Introduction
Introduction to attachment theory and attachment styles
John Bowlby (Reference Bowlby1986, Reference Bowlby1998) describes attachment theory as an explanatory model of interpersonal and intrapersonal relationships through the human tendency to establish strong emotional bonds with certain people throughout life. First, he emphasizes that this need is fundamental to human beings and is present throughout the life cycle, that is, from “the cradle to the grave” (Bowlby Reference Bowlby1986). At the same time, the goal of attachment is to maintain a relationship that generates physical and psychological comfort in the face of possible and diverse threats by maintaining contact with an attachment figure. Thus, attachment theory is a way of conceptualizing the human tendency to establish emotional bonds (attachments) with certain people, as well as an attempt to explain the suffering and anxiety generated by the unwanted separation or emotional loss of those bonds (Bowlby Reference Bowlby1986).
For Yárnoz (Reference Yárnoz2008), attachment theory is a way of explaining and trying to understand relationships, while for Marrone (Reference Marrone2001) it is the basis of empathy and compassion, proposing a theory of affections and emotional regulation that underpins emotional difficulties, since there isa clear relationship between attachment and psychological difficulties existing in childhood, adolescence, and adulthood.
For a long time, empirical research on attachment focused primarily on the study of the development of bonds and their implications during the first years of life (Ainsworth, Blehar, Waters, & Wall Reference Ainsworth, Blehar, Waters and Wall1978). However, beginning in the 1980s, authors such as Main, Kaplan, and Cassidy (Reference Main, Kaplan, Cassidy, Bretherton and Waters1985) and Hazan and Shaver (Reference Hazan and Shaver1987) promoted theoretical development and empirical research on attachment in later stages of childhood (Zeifman & Hazan Reference Zeifman, Hazan, Cassidy and Shaver2008).
Based on these studies, an attachment figure in adulthood is defined as one who assumes the role of a secure base, facilitating the development of activities of exploration and personal development. It is also a figure that offers a sense of comfort in threatening or stressful situations, and is therefore used as a safe haven. Ultimately, it generates in the individual the need to avoid or reduce separation, whether concrete or symbolic (Hazan & Shaver Reference Hazan and Shaver1994).
John Bowlby’s attachment theory (Reference Bowlby1986, Reference Bowlby1998) posits that the bonds a person has maintained with their attachment figures during childhood can condition, although not necessarily determine, that person’s experience in later relationships with themselves and with others. Therefore, it is believed that attachment styles in adulthood generate behavioral patterns that maintain a certain continuity and stability with respect to the attachment styles displayed in previous stages (Ravitz et al. Reference Ravitz, Maunder and Hunter2010). The most relevant characteristics of the 4 adult attachment styles are described below:
− A person with a secure attachment style is characterized by valuing close relationships, by their ability to maintain them without losing their personal autonomy, and by their consistency and good judgment when discussing close relationships and related topics. They are able to handle stressful situations in daily life, notice what is going well and what is going wrong, regulate their emotions, and express their discomfort constructively, as well as facilitate collaboration and satisfying relationships.
− People with a preoccupied attachment style are characterized by overinvolvement in intimate and friendship relationships, by their dependence on others’ opinions of their personal worth and acceptance, by their tendency to idealize some people, and by their inconsistency or exaggerated emotionality when discussing these relationships. In interpersonal conflicts, they tend to blame themselves while maintaining a positive view of others. They will have difficulty regulating their emotions, and their excessive expressions of distress provoke others to mobilize, although attempts to obtain consistent attention are frequently frustrated, which again reflects the image of a person who is not being cared for.
− People with an avoidant attachment style downplay close relationships, emphasize independence, autonomy, and self-sufficiency, have restricted emotionality, and their ideas about the relationships they have had or would like to have are unconvincing. In interpersonal problems, they maintain self-esteem by placing the primary responsibility on others. They emphasize their self-sufficiency and avoid expressing their needs. They tend to trivialize or minimize their problems and difficulties. They neutralize their strongest emotions, and in cases of emotional distress, they use avoidance mechanisms and distance themselves from others.
− People with a disorganized attachment style avoid intimate relationships due to distrust and fear of abuse or abandonment. Their sense of personal insecurity is prominent, with emotional dysregulation occurring, and they frequently maintain chaotic relationships. In a healthcare setting, they are the patients who cause the most difficulties when it comes to relating to themselves.
Importance of attachment theory in palliative care
As described, throughout life, human beings need relationships and bonds that convey security, emotional support, protection, and support. Because of this, every person will seek proximity and contact with their attachment figure at certain times in their life, especially if there is a perception of danger, fear, and threats to the integrity of the person and their family. Therefore, it is expected that when a person experiences chronic suffering or discomfort, they will activate their attachment system to soothe or contain this concomitant discomfort (Bowlby Reference Bowlby1998).
The diagnosis of an advanced life-threatening illness brings existential challenges that activate the attachment system (Scheffold et al. Reference Scheffold, Philipp and Vehling2019), creating a greater need to establish secure bonds that can help reduce the suffering that appears in facing the threat and proximity of death. This attachment behavior contributes to the person’s adaptation to the environment and to their survival (Bowlby Reference Bowlby1993), becoming more important in the experiences of existential suffering (Tarbi et al. Reference Tarbi, Moore and Wallace2024) that appear during the process of advanced illness or end of life.
