The pragmatic application of attachment theory in medical decision making regarding emotionally unstable personality disorder presentations to healthcare settings

Abstract

A hypothesis is formulated whereby individuals with adverse childhood experiences can come to have a disrupted attachment system and this can impact the manner in which individuals engage in healthcare. Maslow's hierarchy of needs suggests a motivation for safety and it is proposed that the healthcare system can come to represent the secure base. Behaviours that lead an individual into the healthcare setting can thus be positively reinforced by satisfying such a dynamic need. Prescribing behaviours are examined relating to this notion. The spectrum of intention-to-die type presentations in an acute healthcare setting are considered. The contribution of the concept of risk and uncertainty to decision makers is examined as a possible component to the propagation of unhelpful care pathways, where risk averse decision making leads to interventions of limited clinical utility for an individual. An introduction to the notion of a "corrupted capacity assessment" is made, which refers to the process of a doctor concluding that an individual lacks capacity without considering that this may be the outcome desired by a patient with capacity. Pragmatic strategies are suggested as a way to minimise iatrogenic harms and maximise therapeutic potential at clinical encounters where risk is a facet. Longitudinal assessments with an acknowledgement of the harms in preceding compulsory care pathways are promoted as well as an articulation of the clinician's anxiety for the purposes of reflection, in order to arrive at a clinical decision that is solely in the patient's best interest. It is suggested that ambivalence over the patient's perception of value to life is explicitly validated at such junctures. Personal responsibility and capacity for individuals presenting should be therapeutic goals if an individual has come to, or is doubting, their own autonomy and wishing to invest such factors in compulsory care pathways.