywords: Diabetes; Attachment style; Trust; Patient–provider relationship; Patient centered; Customer service; USA

Introduction

become knowledgeable about their conditions,

share in decision making, receive education and

disease self-management support, and are provided

with optimal medication management in a sus-

tained, consistent and timely fashion ( Katon et al.,

1997 ; Von Korff, Gruman, Schaefer, Curry, &

Wagner, 1997 ). Such a partnership between patients

and providers facilitates adoption of guideline and

evidence-based treatments, increases patient-cen-

tered interactions ( Ciechanowski, Wagner et al.,

2004 ; Neumeyer-Gromen, Lampert, Stark, &

Kallischnigg, 2004 ; Stewart, 1995 ), and contributes

Chronic illness care is optimally carried out in a

collaborative process with active follow-up and

tracking of outcomes and adherence by providers

and the health care system. Patients, in turn,

$ Supported by grant K23 DK60652-01 (National Institute of

Digestive and Diabetes and Kidney Diseases).

Corresponding author. Tel.: +1 206 543 8848.

E-mail addresses: pavelcie@u.washington.edu

(P. Ciechanowski) , wkaton@u.washington.edu (W.J. Katon) .

doi: 10.1016/j.socscimed.2006.08.002

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to optimal management of complex illnesses with

complicated self-care and treatment regimens such

as diabetes.

Despite promising changes in chronic disease

management in today’s health system, the prevailing

delivery model may not support such a collabora-

tive process because of system-wide fragmentation.

As the recent Institute of Medicine Crossing the

Quality Chasm report describes, contemporary

health care delivery is characterized by frequent

handoffs between providers, infrequent clinical

follow-up, reliance on in-person physician visits

with limited web-based or phone contact, lack of

support for behavioral change, and lack of time and

resources for patient self-management training

(2001). While the current health system is frustrat-

ing for many patients with chronic conditions

(1997), the capacity for a patient to successfully

navigate this system and experience patient-centered

care may be especially challenging for patients with

speciﬁc interpersonal characteristics.

The ‘‘Chasm’’ report recognizes the importance of

individual differences in preferences and approaches

in working with health care professionals (2001).

Patients with more reluctance depending on physi-

cians and health care teams may have greater

difﬁculty receiving high-quality health care and

achieving optimal outcomes in a fragmented health

system. Such patients may be more sensitive to the

lack of shared decision making and pervasive lack

of coordination and continuity of routine health

care compared to patients who are more comfor-

table in the traditional patient–physician role. There

has not been a well-established theoretical approach

to understanding and working with individual

differences in patients’ preferences for interacting

with providers within the health care system.

Attachment theory—a model that recognizes that

all individuals have underlying cognitive-emotional

schemas guiding their perceptions and behaviors in

interpersonal relationships—provides a promising

conceptual framework with which to practically

approach individual differences in preferences for

receiving health care (2001; Dozier, Cue, & Barnett,

1994 ).

In developing attachment theory, John Bowlby

proposed that all individuals psychologically incor-

porate prior experiences with caregivers, forming

enduring mental representations of caregiving that

persist into adulthood called ‘‘internal working

models’’ ( Bowlby, 1977 ). Such models are learned

ways of interacting in relationships throughout life,

particularly at vulnerable times (e.g. managing one’s

disease or symptomatic and functional challenges of

illness). These models inﬂuence whether individuals

deem themselves worthy of care (model of self) and

whether others are perceived as trustworthy to

provide care (model of other). Studies demonstrate

high stability and continuity of attachment models

between infancy and adolescence ( Hamilton, 2000 )

and infancy and adulthood ( Waters, Merrick,

Treboux, Crowell, & Albersheim, 2000 ). Based on

empirical research in infants, children and adults

over the past three decades, social psychologists

( Grifﬁn & Bartholomew, 1994 ) have identiﬁed four

patterns of attachment behaviors in adults: secure,

preoccupied, dismissing and fearful. These four

attachment styles can be considered conceptually

distinct dimensions and individuals may be char-

acterized interpersonally by varying degrees of each.