The 4 attachment styles influence differently social functioning, coping and adaptation to the disease process, response to stress, psychological well-being and even healthy behavior, therapeutic adherence and clinical management (Ciechanowski et al. Reference Ciechanowski, Katon and Russo2002; Maunder and Hunter Reference Maunder and Hunter2001; Schmidt et al. Reference Schmidt, Nachtigall and Wuethrich-Martone2002). Specifically, in relation to patients with oncological disease and/or with palliative needs, the identification of the attachment style of patients and family members helps healthcare professionals to adjust the therapeutic relationship and to be able to focus attention on the psychosocial needs of those patients and families who need it most, identifying the most complex cases, and proposing communication and relationship styles in accordance with the needs of that support, according to their attachment styles (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Hooper et al. Reference Hooper, Tomek and Newman2012; Lo et al. Reference Lo, Walsh and Mikulincer2009; Nicolaisen et al. Reference Nicolaisen, Hansen and Hagedoorn2014; Nissen Reference Nissen2016; Petersen and Koehler Reference Petersen and Koehler2006; Philipp et al. Reference Philipp, Vehling and Scheffold2017; Strauss and Brenk-Franz Reference Strauss, Brenk-Franz, Hunter and Maunder2016; Tan et al. Reference Tan, Zimmermann and Rodin2005).
Attachment styles and their measurement
Different measurement instruments are available to evaluate the 4 attachment styles, considering the theoretical approach and the nomenclature of the classification of attachment styles, although all instruments differentiate between secure attachment styles and different subtypes of insecure attachment (Martínez and Santelices Reference Martínez and Santelices2005). Main, Kaplan, Cassidy (Reference Main, Kaplan, Cassidy, Bretherton and Waters1985), through the Adult Attachment Interview (AAI), differentiate 3 adult attachment styles that are similar to the childhood categories: secure/autonomous, avoidant, and anxious/preoccupied, although there would be a fourth “unclassifiable” one.
From another theoretical perspective, Hazan and Shaver (Reference Hazan and Shaver1987) considered that adults with different attachment histories would classify themselves according to their way of thinking, feeling and behaving in close relationships, giving rise to 3 primary interpersonal styles during adolescence and adulthood (Hazan and Shaver Reference Hazan and Shaver1987).
Bartholomew and Horowitz (Reference Bartholomew and Horowitz1991) integrates the categorical and dimensional views with the 4-category model and classifies the attachment styles of individuals (Bartholomew and Horowitz Reference Bartholomew and Horowitz1991) systematizing Bowlby’s conception of “internal operating models” and defining individual differences in adult attachment in terms of the intersection of 2 dimensions: on the one hand, the self-model dimension (self-perception) and the perception of others, and on the other hand, the anxiety/dependence and avoidance dimensions. Both dimensions are dichotomized as positive or negative and, when combined, make up the 4 styles attachment patterns (Fig. 1; Bartholomew et al. Reference Bartholomew, Kwong, Hart and Livesley2001).
Two-dimensional model of adult attachment. Source: Extracted from Bartholomew and Horowitz (Reference Bartholomew and Horowitz1991), modified from Viel (Reference Viel2019).
Thus, over the past 15 years, research on adult attachment has generated 2 parallel lines of research, each of which is based on different conceptualizations and theories, and therefore there are also different ways of assessing this construct (Martínez and Santelices Reference Martínez and Santelices2005). Table 1 shows the most used instruments, according to these lines of research.
Questionnaires used according to representational or behavioral system
A better understanding of how attachment styles shape the psychosocial experiences of patients with advanced illness and their families may help the development of individual and effective interventions in palliative care settings. Given the complexity of psychological, relational, and existential challenges in end-of-life contexts, identifying how different attachment patterns influence coping, communication, and psychological adjustment is critical. Additionally, gaining clarity on the most appropriate and psychometrically sound instruments for assessing attachment in these settings can enhance clinical assessment and tailored support. This systematic review addresses the following research questions:
1. How do attachment styles influence the psychosocial adjustment and experiences of patients and family members in the context of advanced illness?
2. What psychosocial factors related to advanced disease are associated with different attachment styles in patients and their caregivers?
3. Which assessment instruments are most commonly used to classify attachment styles in palliative care settings, and which demonstrate the strongest psychometric properties for this context?
The aim of this paper was (a) to describe the psychosocial factors related to advanced disease that are influenced by the attachment styles of patients and family members, and (b) to identify the assessment instruments to classify the attachment styles of patients most used in palliative care settings and to select those that present better psychometric properties.
Methods
The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Liberati et al. Reference Liberati, Altman and Tetzlaff2009).
Search strategy and information sources
A comprehensive literature search was conducted from January 10 and 20, 2024. We updated the search on to February 8, 2025.
The study of attachment in the oncology population is relatively recent, so this review includes studies published in peer-reviewed journals from the last 2 decades, specifically studies published between October 2005 and February 8, 2025. Searches for each data base are shown in Supplementary Appendix.
The systematic searches were conducted across the PubMed, PsycINFO, SCOPUS, Google Scholar, Dialnet, and Web of Science databases. Observational study designs were considered, including cross-sectional, longitudinal or cohort. No single-case studies or previously conducted systematic reviews or narrative studies were included in this review to avoid interpretive bias. Only published in English and Spanish were included in.
The flowchart of the search process is presented in Fig. 2 (PRISMA diagram).
PRISMA flowchart.
Inclusion and exclusion criteria
The review included studies of adults aged 18 or older, both general and clinical populations samples. A search strategy was devised to include the following keywords and synonyms for the terms related to attachment, in the context of end of life, advanced cancer, the field of care and palliative care, people with advanced illness and their primary family caregivers. Specifically, the following terms from headings in English and Spanish were used referring to the problem, to the population and to processes: (“advanced cancer” OR “terminal illness” OR “palliative care” OR “end of life”) AND (“patients” OR “family caregivers”) AND (“attachment styles” OR “attachment” OR “attachment measuring” OR “attachment assessment” OR “attachment scales”) AND (“adults” OR “adult patients” OR “aged 18 years or older” OR “aged 18+” OR “over 18”).
In this sense, empirical studies that broadly examined the impact of the attachment style of patients and family members on the experience of advanced illness and the process of death were included. The association of different attachment styles with different psychological aspects such as emotional distress, existential suffering, existential loneliness, death anxiety, as well as social support, family caring abilities, coping strategies, adaptation and emotional adjustment to the disease process of both patients and their family carers was examined. Finally, the influence that attachment styles could have on the therapeutic relationship between the professional and the patient was examined.
