From the Editor

Patrick is not participating in physiotherapy, and is thus not eligible for discharge. To the staff on the orthopedics ward at the hospital where I work, that’s a Big Problem.

On Tuesday afternoons, I finish at the Birchmount campus of The Scarborough Hospital and drive to the General, where I see patients on medical and surgical floors. And on a recent Tuesday, I met Patrick.

For the record, Patrick has more than one Big Problem. Patrick smokes and he drinks too much. Patrick has diabetes and lung changes. Patrick is obese. And it’s the combination of all of the above that led to the fall that left him with the fractured hip and the surgery. If Patrick is doing badly – this is his second hospitalization in fifteen months – it’s not for lack of health-care effort. Since his last discharge, he has seen an endocrinologist, his family doctor, and a respirologist. Patrick has home care. Patrick is, in other words, a heavy user of the health-care system. And if we are serious about restraining health costs in light of an aging population, we need to find better ways of dealing with people like Patrick.

This week’s Reading: an excerpt from the new Maunder-Hunter book. In it, the authors forward the following idea: people like Patrick can be better helped if we think about attachment theory.

As you will recall, attachment theory is based on experiments with children exposed to strangers. To summarize (and possibly oversimplify) some very clever experiments: after seeing the stranger, if the child seeks out the parent, and is soothed, it’s considered healthy, or secure attachment, as opposed to insecure attachments, like avoidant attachment and resistant attachment (where the child is less interested in the parent or is difficult to soothe).

This is a terrific and important book – and of interest to all clinicians.

It’s thoughtful and relevant. Do you see patients? You should get this book.


New Psychiatry Book

Love, Fear and Health: How Our Attachments to Others Shape Health and Health Care

Robert Maunder and Jonathan Hunter, University of Toronto Press, 2015

Health care is not what it seems. Consider a few popular prototypes of medicine.

The House version: Medicine is a detective exercise in which only logic, instinct, and high-tech investigation stand between health care providers and the identification of the problem.

The ER version: Medicine consists of a series of life or death crises that demand swift and dramatic professional intervention.

The Scientific American version: Medicine consists of the application of dazzling scientific breakthroughs to improving health.

The Conspiracy Theory version: Medicine is a shell game in which mega-corporations exploit human suffering for profit.

The Marcus Welby version: Medicine is the way that wise and kindly doctors who know best help patients to get better.

The Money Pit version: Medicine is an unstoppable force pushing Western economies to the brink of bankruptcy.

None of these versions is dead wrong. But none is completely right.

Dr. Robert Maunder

So opens a new book written by psychiatrists Drs. Robert Maunder and Jonathan Hunter. The book takes a new look at health care – it considers economics, policy, patient care, and ties it all together with attachment theory.

In this book, Drs. Maunder and Hunter use attachment theory “to better understand how close relationships affect health.” Think less of a dissertation on John Bowlby’s original work, and more about the patients who will be in your waiting room tomorrow morning.

Sounds sweeping? The book is ambitious, clever, compelling – and, yes, it works.

Dr. Jonathan Hunter

Having trained at the University of Toronto, I know both of the authors. And while I didn’t spend much time with Dr. Hunter during my training, I found our conversations during my PGY1 year to be provocative and interesting. During one, when I told him that a woman had borderline personality disorder, he pushed me to think differently – a tall order for a junior resident who had been intellectually clinging to his earmarked copy of DSM-IV.

Years have passed, but having read this book, I feel he’s still pushing me to think differently.

The book opens with a discussion about health care. The book reviews familiar facts about our system – that a small percentage of patients use a disproportionately large percentage of resources. The authors review much data, noting the biological roots of illness, but also the limits of this model. They talk about vexing health care – a term they coin to “because it runs counter to the very attractive idea that the one-two punch of a biomedical understanding of disease plus technological/pharmaceutical responses to this knowledge will be sufficient to find our way out of the extraordinary costs of our current dilemma.”

Patrick isn’t mentioned in the book, of course, but they do talk about people like Patrick. Consider the obese: as much as we try to educate people about diet and exercise, a full 80% of diets fail. The authors push further, noting that despite the public health campaigns: one in five smoke; one in four are obese; one in four men drink too heavily.

Can we do better?

The authors tie health-care use and outcomes to attachment theory. They note that attachment shapes the brain – literally. Tapping current neurocognitive and evolutionary theories, they explain: “During evolution, longer protected development has allowed for the development of larger brains, which in turn has facilitated more sophisticated social communication, which enhances brain development and allows for more sophisticated ways for societies to protect and enhance the care of infants.” They see the core attachment between an infant and his parents as shaping the development of connections between the brain’s regions. But if that process is disrupted, the person carries the weight of insecure attachment, with resulting damage to health (a person “quickly ameliorates feelings of insecurity [with] some of the most important disease-promoting aspects of our lifestyles, especially obesity, alcoholism, and smoking”) and the relationship to health-care providers (leading a person “use relationships with health care providers to regulate feelings rather than to identify and treat diseases”).

Connecting attachment theory with health care isn’t exactly new terrain. Indeed, it’s a hot area of research. The contribution here: Drs. Maunder and Hunter pull together a big literature simply and effectively. They review biological implications of attachment. They provide real-world examples. And they do all of the above, and with an edge: one chapter is titled “Why Are So Many of Us Fat, Drunk, Stationary Smokers?” It’s a chapter about people like my patient Patrick.

In that chapter, by the way, Drs. Maunder and Hunter tie poor health behaviours to poor attachment.

Finally, the book closes with scenarios for patients and providers. In a chapter that is particularly relevant to us clinicians, they run through suggestions for dealing with patients with insecure attachment. To the provider of a patient with fearful attachment: “be patient,” “act in good faith,” and so on. It’s a strong contrast from the approach that a treatment team may take with a patient like Patrick who seems to test everyone’s patience.

And there are larger implications of this work. Near the end, the authors consider some policy issues. Anti-smoking ads have middling success. Should public health messaging take into account attachment? Drs. Maunder and Hunter argue yes, and think that a radio ad talking about your partner loving that you quit would be more powerful than telling you that smoking could kill you. Better trained day-care workers, support for gay marriage and financial rewards for caregivers of those with dementia could all be seen through the lens of attachment.

These points are thought-provoking. The core of the book, though, is practical: how to deal with patients who we typically don’t deal so well with. It’s a big and timely topic. Consider: A recent Wall Street Journal article looked at major American hospitals that are working to better use mental health services within medical and surgical teams. The article didn’t discuss attachment theory, but the larger point ties nicely into this book: treating complex patients with physical health problems means understanding these patients better, including their mental health needs.

That article can be found here:

The full Introduction is attached. And I note:

From LOVE, FEAR, AND HEALTH: How Our Attachments to Others Shape Health and Health Care by Robert Maunder and Jonathan Hunter. Copyright © 2015. Reprinted by permission of University of Toronto Press.

This book can be found at leading bookstores, including Caversham Booksellers.

Readers may also be interested in another newly-released book on this topic, edited by Drs. Maunder and Hunter, which is more technical:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.