Clinically and descriptively, however, it is often

more useful to conceptualize individuals in terms of

their predominant attachment style so as to better

understand developmental and behavioral charac-

teristics of each style.

Adults who have predominantly secure attach-

ment style are generally believed to have experi-

enced consistently responsive ( Ainsworth, Blehar,

Waters, & Wall, 1978 ) early caregiving (in the

process developing a positive model of self

and other; Fig. 1 ) and are generally comfortable

depending on and being readily comforted by

others. Adults with predominantly preoccupied

attachment style are posited to have experienced

inconsistently responsive caregiving ( Bartholomew,

1990 ) and in an effort to ensure proximity to

caregivers, they use strategies in which the attach-

ment behavioral system is ‘‘hyperactivated’’ through

exaggeration of behaviors attracting support ( Mi-

kulincer, Shaver, & Pereg, 2003 ). They are generally

emotionally dependent on others’ approval (positive

model of other), often to the point of being

‘‘clingy,’’ but generally have poor self-worth (nega-

tive model of self).

The remaining two styles, dismissing and fearful

attachment styles, are characterized by strategies in

which the attachment behavioral system is ‘‘deacti-

vated’’ ( Mikulincer et al., 2003 ), i.e. there may be

avoidance of support-seeking behaviors or denial or

minimization of emotions and cognitions associated

with attachment needs. Adults with predominantly

dismissing attachment style are believed to have

experienced early caregiving that was largely emo-

tionally unresponsive. As a result, they develop

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Fig. 1. Attachment style categories and model of self and other. Adapted from Bartholomew & Hororwitz (1991) .

strategies from an early age in which they become

‘‘compulsively self-reliant’’ ( Bowlby, 1977 ) (positive

model of self) and uncomfortable trusting others

(negative model of other). Individuals with dismiss-

ing attachment style are described as lacking in

emotional self-disclosure and as emotionally cool or

aloof ( Bartholomew, 1990 ). They distract them-

selves from emotions at times of upset and they

actively avoid seeking out support. Because of their

high interpersonal self-reliance, they may also have

moderate to high self-conﬁdence. While downplay-

ing the importance of relationships they often stress

the importance of independence, freedom and

achievement.

Individuals with predominantly fearful attach-

ment style may initially desire social contact (i.e.,

not highly self-reliant), but this desire is inhibited by

fear of rejection. These individuals are proposed to

have had overly critical, harsh or rejecting caregiv-

ing (negative model of self and other) and as adults

demonstrate interpersonal approach-avoidance

behavior stemming from a fear of intimacy

( Bartholomew, 1990 ). Interpersonally, they appear

as hesitant, vulnerable, shy, self-conscious or as

having a low self-conﬁdence ( Bartholomew, 1990 ).

When confronted with problems or upsetting

matters, they are emotionally reactive, but do not

actively deal with their distress or seek support.

They can acknowledge feeling bad but avoid self-

disclosure or appearing upset in front of others

because of fear of rejection. Individuals with fearful

attachment style may have a few close relationships

that typically take years to establish and have

difﬁculty breaking off such relationships because of

fear of ever ﬁnding another relationship.

Previous studies in community, college and

medical populations have explored how adult

attachment processes may interpersonally inﬂuence

stress, coping and health-related outcomes. For

example, in student samples it has been conﬁrmed

that in stressful situations, compared to individuals

with secure attachment styles, individuals with

dismissing attachment style demonstrate less self-

disclosure and reciprocity ( Mikulincer & Nachshon,

1991 ) and individuals with fearful attachment style

demonstrate less collaboration ( Lopez et al., 1997 ).

In a study of expectant parents, parents with secure

attachment style were more willing to seek out

therapy for mental health problems and were more

satisﬁed with care compared to parents with

insecure attachment styles ( Riggs, 2001 ). In another

study, patients with dismissing attachment style

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were least likely to seek out support in the form of

psychotherapy ( Riggs, Jacobovitz, & Hazen, 2002 ).

