By Jon G. Allen, Ph.D., and Michael D. Groat, Ph.D.
The Menninger Clinic
Protective, healing relationships between doctors and patients are founded on trust. Patients come to trust their doctor when they feel understood and have their concerns responded to with care and compassion. This kind of emotional responsiveness is especially crucial when patients are emotionally distressed. Empathic attunement—the cornerstone of the patient-physician bond— involves “mentalizing,” that is, a term we use in our work at The Menninger Clinic that means attentiveness to mental states such as thoughts and feelings in self and others. This fundamentally human capacity enables physicians to be attuned to patients and to understand how they think and feel about their illness. This foundation of understanding strengthens doctors’ connections to patients, and it improves patient satisfaction and clinical effectiveness.
This foundation matters in healthcare because patients are not easily influenced by those with whom they are not connected. An understanding of how to cultivate connection through a “mentalizing” stance, one of active curiosity, concern and openness to the patient’s view of things, can help do just that. Mentalizing begets understanding, trust and connection, and it promises to improve the social influence of physicians. Given how much of health involves lifestyle factors such as exercise, weight management and sleep, physicians’ abilities to persuade their patients to exercise better self-care will ultimately benefit patients and their families, and lower the costs of healthcare.
Attachment theory and research, pioneered in the middle of the last century by psychoanalyst John Bowlby and psychologist Mary Ainsworth has provided the basis of our understanding of the crucial benefit of emotionally supportive relationships for coping with stress—including the stress of illness. Bowlby recognized that all kinds of threatening situations activate the child’s attachment needs—exposure to danger, injuries and illnesses, and separations from trusted caregivers. Bowlby and his colleagues were particularly concerned with the plight of children who were separated from their caregivers in the course of hospitalizations, and they played a significant role in reforms that enabled parents to remain with their children during such hospitalizations.
The prototype of a secure attachment relationship is the mother-infant bond; securely attached children confidently reach out to their caregiver when they are distressed, and the contact they achieve is comforting, restoring a feeling of safety and security. In contrast, insecurely attached children do not find such contact soothing, or they may have given up seeking comfort and thus must do their best to manage their distress on their own.
Going it alone when ill is going it the hard way. Scientific study has confirmed the importance of an attentive, soothing patient-doctor relationship. Psychologist Jim Coan, conducting neuroimaging research at the University of Virginia, found that merely holding a partner’s hand during a stressful laboratory situation significantly diminished brain activity associated with distress as well as brain activity associated with effortful regulation of distress. Moreover, the mere contact with a partner was especially effective in decreasing the load on the brain when the relationship was highly secure.
Our colleague, psychoanalyst Peter Fonagy at University College London, has made a significant contribution to contemporary attachment theory by identifying the means by which secure attachment relationships are developed and maintained: mentalizing. Mentalizing entails attunement to mental states—such as desires, feelings, and thoughts—in oneself and others. Thus mentalizing overlaps with empathy, as long as we include empathy for oneself. Children become securely attached to their caregivers when their caregivers mentalize, that is, tune into the child’s emotional distress, understand the basis of the distress, and respond promptly and sensitively to it. Caregivers’ failure to mentalize results in higher levels of emotional distress and insecure attachment.
We believe that attunement to the attachment aspects of relationships as well as attention to mentalizing is as applicable to general medical practice as it is to psychiatry.
Bowlby made the strong claim that attachment security is essential for all of us throughout life—from the cradle to the grave, as he put it. Plainly, grave injuries and illnesses activate attachment needs throughout life, because these conditions are threatening. Perforce, the doctor-patient relationship takes on features of an attachment relationship, and patients’ attachment security is likely to play a role in the extent to which they approach this relationship from a foundation of trust.
No one doubts that effective medical care depends not only on medical expertise but also on the quality of the doctor-patient relationship. We believe that attachment theory—with the help of the concept of mentalizing—helps to clarify the ingredients of a healing relationship. As Bowlby and Ainsworth articulated over a half-century ago, the core of this relationship is sensitive responsiveness to the patient’s distress. When the doctor maintains a mentalizing stance, the patient will be more attuned to his or her emotional distress and better able to communicate it; consequently, the distress will become more bearable, the patient will feel more secure in the relationship and the optimal foundation for healing will be established.
Jon G. Allen is a senior psychologist, author, educator and researcher at The Menninger Clinic who is also professor in Baylor College of Medicine’s Menninger Department of Psychiatry & Behavioral Sciences. Psychologist Michael D. Groat is program director for the Professionals in Crisis inpatient program that treats individuals from medicine, law, entertainment, business and education. Dr. Groat is an assistant professor in the Menninger Department of Psychiatry & Behavioral Sciences.
