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Social Science & Medicine 63 (2006) 3067–3079
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
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.
r 2006 Elsevier Ltd. All rights reserved.
Keywords: Diabetes; Attachment style; Trust; Patient–provider relationship; Patient centered; Customer service; USA
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
0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.
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P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
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
P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
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
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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P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
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
P. Ciechanowski, W.J. Katon / Social Science & Medicine 63 (2006) 3067–3079
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
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
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
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
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
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-
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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