The scales or assessment instruments used to classify attachment styles were also examined.
Studies that used samples of patients under 18 years of agefrom non-palliative health contexts, and in some cases, that did not have measures to assess attachment style were excluded. Only studies that were in English or Spanish were considered. To reduce the potential for interpretive bias, this review excluded single-case reports, as well as prior systematic and narrative reviews.
Selection and data collection process
The selection of articles followed a 4-phase process: (1) export and elimination of duplicates (2) preliminary screening of titles and abstracts; (3) full-text screening; and (4) final inclusion in the review.
The initial screening phase involved reviewing titles and abstracts to assess their eligibility for the subsequent full-text screening. During this stage, a color-coding system was employed to classify each article: green (include), amber (uncertain), and red (exclude). Researcher KS was responsible for the export of records, removal of duplicates, and the initial screening. Articles marked as amber (uncertain) were re-evaluated by a second researcher, JTL, to determine their suitability for the next phase. To reduce the likelihood of prematurely excluding potentially relevant studies, a deliberately inclusive approach was adopted: any study presenting ambiguity or insufficient information in the title or abstract was advanced to the full-text screening. The second screening was performed independently by 2 researchers, QB and JTL. Discrepancies between reviewers were resolved through discussion and consensus with the involvement of a third author (SV) to help reach agreement.
To integrate findings across study types, we extracted key characteristics from each article, including lead author and country, year of publication, study aim, participant characteristics (sample size, mean age), study design and setting, attachment assessment tools, main results, and conclusions. Quantitative data were summarized descriptively and compared narratively across outcomes and measures (e.g., associations between attachment style and psychological distress), while qualitative findings were thematically synthesized. No meta-analysis was conducted due to heterogeneity in study designs and measures (Table 3).
Risk of bias assessment
Methodological quality and risk of bias were assessed for each empirical study using the criteria proposed by Hawker et al. (Reference Hawker, Payne and Kerr2002). For each study, the following areas were analyzed: title and abstract, introduction and objectives, methodology, sample, data analysis, ethical aspects, results, generalization and transferability, and implications of the study for practice. Of the 9 aspects, a score was obtained on a Likert scale from 0 to 4, where 4 indicated the highest quality and 0 indicated very low quality, and a total score (Table 2). This tool contributed to the transparency and reliability of the quality assessment process. Two reviewers independently assessed the risk of bias for each included study, conducting their evaluations separately to ensure methodological objectivity. Discrepancies were resolved through discussion, with consensus achieved in all instances. In cases where consensus was difficult to achieve, a third reviewer (SV) was consulted to assist in reaching an agreement.
Methodological quality, risk of bias, and quality assessment for the included empirical studiesa
a Hawker´s criteria for quality assessment of empirical studies. Maximum score = 36.
Results
Included studies
Initially, 1847 articles were identified and 1656 were excluded because they were duplicates or did not meet the inclusion criteria (Fig. 2).
For an initial selection, 191 articles were identified and after evaluating the inclusion and exclusion criteria, 53 articles were preselected. There was no disagreement between the researchers about the inclusion of the articles in the study.
Subsequently, a total of 24 articles were excluded, 16 of which were not carried out in palliative or end-of-life contexts, 4 studies did not include measures to assess attachment style, and 2 were carried out in a population other than that of our review; 3 were review studies and 4 were cases studies, Finally, 2 researchers reviewed the full text of the preselected studies, and it was decided to include 24 articles for the systematic review.
The average quality of the selected articles (n = 24) was 33.3, and 2 of them (Lo et al. Reference Lo, Walsh and Mikulincer2009; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018) obtained the maximum score, while 13 studies obtained scores below the average (Cicero et al. Reference Cicero, Lo Coco and Gullo2009; Gauthier et al. Reference Gauthier, Rodin and Zimmermann2012; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Oldham et al. Reference Oldham, Dobscha and Goy2011; Philipp et al. Reference Philipp, Vehling and Scheffold2017; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020) (Table 2).
Characteristics of the selected studies
Configuration and design features
The oldest study was published in 2006 (Hunter et al. Reference Hunter, Davis and Tunstall2006) and the last ones in 2020 (Mah et al. Reference Mah, Shapiro and Hales2020; Ramos et al. Reference Ramos, Langer and Todd2020). And 26% of the studies had been carried out in Canada (n = 729.2%), followed by Germany (n = 5, 20.8%) and Italy with 3 works; and 2 works in the United States). The remaining studies were represented by 1 study in each country and were the following: Australia, Turkey, Greece, Sweden, Iran, Poland, and China (n = 1, 4.2%). None was carried out in Spain.
Regarding the study design only 3 studies (12.5%) of 24 present a qualitative analysis methodology (Kunsmann-Leutiger et al. Reference Kunsmann-Leutiger, Loetz and Frick2018; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019).
Most studies employ quantitative methodology (n = 21; 87.5%), of which 4 use longitudinal designs (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Lo et al. Reference Lo, Walsh and Mikulincer2009; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016). while the remaining studies follow a cross-sectional design, as do the 3 qualitative studies (Braun et al. Reference Braun, Hales and Gilad2012; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Gauthier et al. Reference Gauthier, Rodin and Zimmermann2012; Hunter et al. Reference Hunter, Davis and Tunstall2006; Lo et al. Reference Lo, Lin and Gagliese2010; Mah et al. Reference Mah, Shapiro and Hales2020; Oldham et al. Reference Oldham, Dobscha and Goy2011; Philipp et al. Reference Philipp, Vehling and Scheffold2017; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Vehling et al. Reference Vehling, Tian and Malfitano2019; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020; Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019) The description of the main characteristics of the included studies can be found in Table 3.
