Attachment, benign paternalism and nuances in autonomy

I would like to share a few thoughts on autonomy ¹ from the perspective of a child psychiatrist concerned with attachment theory. Autonomy from my developmental perspective concerns ‘balanced dependency’, a dependency on others which changes with age and state. When ill, our dependency needs change, and we manage them differently. The only truly ‘autonomous’ people can be expected to end up in high-security prisons for recidivists.

Attachment theory in current versions emphasises that it is not about ‘bonds’ but about strategies to handle danger and threat, which develop depending on the contingencies to our distress signals during our earliest years and the ways in which our affective disarray can become soothed: dis-ease gets eased.

Put rather simply, the Type A strategy has a variety of forms, but underlying them is a trend to aim for self-sufficiency and avoid conflict with those in positions of power. Their distress signals are often low-key or not displayed. They appreciate the medical style referred to as ‘benign paternalism’: the doctor is the accepted expert and they wish to follow the expert's advice. They can feel distinctly out of sorts and rejected if asked to decide between treatment options.

There is some evidence that the previous generation of US doctors also had a predilection for a Type A strategy. ¹ Whether this has changed today is unanswered. The doctors' strategies also feed into the dynamic between the different attachment strategies used by patients and understanding their symptom language and needs for varieties of paternalism. ²

The Type C attachment favours prioritising their own viewpoint (currently the media portrayal of Donald Trump illustrates the strategy well). This can be expected to put the Type C strategists in conflict with doctors who tend to paternalistic approaches.

In order to resolve the issues in your editorial ¹ we need to elaborate our understanding of autonomy and how we develop different predilections for degrees of paternalistic medicine – and doctors need to be aware of their own attachment strategies and how these interact with those of their patients. This is the core dilemma for improving medical communication, and, incidentally, can be expected to help resolve the issues around meeting the neglected needs of somatising patients.