Robert Maunder | University of Toronto (original) (raw)

Papers by Robert Maunder

Research paper thumbnail of Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak

Emerging Infectious Diseases, 2006

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to ... more Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.

Research paper thumbnail of Failures in interpersonal psychotherapy (IPT): factors related to treatment resistances

Journal of Clinical Psychology, 2011

Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan an... more Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan and across cultures. However, even when delivered with fidelity, some patients drop out and others do not improve sufficiently. Attention to IPT treatment attrition, dropout, nonresponse, or failure can elucidate its limitations and the opportunities to improve its effectiveness. Studies of factors known to moderate and negatively predict IPT depression treatment response are reviewed along with recommended modifications to improve outcomes. Although the risk of treatment failure always exists, it is possible to enhance treatment effectiveness by attending to the therapeutic alliance, strategically addressing depression, and adapting IPT to patient characteristics. These include adding pharmacotherapy, extending the course of treatment, and targeting specific symptoms or interpersonal vulnerabilities. Case examples illustrate several of these points.

Research paper thumbnail of Attachment and Psychosomatic Medicine: Developmental Contributions to Stress and Disease

Objective: The object of this study was to evaluate the evidence linking attachment insecurity to... more Objective: The object of this study was to evaluate the evidence linking attachment insecurity to illness. Attachment theory describes lifelong patterns of response to threat that are learned in the interaction between an infant and his or her primary caregiver. Despite its biopsychosocial domain, attachment theory has only recently been applied to psychosomatic medicine. Method: MEDLINE and PsychInfo databases were searched from 1966 to 2000 for English language papers with key words "attachment" and "object relations." Papers and their cited references were reviewed if they were directly related to physical illness, symptoms, or physiology. A hypothetical causal model was developed. Results: Direct and indirect evidence from survey studies supports an association between attachment insecurity and disease. Animal studies and human experiments suggest that attachment contributes to individual differences in physiological stress response. There is also less robust support for insecure attachment leading to symptom reporting and to more frequent health risk behaviors, especially substance use and treatment nonadherence. Evidence supports the prediction from attachment theory that the benefits of social support derive more from attachment relationships than nonattachment relationships. Conclusions: Although the available data are suggestive rather than conclusive, the data can be organized into a model that describe attachment insecurity leading to disease risk through three mechanisms. These are increased susceptibility to stress, increased use of external regulators of affect, and altered help-seeking behavior. This model warrants further prospective investigation. Key words: Attachment, disease model, stress, development, biopsychosocial.

Research paper thumbnail of Psychobiological subtypes of ulcerative colitis: pANCA status moderates the relationship between disease activity and psychological distress

The American journal of gastroenterology, 2006

Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. ... more Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions. In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination, and endoscopy using the St. Mark's index, and depressive symptoms and health anxiety were measured with self-report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated. In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation = 0.48, p < 0.001) ...

Research paper thumbnail of Halpern, J. and Maunder, R.G. Acute and chronic workplace stress in emergency medical technicians and paramedics

Research paper thumbnail of Concerns of patients with inflammatory bowel disease: results from a clinical population

The American Journal of Gastroenterology, 2001

Research paper thumbnail of Using attachment theory to understand illness behavior

This article examines a model of illness as a stressor that activates an individual's characteris... more This article examines a model of illness as a stressor that activates an individual's characteristic attachment behaviors. These behaviors are the result of the attachment system, a mammalian trait that exists in order to maximize the odds of survival of an infant born without the necessary maturation for immediate independence. Attachment concepts, such as attachment style, coherence, and reflective functioning, are briefly explained, followed by examples of their application to the psychological management of patients with medical or surgical illness. Attachment theory provides a unique, simple, and pragmatically useful model for understanding the particular ways that individuals can feel and react when stressed by illness, and how the professional may help manage that distress.

