Nonadherence to treatment by patients represents one of the most prevalent and important challenges to the practice of psychiatry. Despite treatment advances and efforts to elucidate the determinants of noncompliance to medical care, nonadherence remains ubiquitous in persons with chronic medical conditions (with average adherence rates of 43% to 78%) and in psychiatric cohorts (with average adherence rates of 50% to 62%).1-3 Researchers in cognitive-behavioral therapy, psychoeducation, and motivational interviewing have made significant contributions to understanding nonadherence and tailoring interventions to improve treatment adherence.4 A psychodynamic theoretical framework is another approach to understanding and improving adherence.
Psychodynamic theory is a framework that could be helpful in clarifying our understanding of nonadherence. In particular, looking at the contributions of attachment theory and research has allowed us to deepen our understanding of nonadherence.5 Strengthening the therapeutic alliance and fostering collaborative physician-patient relationships may result in improved adherence.
Psychological and psychodynamic antecedents of nonadherence
Cohen and colleagues6 have written extensively on the connection between early childhood trauma and nonadherence or resistance to care in adult patients with posttraumatic stress disorder and comorbid depression. They postulated that traumatized patients’ sense of a foreshortened future may be related to failure to engage in or accept medical treatment, which suggests that early childhood trauma is a psychological risk factor for adult nonadherence.
Psychodynamic determinants and adaptive (and maladaptive) defenses related to nonadherence in psychiatric patients include5,7-9:
• Limited understanding of the illness
• Denial, rationalization, and isolation of affect
• Feeling coerced, disrespected, or infantilized by the physician
• Feeling deceived or manipulated
• Sensing that the psychiatrist is tentative or ambivalent when presenting the information
As prescribers, our failure of empathy often stems from an unconscious need to feel separate from our patients—to defend ourselves against overwhelming distress and maintain a safe space and emotional distance—consequently, abstinence and neutrality are overemphasized.10 A collaborative stance promotes adherence, while paternalistic or categorical medication advice could be perceived as coercive and could result in partial or nonadherence.
Attachment theory and nonadherence
A recent focus on the interface between attachment theory and psychoanalytical theory has deepened our understanding of the psychodynamics of nonadherence. Attachment theory is based on the premise that early life experiences with caregivers are internalized and determine how individuals relate to others in adulthood. Attachment concepts were originally conceived to understand the evolutionary, adaptive, and biological aspects of parent-infant care giving. Most recently, clinical research has validated the usefulness of attachment concepts in understanding nonadherence.11-13
The disruption in attachment bonds by separation, rejection, loss, inconsistent attunement, or fear can lead to problematic behavior during childhood and possibly across the life span. Research has demonstrated that the caregiver’s sensitivity to the infant’s needs (availability and responsiveness) is essential to ensure secure attachments and lead to an empirically based classification of mother-infant dyads.
What is already known about the psychodynamics of nonadherence?
■ Classical psychoanalytic theory, with emphasis on concepts of resistance, transference, and countertransference, has shed some light and guided clinicians who work with patients who are nonadherent. Some helpful psychodynamic concepts include clinicians’ failure of empathy that stems from an unconscious need to feel separate from our patients’ distress, and their use of defenses of denial, rationalization, and isolation of affect.
What new information does this article add?
■ In this article, emphasis shifts to understanding nonadherence using the paradigm of attachment theory.
What are the implications for psychiatric practice?
■ Identifying adults with dismissing attachment style can be predictive of nonadherence to care. Dismissing individuals are compulsively self-reliant and tend to idealize or devalue with facility, but they can be easily engaged in psychotherapy and are open to the possibility of “earned attachment” through collaborative, nonconfrontational psychotherapeutic interventions.
Ainsworth and colleagues14 observed in their laboratories infants’ reactions to separation from the mother, exposure to a stranger, and reunion with the mother. They initially described 3 types of attachment interactions: secure, avoidant, and ambivalent. Secure infants are consoled by reunion and reconnection with the mother; infants with avoidant attachment are indifferent and avoid the mother when reunited; and infants with ambivalent attachment, although preoccupied with the mother’s whereabouts during separation, are inconsolable during reunion. Secure infants have sensitive and attuned parents; avoidant infants have parents who are emotionally constricted and uncomfortable with physical contact; and ambivalent infants have parents who oscillate in their stance from available and responsive to insensitive and rageful.14