In medical populations, similar coping ap-

proaches have also been found. Among patients

with breast cancer, chronic leg ulcers and alopecia

those with dismissing attachment style more

often used denial coping compared to patients with

secure attachment style ( Schmidt, Nachtigall, Wue-

thrich-Martone, & Strauss, 2002 ). In HIV positive

patients, secure attachment style was associated

with less perceived global stress in the prior month

compared to patients with insecure attachment style

( Koopman et al., 2000 ).

Previous studies have explored the potential

inﬂuence of attachment styles on treatment adher-

ence and outcomes in patients with diabetes. For

example, studies have demonstrated poorer diabetes

self-care, insulin and hypoglycemic medication

adherence and higher glucose levels in diabetic

patients with fearful and dismissing attachment

style as compared to patients with secure attach-

ment style ( Ciechanowski, Russo et al., 2004 ;

Ciechanowski, Hirsch, & Katon, 2002 ; Ciechanows-

ki, Katon, Russo, & Walker, 2001 ; Turan, Osar,

Turan, Ilkova, & Damci, 2003 ).

In this paper, we present the results of a

qualitative investigation of the experiences of

patients with type 2 diabetes in their interactions

with the health care system in managing diabetes,

while taking into account their general capacity to

rely on others based on attachment theory. We

hypothesized that compared to patients with secure

attachment style, those with dismissing and fearful

attachment style would be: (1) less satisﬁed with

interactions with health care providers; (2) less

trusting of health care providers and (3) less able to

collaborate in health care settings.

demographic data, clinical characteristics, self-care

adherence and attachment styles of patients attend-

ing this clinic within the prior 2 years. Response

rate to this questionnaire was 58%. To guide

selection of a patient subgroup for recruitment to

the qualitative study, purposive sampling ( Patton,

1990 ) was used to achieve maximum variation in

gender, age, race/ethnicity and in attachment styles

directly or inversely associated with trust and ability

to rely on others. To optimally explore health

care experiences among patients with low levels of

trust, we intended to recruit approximately twice as

many patients within each of dismissing and

fearful attachment style groups as within the secure

attachment style group.

We also aimed to ensure maximum variation in

glucose control among study patient based on

glycosylated hemoglobin (Hb A1c ). Hb A1c is accepted

as the best measure of recent glycemic control (last

120 days) and is used to guide clinical management

( Goldstein et al., 1995 ). Lowering Hb A1c has been

associated with a reduction of microvascular and

macrovascular diabetic complications and the Amer-

ican Diabetes Association recommends developing

or adjusting the management plan to achieve normal

(4–6%) or near-normal ( o 7%) Hb A1c values (2005).

To measure Hb A1c , the University of Washington

Diabetes Care Center laboratory uses a Bayer

DCA2000, which is certiﬁed by the National

Glycohemoglobin Standardization Program as hav-

ing documented traceability to the Diabetes Control

and Complications Trial reference method.

Attachment style determination

Participants completed the Relationship Ques-

tionnaire (RQ) ( Grifﬁn & Bartholomew, 1994 ),

created by Bartholomew and colleagues based on

Bowlby’s attachment theory ( Bowlby, 1977 ), which

measures respondent attachment style. This mea-

sure demonstrates convergent and discriminant

validity with other self-report and interview ratings

( Scharfe & Bartholomew, 1994 ). Since preoccupied

attachment style has not been consistently asso-

ciated with diabetes treatment adherence or adverse

outcomes compared to secure, dismissing and

fearful attachment styles ( Ciechanowski et al.,

2006 ), an a priori decision was made not to include

this attachment style group in this study.