Research paper thumbnail of Physicians’ difficulty with emergency department patients is related to patients’ attachment style

Social Science & Medicine, 2006

Doctors experience 10-20 percent of patient interactions as being personally difficult, but the s... more Doctors experience 10-20 percent of patient interactions as being personally difficult, but the sources of difficulty are incompletely understood. In particular, physician-perceived difficulty has not been studied from the perspective of an established model of interpersonal relationships. Our objective was to determine whether a relationship exists between patients' attachment style and the degree of difficulty experienced by their attending physician in an Emergency Department in Pretoria, South Africa. Patients of an Emergency Department (n=165) completed the Experiences in Close Relationships-Revised Questionnaire to measure attachment anxiety and attachment avoidance. Their physicians (n=26), blind to the attachment measure, rated perceived difficulty using the Difficult Doctor-Patient Relationship Questionnaire. Four categories of attachment style were identified by cluster analysis of attachment scores. Patients were divided into difficult and non-difficult groups using a cut-off score. Two percent of patients with a secure attachment style were experienced as difficult, whereas the prevalence of difficulty in the insecure styles was 'preoccupied' 17 percent, 'dismissing' 19 percent and 'fearful' 39 percent (χ 2 =16.383, df=3, p=0.0009), supporting the hypothesis that the physician's perception of patient difficulty is related to the patient's attachment style. The degree to which physicians serve attachment functions for patients in crisis merits further investigation.

Research paper thumbnail of Downtime after Critical Incidents in Emergency Medical Technicians/Paramedics

BioMed Research International, 2014

Effective workplace-based interventions after critical incidents (CIs) are needed for emergency m... more Effective workplace-based interventions after critical incidents (CIs) are needed for emergency medical technicians (EMT)/paramedics. The evidence for a period out of service post-CI (downtime) is sparse; however it may prevent posttraumatic stress disorder (PTSD) and burnout symptoms. We examined the hypothesis that downtime post-CI is associated with fewer symptoms of four long-term emotional sequelae in EMT/paramedics: depression, PTSD, burnout, and stress-related emotional symptoms (accepted cut-offs defined high scores). Two hundred and one paramedics completed questionnaires concerning an index CI including downtime experience, acute distress, and current emotional symptoms. Nearly 75% received downtime; 59% found it helpful; 84% spent it with peers. Downtime was associated only with lower depression symptoms, not with other outcomes. The optimal period for downtime was between <30 minutes and end of shift, with >1 day being less effective. Planned testing of mediation of the association between downtime and depression by either calming acute post-CI distress or feeling helped by others was not performed because post-CI distress was not associated with downtime and perceived helpfulness was not associated with depression. These results suggest that outcomes of CIs follow different pathways and may require different interventions. A brief downtime is a relatively simple and effective strategy in preventing later depression symptoms.

Research paper thumbnail of The Experience of the 2003 SARS outbreak as a traumatic stress among frontline health-care workers in Toronto: lessons learned

SARS, 2005

The outbreak of severe acute respiratory syndrome (SARS) in the first half of 2003 in Canada was ... more The outbreak of severe acute respiratory syndrome (SARS) in the first half of 2003 in Canada was unprecedented in several respects. Understanding the psychological impact of the outbreak on healthcare workers, especially those in hospitals, is important in planning for future outbreaks of emerging infectious diseases. This review draws upon qualitative and quantitative studies of the SARS outbreak in Toronto to outline the factors that contributed to healthcare workers&amp;amp;amp;amp;#39; experiencing the outbreak as a psychological trauma. Overall, it is estimated that a high degree of distress was experienced by 29-35% of hospital workers. Three categories of contributory factors were identified. Relevant contextual factors were being a nurse, having contact with SARS patients and having children. Contributing attitudinal factors and processes were experiencing job stress, perceiving stigmatization, coping by avoiding crowds and colleagues, and feeling scrutinized. Pre-existing trait factors also contributed to vulnerability. Lessons learned from the outbreak include: (i) that effort is required to mitigate the psychological impact of infection control procedures, especially the interpersonal isolation that these procedures promote; (ii) that effective risk communication is a priority early in an outbreak; (iii) that healthcare workers may have a role in influencing patterns of media coverage that increase or decrease morale; (iv) that healthcare workers benefit from resources that facilitate reflection on the effects of extraordinary stressors; and (v) that healthcare workers benefit from practical interventions that demonstrate tangible support from institutions.

