Opening Intensive Care Units to Family Members: A Contribution From the Attachment Theory.

Abstract

As clinical psychologists working in the hospital, we often meet family members suffering from being separated from their loved ones during intensive care unit (ICU) hospitalization because of restricted visiting hours. In many institutions, expanding ICU visiting hours and opening ICUs to family members, including children, are not common practice.2 Among the fears associated with open visitation and reported by clinicians are increased infections, concerns for patients’ health, and interference with the provision of care. However, over the last decade, studies have shown that adopting an open ICU visiting policy does not expose patients to additional risk for infection.3 On the contrary, open visiting policies were proven to positively influence patients’ health by decreasing cardiovascular complications, delirium, anxiety, hormonal markers of stress, and days of recovery.4,5 We suggest that an open visiting policy, which preserves the patient-family member relationship at times of severe illness, may be beneficial because it meets a main psychological need: the attachment need.Bowlby’s attachment theory6 claims that all humans have a biologically based, innate need to form close ties with specific people (generally the parent during childhood and the partner in adult age), with the aim of ensuring protection and survival. Attachment behavior is activated to guarantee the proximity to the attachment figure, especially in situations of physical and/ or psychological danger, which generate fear, worry, or suffering. In these situations, individuals are likely to search the proximity of their attachment figure to regulate emotions, restore a feeling of security, and decrease anxiety.7 The attachment system, which develops during childhood, remains active in adulthood when it is generally directed toward a partner. In adult couples, the attachment relationship becomes more symmetrical and each partner is able to offer a secure base for the other, activating the caregiving system, which is another innate motivational system that prompts us to protect and provide care to our children or partner. The loss or prolonged separation from the attachment figure has been proven to negatively affect the physical and psychological health of children and adults.8Attachment theory offers a lens to understand the family members’ search for proximity to their attachment figures during ICU hospitalization and the positive effects of this proximity on patients’ and family members’ well-being. Hospitalization of a family member in the ICU often provokes feelings of fear, worry, suffering, and powerlessness. Investigators have found that limitations on visiting were reported as the third-leading cause of stress by ICU patients.9 Hence, ICU hospitalization may activate the patient’s search of their attachment figure to restore a feeling of safety and emotional well-being. Likewise, it may activate the family member’s need to care for the patient. Therefore, it is not surprising that open ICU visiting policies, which respect the attachment needs of patients and families, have proven to promote patients’ well-being,10 decrease family members’ stress and anxiety,11 and decrease formal complaints.12We hope that the attachment theory may help clinicians in making sense of family members’ need for proximity and offer a scientific framework in support of open visiting policies in ICUs. We advocate that clinical practice in the ICU will take into account the importance of attachment relationships for the individuals’ and families’ well-being.13 Support should be offered to clinicians to assist them in the sensitive transition to open visiting policies to preserve their psychological well-being.