Items assessing each attachment style consist of

paragraphs describing each style ( Table 1 ). Respon-

dents are asked to think of all past and current close

Study design

Subjects and settings

Twenty-seven patients with type 2 diabetes

attending the University of Washington Diabetes

Care Center in Seattle, Washington were recruited

to the study. This tertiary care clinic provides

diabetic health care for 3000 patients and is staffed

by eight physicians, two nurse practitioners and two

nutritionists. Patients were identiﬁed from clinic

rosters and had initially responded to a self-report

questionnaire from the Diabetes Care Study

(N ¼ 395 type 2 diabetes patients) which assessed

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3071

Table 1

Descriptive paragraphs of attachment styles ( Bartholomew &

Horowitz, 1991 )

tives of diabetes care and health care, including the

patient–provider relationship. Telephone interviews

were shorter in duration and addressed recent

intervening clinic visits that patients attended at

the Diabetes Care Center.

Interview topics included: (1) assessment of the

patients’ understanding of diabetes and related

complications; (2) a review of all prior and current

health care relationships related to diabetes treat-

ment; (3) discussion of health visit frequency, modes

of contact with providers and perceived quality of

prior and current patient–provider relationships;

(4) assessment of diabetes self-management; (5)

discussion of patients’ attachment style character-

istics; (6) patients’ perceptions of how family may

help with or hinder diabetes self-management.

Patients’ prior interviews were reviewed and

additional questions were added to subsequent

interviews to address issues raised by a patient in

a previous interview, or in response to emerging

themes that arose from the interview with the same

patient or with other patients.

Secure attachment

style

It is easy for me to become emotionally

close to others. I am comfortable

depending on them and having them

depend on me. I don’t worry about

being alone or having others not accept

Fearful attachment

style

I am uncomfortable getting close to

others. I want emotionally close

relationships, but I ﬁnd it difﬁcult to

trust others completely, or to depend

on them. I worry that I will be hurt if I

allow myself to become too close to

others

Dismissing

attachment style

I am comfortable without close

emotional relationships. It is very

important to me to feel independent

and self-sufﬁcient, and I prefer not to

depend on others or to have others

depend on me

Preoccupied

attachment style a

I want to be completely emotionally

intimate with others, but I often ﬁnd

that others are reluctant to get as close

as I would like. I am uncomfortable

being without close relationships, but I

sometimes worry that others don’t

value me as much as I value them

Analysis

Patients with preoccupied attachment style were not included

in this current study.

We used a constant comparative approach in

which contemporaneous data collection and the-

matic analysis of interview data took place ( Strauss

& Corbin, 1990 ). All interviews were audiotaped,

transcribed and managed using QSR N6 Version 6.0

(QSR International Pty Ltd.). Themes related to

health care experiences were derived from data

rather than being imposed in the analysis, though

the interviewer was not blinded to patients’ attach-

ment style categories. Emerging themes, issues and

hypotheses from earlier interviews informed subse-

quent interviews in an iterative process ( Strauss &

Corbin, 1990 ). Data were organized into initial and

higher level codes and clustered across transcripts to

derive primary interpretative themes.

relationships when completing the questionnaire

and to choose the style suiting them best.

Semi-structured interviews

Each patient was enrolled for 3 months. In-

person interviews took place at the University of

Washington Medical Center. Interviews usually

occurred on the day of a scheduled Diabetes Care

Center appointment and were tape-recorded with

patients’ consent and transcribed in full. The study

protocol was reviewed and approved by the Uni-

versity of Washington institutional review board.

All participants gave written informed consent.

Semi-structured interviews were conducted by

the ﬁrst author (PC). A repeat interview design

facilitated the development of trust and rapport

( Mathieson, 1999 ), particularly around issues pa-

tients might have initial reluctance to discuss. Two

in-person interviews lasting 30–50min were con-

ducted 3 months apart, interspersed with an inter-

view conducted by telephone. In-person interviews

enquired about various aspects of patients’ perspec-

Results

11.8 years

(range 19.9–85.3 years); 194 patients (49.1%) were

female; 72 patients (18.2%) belonged to a race/

ethnic minority; 329 patients (83.3%) had at least

one year of college education; 157 patients (41.8%)

had secure attachment style; 114 patients (30.3%)

had dismissing attachment style; 72 patients

(19.1%) had fearful attachment style; 258 patients

Among 395 patients with type 2 diabetes from the

clinic-wide sample: mean age was 56.8

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