Findings from the studies included in this review
Characteristics of the participants
Most studies (n = 20; 83.3%) included both male and female patients, 8 (33.3%) studies involved caregivers (both sexes) along with patients or family members and only 1 study (4.2%) included only female patients.
The majority (n = 19, 79.2%) were conducted with patients diagnosed with some type of advanced oncological disease (Braun et al. Reference Braun, Hales and Gilad2012; Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Gauthier et al. Reference Gauthier, Rodin and Zimmermann2012; Kunsmann-Leutiger et al. Reference Kunsmann-Leutiger, Loetz and Frick2018; Lo et al. Reference Lo, Lin and Gagliese2010, Reference Lo, Walsh and Mikulincer2009; Mah et al. Reference Mah, Shapiro and Hales2020; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021, Reference Philipp, Vehling and Scheffold2017; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019; Vehling et al. Reference Vehling, Tian and Malfitano2019; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020; Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019). In 4 of them (Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Hunter et al. Reference Hunter, Davis and Tunstall2006; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016), the patients had an oncological diagnosis, but could present other advanced stages, although in no case was it a surviving population or newly diagnosed. Finally, in 2 of the studies (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Oldham et al. Reference Oldham, Dobscha and Goy2011), they expanded the diagnoses of advanced diseases by adding other chronic diseases with no possibility of cure to oncological diagnoses. Regarding the healthcare context or place where patients were cared for, the majority (n = 14) were outpatients (Braun et al. Reference Braun, Hales and Gilad2012; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Lo et al. Reference Lo, Lin and Gagliese2010, Reference Lo, Walsh and Mikulincer2009; Mah et al. Reference Mah, Shapiro and Hales2020; Philipp et al. Reference Philipp, Vehling and Scheffold2017; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019; Vehling et al. Reference Vehling, Tian and Malfitano2019; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020; Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014), and to a lesser extent (n = 4), home patients and only in 3 studies, the patients in the sample were admitted to palliative care units (hereinafter referred to as PCU) (Kunsmann-Leutiger et al. Reference Kunsmann-Leutiger, Loetz and Frick2018; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019). Three of the studies did not specify the services or the context in which they were being attended and studied (Cicero et al. Reference Cicero, Lo Coco and Gullo2009; Oldham et al. Reference Oldham, Dobscha and Goy2011; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021).
Assessment measures for attachment style
Of the studies analyzed, only 1, that was a study of clinical interviews did not use any scale (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017) (Table 4).The most frequently used scales was the Experiences in Close Relationships (ECR) scale, including its original version (n = 6), the shortened version ECR-M16 (n = 8), and the revised version (ECR-R) (n = 2), accounting for 65.2% of the total scales used (Table 4). Of the remaining studies (n = 23), the majority (n = 15, 65.2%) used as a self-report measure 1 of the versions of the ECR scale, either the original ECR-M36 by Brennan, Clark & Shaver (Reference Brennan, Clark, Shaver, Simpson and Rholes1998) (Braun et al. Reference Braun, Hales and Gilad2012; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Gauthier et al. Reference Gauthier, Rodin and Zimmermann2012; Lo et al. Reference Lo, Lin and Gagliese2010; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020), the ECR-M36-Revised by Fraley, Waller & Brennan (Reference Fraley, Waller and Brennan2000) (Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014) or the reduced and validated version for the cancer population, Modified Brief Experience in Close Relationship (ECR-M16) by Lo, Walsh, Mikulincer, et al. (Reference Lo, Walsh and Mikulincer2009) (Lo et al. Reference Lo, Walsh and Mikulincer2009, Reference Lo, Lin and Gagliese2010; Mah et al. Reference Mah, Shapiro and Hales2020; Philipp et al. Reference Philipp, Vehling and Scheffold2017, Reference Philipp, Mehnert-Theuerkauf and Koranyi2021; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016; Vehling et al. Reference Vehling, Tian and Malfitano2019).
Questionnaires used in the articles included in the systematic review
a Percentage calculated on articles that use scales (n = 23). One article that use interviews was excluded.
In 3 studies, the Relationship Questionnaire by Bartholomew and Horowitz (Reference Bartholomew and Horowitz1991) was used (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Hunter et al. Reference Hunter, Davis and Tunstall2006; Oldham et al. Reference Oldham, Dobscha and Goy2011); and in 2 other studies, the Revised-Adult Attachment Scale by Collins and Read (Reference Collins and Read1990) was used (Ramos et al. Reference Ramos, Langer and Todd2020; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019). The remaining described scales were each used in only 1 study: the AAI by George et al. (Reference George, Kaplan and Main1996), (Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019), the Adult Attachment Projective (APP) by George and West (Reference George and West2012) (Kunsmann-Leutiger et al. Reference Kunsmann-Leutiger, Loetz and Frick2018), and finally Cicero et al. (Reference Cicero, Lo Coco and Gullo2009) used the Relationship Style Questionnaire (RSQ) by Griffin and Bartholomew (Reference Griffin and Bartholomew1994).
Characteristics of the variables studied
Attachment styles and experience of distress, emotional discomfort, and other psychological symptoms. In 6 studies (Cicero et al. Reference Cicero, Lo Coco and Gullo2009; Hunter et al. Reference Hunter, Davis and Tunstall2006; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018; Vehling et al. Reference Vehling, Tian and Malfitano2019), there was a direct relationship between insecure attachment styles and the presence of greater distress, depression, anguish, death anxiety, or demoralization, as well as greater difficulties in coping and adapting to cancer (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Hunter et al. Reference Hunter, Davis and Tunstall2006; Ramos et al. Reference Ramos, Langer and Todd2020; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020).
Attachment styles and family. Cancer is considered a “family disease” (Baider Reference Baider2003; Davis-Ali et al. Reference Davis-Ali, Chesler and Chesney1993) and represents a family crisis. In this sense, attachment has a predominant place, since the family is one of the main systems that provide shelter, help, and emotional support in times of difficulty or internal imbalance. In 6 studies (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Hunter et al. Reference Hunter, Davis and Tunstall2006; Ramos et al. Reference Ramos, Langer and Todd2020; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020), they associated the insecure attachment style with greater depressive symptoms, stress and worse adjustment and adaptation to the disease in family caregivers, as well as communication difficulties between the couple.