Research paper thumbnail of Attachment Insecurity, Responses to Critical Incident Distress, and Current Emotional Symptoms in Ambulance Workers

Stress and Health, 2012

Ambulance workers are exposed to critical incidents that may evoke intense distress and can resul... more Ambulance workers are exposed to critical incidents that may evoke intense distress and can result in long-term impairment. Individuals who can regulate distress may experience briefer post-incident distress and fewer longterm emotional difficulties. Attachment research has contributed to our understanding of individual differences in stress regulation, suggesting that secure attachment is associated with effective support-seeking and coping strategies, and fewer long-term difficulties. We tested the effect of attachment insecurity on emotional distress in ambulance workers, hypothesizing that (1) insecure attachment is associated with symptoms of current distress and (2) prolonged recovery from acute post-critical incident distress, coping strategies and supportive contact mediate this relationship. We measured (1) attachment insecurity, (2) acute distress, coping and social contact following an index critical incident and (3) current symptoms of post-traumatic stress, depression, somatization and burnout and tested the hypothesized associations. Fearful-avoidant insecure attachment was associated with all current symptoms, most strongly with depression (R = 0.38, p<0.001). Fearful-avoidant attachment insecurity was also associated with maladaptive coping, reduced social support and slower recovery from social withdrawal and physical arousal following the critical incident, but these processes did not mediate the relationship between attachment insecurity and current symptoms. These findings are relevant for optimizing post-incident support for ambulance workers.

Research paper thumbnail of Facilitating Adjustment to Inflammatory Bowel Disease: A Model of Psychosocial Intervention in Non-Psychiatric Patients

Psychotherapy and Psychosomatics, 1999

There is no consensus about the most appropriate psychosocial interventions for people with infla... more There is no consensus about the most appropriate psychosocial interventions for people with inflammatory bowel disease (IBD) or the most appropriate criteria by which to select which patients might benefit from the available interventions. Nonetheless the perception that stress and other subjective factors contribute to suffering in IBD is persistent and professionals are often called upon to offer appropriate support. A model of normal psychosocial adjustment to IBD and the interventions which can improve difficulties with adjustment will facilitate rational therapeutic intervention and needed research in this area. A model of normal adjustment to IBD is developed from a synthesis of the empirical literature and clinical experience in a tertiary care medical/surgical IBD centre and is used to identify potential points of psychosocial intervention. Normal adjustment to IBD can be understood as a process involving the interaction of a triad of adaptive challenges: illness uncertainty, loss and change, and suffering. Each of these challenges requires different criteria of psychosocial assessment and may lead to different interventions. Although the interventions available for improving adjustment to IBD have not been exhaustively investigated, the existing data support the value of further study. The model of psychosocial adjustment presented here provides a synthesis of the existing data and a starting point for further research.

Research paper thumbnail of Insecure Attachment in a Subgroup with Ulcerative Colitis Defined by ANCA Status

Digestive Diseases and Sciences, 2000

This study is the first test of the novel hypothesis that perinuclear anti-neutrophil cytoplasmic... more This study is the first test of the novel hypothesis that perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) marks an etiological division between stress-susceptible and stress-neutral ulcerative colitis. Subjects were 47 UC patients with known p-ANCA status (19 p-ANCA-positive, 28 p-ANCA-absent). Controls were 77 university students. Subjects and controls completed the Reciprocal Attachment Questionnaire. Subjects were categorized as avoidant/nonavoidant and anxious/nonanxious based

Research paper thumbnail of Identifying, describing, and expressing emotions after critical incidents in paramedics

Journal of Traumatic Stress, 2012

For paramedics, critical incidents evoke intense emotions and may result in later psychological d... more For paramedics, critical incidents evoke intense emotions and may result in later psychological difficulties. We examined 2 ways to deal with emotions after critical incidents: (a) identifying emotions, and (b) describing and expressing emotions, and their association with recovery from acute stress and psychological symptoms. We surveyed 190 paramedics, examining how impaired capacity to identify and describe emotions (alexithymia) and voluntary expression of emotions during contacts with others in the first 24 hours after the incident were associated with recovery from acute stress and current symptoms of PTSD, depression, burnout, and somatization. Overall alexithymia was not associated with recovery, but the component of difficulty identifying feelings was associated with prolonged physical arousal (χ(2) = 10.1, p = .007). Overall alexithymia and all its components were associated with virtually all current symptoms (correlation coefficients .23-.38, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Voluntary emotional expression was unrelated to current symptoms. Greater emotional expression was related to greater perceived helpfulness of contacts (χ(2) = 56.8, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). This suggests that identifying emotions may be important in managing occupational stress in paramedics. In contrast, voluntary emotional expression, although perceived as helpful, may not prevent symptoms. These findings may inform education for paramedics in dealing with stress.