Attachment styles and family capabilities related to the needs of patient care in the face of an advanced illness. The secure attachment style was associated with greater capacities to request and receive family support, either from their caregiving environment or from health professionals (Braun et al. Reference Braun, Hales and Gilad2012; Mah et al. Reference Mah, Shapiro and Hales2020). Care did not only refer to practical support, but importance was given to knowledge of the relational nature and the bond between them so that they can be supportive in the more psychological or existential management of the disease process. And, on the contrary, insecure attachment styles presented greater difficulties; in the case of patients with insecure-avoidant attachment styles, they believed they deserved care, but they did not trust that others could provide it. Often, their caregivers underestimated their needs because of this self-sufficiency and tendency to minimize emotional, relational and practical needs.
Attachment styles and professional-patient relationships. 33% of the studies (n = 8) (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Hunter et al. Reference Hunter, Davis and Tunstall2006; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019) point out that the professional-patient relationship is affected by the patients’ attachment styles and by the professionals’ established reactions toward them. All of them conclude that it is essential to offer individualized support and adapt the intervention to the needs of these patients according to their attachment style. But, in addition, the health professional, as a trustworthy person, can function as a new and worthy “attachment figure” and the palliative care unit as a “safe place” that aims to accompany patients to die in peace.
Attachment and spirituality: existential needs at the end of life. In general, insecure attachment styles are negatively associated with spiritual well-being and patients are generally worse at coping with spiritual aspects, increasing their psychological distress (Philipp et al. Reference Philipp, Vehling and Scheffold2017; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019). Specifically, demoralization, existential distress, death anxiety, and difficulties in managing “Double Awareness” (Rodin and Zimmermann Reference Rodin and Zimmermann2008) are associated with insecure attachment styles (Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021; Vehling et al. Reference Vehling, Gerstorf and Schulz-Kindermann2018, Reference Vehling, Tian and Malfitano2019). Existential loneliness is also one of the many factors associated with the experience of existential suffering at the end of life, and there is a clear association between the lack of an attachment figure in times of need for protection and security and the negative experience of existential loneliness, which is not associated with social or physical loneliness (Viel Reference Viel2019). Thus, Attachment Theory is important to understand individual differences in managing feelings of loneliness at the end of life (Petersen and Koehler Reference Petersen and Koehler2006), paying special attention to patients with insecure attachment styles who will be more likely to respond with high levels of suffering to loneliness, higher levels in preoccupied patients than in avoidant patients (Hunter et al. Reference Hunter, Davis and Tunstall2006).
To cope with the emotional and existential distress generated by the negative experience of loneliness, patients can feel safe, not only because of the physical proximity of the attachment figure, but also when they think and feel mentally close to it, as a “symbolic proximity,” that is, they access the mental representation of a security figure, without the need for physical contact (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017).
Discussion
This systematic review suggests that incorporating attachment theory into comprehensive palliative care may offer meaningful benefits for patients with cancer or other advanced illnesses, as well as for their families or caregivers, both from an empirical and clinical perspective.
Including attachment as a theoretical framework for palliative psychology within the integrated model of palliative care could be a promising initiative for developing effective psychological interventions in the future.
In fact, the most representative authors in this field (Hunter et al. Reference Hunter, Davis and Tunstall2006; Petersen and Koehler Reference Petersen and Koehler2006; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Tan et al. Reference Tan, Zimmermann and Rodin2005) propose a palliative care approach that considers attachment theory, and that therapeutic and psychotherapeutic interventions are based on their knowledge and contributions. To this end, attachment styles must be identified and recognized during the first visit to a PCU (Petersen and Koehler Reference Petersen and Koehler2006), allowing us to observe the experience of separation and anxieties generated by the experience of advanced illness, as well as the relational characteristics of the patient with his or her family and with the health professional who is caring for him or her, mostly a medical professional (Petersen and Koehler Reference Petersen and Koehler2006). They also suggested that early detection and intervention could help repair previous traumatic experiences, rebuild bonds and work on pending issues or unresolved conflicts in advance (Petersen and Koehler Reference Petersen and Koehler2006), which could contribute to early palliative psychological care if we could identify these patients and family members early. Likewise, the PCU was proposed as a safe environment where the professional, as a trustworthy person, would be like a new attachment figure (Petersen and Koehler Reference Petersen and Koehler2006).
Therefore, identifying attachment styles and understanding their influence on the coping and adaptation of patients and family members to illness, end of life and the grieving process provides an essential theoretical and clinical framework for the personalized and individualized care of patients treated in ICUs, whether they are inpatients, outpatients or in home care (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017). This paradigm is of vital importance for professionals to adapt their intervention to the different attachment styles and to maximize the effectiveness of the treatment, given the special situation of high vulnerability that comes with the experience of advanced illness or end of life, where the establishment of a therapeutic relationship of trust or therapeutic alliance with the patient is of utmost importance.
Although the study is primarily conceptual in nature, it has allowed us to offer attachment theory-based intervention models with sufficient clinical benefit and to propose the foundations for future research, using empirical evidence, into the impact that these psychotherapeutic proposals have on the psychological well-being and improvement of the quality of life of these patients and their families or caregivers. Thus, the findings of our study recommend that in cases where one works with patients with an avoidant attachment style, that is, those who minimize the effects of their illness on their life and mood, it would be advisable that the professional’s support is not perceived as something that undermines their own sense of individuality, independence, autonomy and self-sufficiency, so the help offered should be more educational and/or psychoeducational in style. In this sense, in addition to showing interest and availability, the professional will pay particular attention to their need to promote a sense of autonomy, and the patient may become more interested and open to a helping relationship (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018; Shalev et al. Reference Shalev, Jacobsen and Rosenberg2022; Tan et al. Reference Tan, Zimmermann and Rodin2005). On the other hand, patients with more anxious attachment styles, who exacerbate their difficulties through hypervigilance and have difficulty feeling supported, would benefit more from predictable support, in which predictability and availability are clearly delimited and identified from the beginning, and who can have the necessary emotional support from the entire interdisciplinary team (Hunter et al. Reference Hunter, Davis and Tunstall2006; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018; Shalev et al. Reference Shalev, Jacobsen and Rosenberg2022). Thus, understanding the relational functioning of the patient and their family will allow healthcare professionals to adapt their interventions and contribute to improving the quality of life, as intended by the palliative care model (Gómez-Batiste et al. Reference Gómez-Batiste, Martínez-Muñoz and Blay2013; Hales et al. Reference Hales, Zimmermann and Rodin2008).
Although most of the studies included are observational, some of them describe interventions where they include, in the psychological treatment carried out, the attachment theory suggesting that, specifically, knowing the attachment styles is essential, because the findings of the reviewed studies revealed a direct association between insecure attachment styles and the presence of psychological symptoms, such as greater experience of existential suffering, death anxiety, demoralization syndrome, existential-spiritual suffering, depression, anxiety, existential loneliness and greater difficulties in coping with advanced illness and end-of-life process (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Hunter et al. Reference Hunter, Davis and Tunstall2006; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Nicholls et al. Reference Nicholls, Hulbert-Williams and Bramwell2014; Petersen and Koehler Reference Petersen and Koehler2006; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021, Reference Philipp, Vehling and Scheffold2017; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Sirito et al. Reference Sirito, Limonero and Méndez2019; Vehling et al. Reference Vehling, Gerstorf and Schulz-Kindermann2018, Reference Vehling, Tian and Malfitano2019; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020; Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014). These results highlight the potential role of insecure attachment style in predicting poor psychosocial outcome (Nissen Reference Nissen2016) and, therefore, these are the patients who are most likely to require specialized psychotherapeutic intervention given their complexity.
The results of these studies also conclude that insecure attachment styles were associated with lower capacities to request and receive family support, either from their caregiving environment or from health professionals (Braun et al. Reference Braun, Hales and Gilad2012; Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; Hunter et al. Reference Hunter, Davis and Tunstall2006; Mah et al. Reference Mah, Shapiro and Hales2020; Nicholls et al. Reference Nicholls, Hulbert-Williams and Bramwell2014; Nissen Reference Nissen2016; Ramos et al. Reference Ramos, Langer and Todd2020; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020; Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014). And in the most extreme cases, these patients, often considered “difficult,” had dysfunctional behaviors that led to late diagnoses and difficulties in adherence with a poorer quality of life (Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019).
In this same sense, it has also been shown that caregiver families, especially the primary caregiver with an insecure attachment style, also presented greater emotional distress, depressive symptoms, worse adjustment to the disease and lower perception of social support (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; De Luca et al. Reference De Luca, Dorangricchia and Salerno2017; Hunter et al. Reference Hunter, Davis and Tunstall2006; Nicholls et al. Reference Nicholls, Hulbert-Williams and Bramwell2014; Ramos et al. Reference Ramos, Langer and Todd2020; Xiaoyun and Fenglan Reference Xiaoyun and Fenglan2020), than families with secure attachment styles. The relevance of this finding is that, in all studies, family and social support was related to better family emotional adjustment, decreasing emotional distress (Yilmaz Özpolat et al. Reference Yilmaz Özpolat, Ayaz and Konaǧ2014).
And, since, for palliative care, the patient and the family are the unit to be treated (Baider Reference Baider2003; Cicero et al. Reference Cicero, Lo Coco and Gullo2009; Davis-Ali et al. Reference Davis-Ali, Chesler and Chesney1993), this systemic and comprehensive approach is essential, incorporating, in the psychotherapeutic intervention, the attachment theory in the care of a profile of patients and family members who present greater psychosocial complexity, therefore, greater risk of suffering and worse coping with the experience of illness.
Our research also highlights the relevance of attachment theory in the professional-patient relationship, which should be based on the helping relationship. A process of change and transformation is proposed toward this type of intervention that requires a model centered on the bond of safety with the patient and requires respect for his or her biography, narrative, personality, values, and lifestyle (Fernández-González et al. Reference Fernández-González, Namías and Bravo2021; Gramm et al. Reference Gramm, Trachsel and Berthold2022; Mah et al. Reference Mah, Shapiro and Hales2020; Prado-Abril et al. Reference Prado-Abril, Fernández-Álvarez and Sánchez-Reales2019; Shalev et al. Reference Shalev, Jacobsen and Rosenberg2022; Shaw et al. Reference Shaw, Chrysikou and Lanceley2019; Tarbi et al. Reference Tarbi, Moore and Wallace2024).
In this new doctor–patient relationship, which includes attachment theory, it is necessary to redefine roles, where the patient is seen by the professional as autonomous, proactive, and has the leading role, and the professional is sensitive and knows how to contain the suffering of the other and identifies the relational needs of patient or family based on their attachment style (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Hunter et al. Reference Hunter, Davis and Tunstall2006; McLean and Hales Reference McLean and Hales2010; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Nissen Reference Nissen2016; Petersen and Koehler Reference Petersen and Koehler2006; Rodin et al. Reference Rodin, Walsh and Zimmermann2007; Scheffold et al. Reference Scheffold, Philipp and Koranyi2018; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019; Tan et al. Reference Tan, Zimmermann and Rodin2005; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019).
In fact, at a clinical level, the most relevant thing is that professionals can become auxiliary attachment figures (Borelli and David Reference Borelli and David2003; Rodin et al. Reference Rodin, An and Shnall2020a; Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016), providing a safe base for the patient and their family (Adshead Reference Adshead1998; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017) knowing that, although time is more limited, it is more intense than in other healthcare contexts (Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019).
In our review, some of these articles propose insights into strategies and tools, as well as some “relational guidance” for professionals, although the scientific evidence regarding their benefits could not be analyzed (Borelli and David Reference Borelli and David2003; Hunter et al. Reference Hunter, Maunder, Le, Hunter and Maunder2016; Milberg and Friedrichsen Reference Milberg and Friedrichsen2017; Nissen Reference Nissen2016; Petersen and Koehler Reference Petersen and Koehler2006; Shalev et al. Reference Shalev, Jacobsen and Rosenberg2022; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019).
And regarding the second objective that we set ourselves in our research, it is important to point out that in order to carry out this type of interventions based on attachment theory, the findings conclude that measures based on categories and not on dimensions should be used since they are more useful in the clinical field and better adapt to the different attachment styles (Maunder and Hunter Reference Maunder and Hunter2016), without ruling out that it is the attachment dimensions that detect more subtle differences between patients and that, therefore, they can also be useful in research (Scheffold et al. Reference Scheffold, Philipp and Vehling2019). Even so, without a clear definitive consensus on whether attachment is mainly a category or a dimension, it seems useful to affiliate categories with dimensional scales (Ravitz et al. Reference Ravitz, Maunder and Hunter2010), as we suggested where, mostly self-report instruments were used as an assessment measure, called “self-reported attachment” (Smith et al. Reference Smith, Msetfi and Golding2010) in which the patient reflects cognitive capacity to respond affectively and behaviorally to the demands of current close relationships. It is recommended to use this term as a first step toward a clear and precise communication of the concept (Nissen Reference Nissen2016).
Because of this, it is necessary to have screening instruments that are easy to administer, brief and adapted to the palliative context, which generate psychotherapeutic effects, such as other questionnaires used in Spanish, the Emotional Distress Detection Questionnaire (DME) or the Primary Caregivers Questionnaire (DME-C), the Existential Loneliness Scale (EDSOL) and the Psychosocial and Spiritual Needs Scale (ENP-E) (Limonero et al. Reference Limonero, Maté and Mateo2016, Reference Limonero, Maté-Méndez and Gómez-Romero2023, Reference Limonero, Mateo and Maté-Méndez2012, Reference Limonero, Tomás-Sábado and Gómez-Romero2014; Mateo-Ortega et al. Reference Mateo-Ortega, Limonero and Maté-Méndez2019; Sirito et al. Reference Sirito, Limonero and Méndez2019).
Thus, based on the above statements and on the result of the analysis of the different articles that make up the systematic review, as well as 3 other systematic reviews (Nicholls et al. Reference Nicholls, Hulbert-Williams and Bramwell2014; Nissen Reference Nissen2016; Ravitz et al. Reference Ravitz, Maunder and Hunter2010), it is concluded that the ECR scale, in its reduced version adapted for this population (Lo et al. Reference Lo, Walsh and Mikulincer2009), called ECR-M16, is an excellent tool of choice to assess the 4 attachment styles, as well as the second-order factors, anxiety and avoidance, in people with advanced cancer (Lo et al. Reference Lo, Walsh and Mikulincer2009). This test has also been validated in German (Philipp et al. Reference Philipp, Vehling and Scheffold2017) and in Greek (Tsilika et al. Reference Tsilika, Parpa and Galanopoulou2016) with similar results.
Limitations
Despite its strengths, this review has several limitations that should be considered. One of them is related to the small number of quantitative investigations on attachment in the care of patients with advanced disease and their families (caregivers), which made it difficult to analyze the degree to which the modulating role of attachment in coping with situations of high emotional impact during the disease process, both for the patient and the care offered by their family members, as well as the generalization of the results. Another limitation would be related to the use of different instruments to evaluate attachment styles due to differences in their conceptualization, which may affect the variability in the interpretation of the results. However, a significant part of the investigations has been carried out with the ECR Scale in its original or abbreviated version, an aspect that would provide some solidity to these results.
Clinical implications
Although the number of empirical studies related to attachment at the end of life has been small, the findings of this review highlight the value of integrating attachment theory as a guiding framework in psychological care within palliative settings. Identifying attachment styles in patients with advanced illness and their caregivers provides a better understanding of their emotional and relational needs, enabling interventions more effectively to each individual.
This paradigm can be added to some of the existing ones in the identification and modulation of existential distress and suffering of patients with advanced cancer (An et al. Reference An, Wennberg and Nissim2020; Bayés Reference Bayés2013; Bayés et al. Reference Bayés, Limonero and Romero2000; Boston et al. Reference Boston, Bruce and Schreiber2011; Breitbart et al. Reference Breitbart, Rosenfeld and Pessin2015, Reference Breitbart, Rosenfeld and Pessin2020; Byock Reference Byock2002; Chochinov et al. Reference Chochinov, Hack and Mcclement2002; Colosimo et al. Reference Colosimo, Nissim and Pos2018; Emanuel et al. Reference Emanuel, Brenner and Spira2020; García Campayo et al. Reference García Campayo, Navarro and Modrego2016; Gómez-Batiste et al. Reference Gómez-Batiste, Martínez-Muñoz and Blay2013; Grossman et al. Reference Grossman, Brooker and Michael2018; Krikorian and Limonero Reference Krikorian and Limonero2012; Limonero et al. Reference Limonero, Mateo and Maté-Méndez2012, Reference Limonero, Maté-Méndez and Gómez-Romero2023; Maté et al. Reference Maté, Bayés and González-Barboteo2008; Maté et al. Reference Maté, Sirgo and Mateo2009; Mateo-Ortega et al. Reference Mateo-Ortega, Limonero and Maté-Méndez2019; Miyamoto et al. Reference Miyamoto, Yamazaki and Shimizu2022; Rodin et al. Reference Rodin, Lo and Mikulincer2009; Rodin and Zimmermann Reference Rodin and Zimmermann2008; Sethi et al. Reference Sethi, Rodin and Hales2020; Sirito et al. Reference Sirito, Limonero and Méndez2019; Tarbi et al. Reference Tarbi, Moore and Wallace2024).
While further research is needed on this topic, the findings of this study are promising for including attachment styles assessment as an essential part of the initial and comprehensive exploration of the palliative needs of the patient and their families (Hunter et al. Reference Hunter, Maunder, Le, Hunter and Maunder2016; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021).
Understanding the influence of attachment styles on patient interactions may facilitate the development of more specific, efficient, and effective interventions. In this sense, the findings of this systematic review conclude that patients and family caregivers with insecure attachment styles will be the ones who mostly need specialized psychotherapeutic support, since they are the ones who obtain the worst results in terms of psychological adaptation and adjustment (Calvo et al. Reference Calvo, Palmieri and Marinelli2014; Hunter et al. Reference Hunter, Davis and Tunstall2006; Miyamoto et al. Reference Miyamoto, Yamazaki and Shimizu2022; Petersen and Koehler Reference Petersen and Koehler2006; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021; Rodin et al. Reference Rodin, An and Shnall2020a, Reference Rodin, An and Shnall2020b; Scheffold et al. Reference Scheffold, Philipp and Engelmann2015, Reference Scheffold, Philipp and Koranyi2018, Reference Scheffold, Philipp and Vehling2019; Sethi et al. Reference Sethi, Rodin and Hales2020; Shahvaroughi-Farahani et al. Reference Shahvaroughi-Farahani, Eskandari and Hasan-Larijani2019; Shalev et al. Reference Shalev, Jacobsen and Rosenberg2022; Slade and Holmes Reference Slade and Holmes2019; Troncoso et al. Reference Troncoso, Paulina Rydall and Rodin2019a; Zaporowska-Stachowiak et al. Reference Zaporowska-Stachowiak, Stachowiak and Stachnik2019). And, although the attachment style is quite stable in adulthood, it can also be a dynamic process, resulting from the combination of different psychological, family, contextual, cultural, economic, and social factors, in which we can intervene (Hunter et al. Reference Hunter, Maunder, Le, Hunter and Maunder2016; Philipp et al. Reference Philipp, Mehnert-Theuerkauf and Koranyi2021).
Although our aim was to explore the role of attachment in the context of advanced illness from a systemic model (Baider Reference Baider2003; Davis-Ali et al. Reference Davis-Ali, Chesler and Chesney1993; Smilkstein Reference Smilkstein1978), the available literature was focused primarily on relationships with primary caregivers, especially spouses. Consequently, there is a gap in research that could address the role of attachment in the adjustment to diagnosis by children, parents, or other significant persons and their caregiving environment of patients with advanced cancer (Milberg and Friedrichsen Reference Milberg and Friedrichsen2017).
In summary, our research presents a coherent and consistent message that further research is needed to demonstrate the effectiveness of incorporating attachment theory into palliative care in order to help professionals, especially psychologists, understand the variability and complexity of patients and the influence that attachment styles have on coping with advanced and end-of-life illness (Fernández-González et al. Reference Fernández-González, Namías and Bravo2021; Miyamoto et al. Reference Miyamoto, Yamazaki and Shimizu2022; Rodin et al. Reference Rodin, An and Shnall2020b; Sethi et al. Reference Sethi, Rodin and Hales2020; Shaw et al. Reference Shaw, Chrysikou and Davis2017, Reference Shaw, Chrysikou and Lanceley2019; Slade and Holmes Reference Slade and Holmes2019; Troncoso et al. Reference Troncoso, Paulina Rydall and Rodin2019a, Reference Troncoso, Rydall and Hales2019b; Wulandari et al. Reference Wulandari, Yunitasari and Kusumaningrum2020). Identifying these patterns allows us to offer more sensitive, personalized, and effective support. Simple and brief tools, such as the ECR-M16-Revised, make it feasible to integrate this approach into daily clinical practice.
Conclusions
This review emphasizes the importance of considering attachment theory as a key element in the psychological care of patients with advanced illnesses. Recognizing how attachment styles influence coping mechanisms, emotional responses, and the dynamics between patients, families, and healthcare providers allows for a more nuanced and person-centered approach to care.
Identifying insecure attachment patterns early in the palliative care process offers professionals the opportunity to adapt their interventions, build stronger therapeutic alliances, and provide support that truly aligns with the emotional needs of everyone. This approach not only enhances the effectiveness of psychological interventions but also contributes to improving the overall well-being of both patients and their caregivers.
While current evidence highlights the clinical value of incorporating attachment assessments into routine practice, further research is necessary to develop standardized tools and evaluate the long-term benefits of attachment-informed interventions. Nonetheless, the findings suggest that an attachment-based perspective can enrich the palliative care model, offering a more comprehensive understanding of the complex psychological challenges faced by patients and families at the end of life.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951525100783.
Author contributions
CSJ, SVS, and JTL conceived and designed the study, collected, and interpreted the data. CSJ and JTL drafted the manuscript and approved the final version. SVS revised both the draft and final manuscript, also providing approval for the final version.
Funding
The authors have not received any funding.
Competing interests
The authors declared that there are no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Ethical approval
This study was reviewed by the Committee on Ethics in Animal and Human Research of the Autonomous University of Barcelona, which concluded that ethical approval was not required for this research.
Highlights table
• Insecure attachment styles are associated with greater psychological distress, existential suffering, and poor adaptation to advanced illness.
• Early identification of attachment patterns could allow for personalized attachment-based interventions in palliative care settings.
• Healthcare professionals could act as auxiliary attachment figures, promoting trust and emotional support during palliative care.
• Attachment theory could offer a valuable clinical framework for improving psychosocial outcomes for both patients and family caregivers.
Open access