Research paper thumbnail of The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults

Journal of Psychosomatic Research, 2006

The purpose of this study was to test predicted relationships between adult attachment and stress... more The purpose of this study was to test predicted relationships between adult attachment and stress using subjective and physiological measures. Sixty-seven healthy adults completed measures of adult attachment and perceived chronic stress. Subjective stress and the high-frequency (HF) and low-frequency (LF) spectral bandwidths of heart rate variability (HRV) were measured during a standardized stress protocol. Attachment anxiety is associated with between-subject differences in chronic perceived stress (P=.001) and subjective acute stress (P=.01). There is a main effect of attachment avoidance on between-subject differences in HF HRV (P=.004). Attachment avoidance is inversely associated with HF HRV, independent of age and variability in respiration. Attachment anxiety is associated with self-reported distress. Attachment avoidance is inversely associated with HF HRV, a marker of vagal influence on cardiac activity, but is not associated with subjective stress.

Research paper thumbnail of Adult attachment measures: A 25-year review

Journal of Psychosomatic Research, 2010

Objective: Over the past 25 years, attachment research has extended beyond infant-parent bonds to... more Objective: Over the past 25 years, attachment research has extended beyond infant-parent bonds to examine dyadic relationships in children, adolescents, and adults. Attachment has been shown to influence a wide array of biopsychosocial phenomena, including social functioning, coping, stress response, psychological well-being, health behavior, and morbidity, and has thus emerged as an important focus of psychosomatic research. This article reviews the measurement of adult attachment, highlighting instruments of relevance to-or with potential use in-psychosomatic research. Methods: Following a literature search of articles that were related to the scales and measurement methods of attachment in adult populations, 29 instruments were examined with respect to their utility for psychosomatic researchers. Results: Validity, reliability, and feasibility were tabulated on 29 instruments. Eleven of the instruments with strong psychometric properties, wide use, or use in psychosomatic research are described. These include the following: Adult Attachment Interview (George, Kaplan, and Main); Adult Attachment Projective (George and West); Adult Attachment Questionnaire (Simpson, Rholes, and Phillips); Adult Attachment Scale (and Revised Adult Attachment Scale) (Collins and Read); Attachment Style Questionnaire (Feeney); Current Relationship Interview (Crowell and Owens); Experiences in Close Relationships (Brennan, Clark, and Shaver) and Revised Experiences in Close Relationships (Fraley, Waller, and Brennan); Parental Bonding Instrument (Parker, Tupling, and Brown); Reciprocal Attachment Questionnaire (West and Sheldon-Keller); Relationship Questionnaire (Bartholomew and Horowitz); and Relationship Scales Questionnaire (Grifiin and Bartholomew). Conclusion: In addition to reliability and validity, investigators need to consider relationship focus, attachment constructs, dimensions or categories of interest, and the time required for training, administration, and scoring. Further considerations regarding attachment measurement in the context of psychosomatic research are discussed.

Research paper thumbnail of Resilience training for hospital workers in anticipation of an influenza pandemic

Journal of Continuing Education in the Health Professions, 2011

Background: Well before the H1N1 influenza, health care organizations worldwide prepared for a pa... more Background: Well before the H1N1 influenza, health care organizations worldwide prepared for a pandemic of unpredictable impact. Planners anticipated the possibility of a pandemic involving high mortality, high health care demands, rates of absenteeism rising up to 20-30% among health care workers, rationing of health care, and extraordinary psychological stress.

Research paper thumbnail of Attachment, Contemporary Interpersonal Theory and IPT: An Integration of Theoretical, Clinical, and Empirical Perspectives

Journal of Contemporary Psychotherapy, 2008

Interpersonal Psychotherapy (IPT) is an effective, pragmatic treatment for depression but interpe... more Interpersonal Psychotherapy (IPT) is an effective, pragmatic treatment for depression but interpersonal explanations of its effectiveness are not fully developed. This paper presents an integration of aspects of attachment theory and contemporary interpersonal theory which explains how interpersonal interactions contribute to a clinical understanding of depression and its treatment through IPT. We test hypotheses of interpersonal change in a case series of depressed patients treated with IPT. The results demonstrate that both attachment insecurity and interpersonal problems improve significantly over a 16 week course of treatment. Further research into the interpersonal processes that alleviate depression is needed.

Research paper thumbnail of Attachment Insecurity Moderates the Relationship Between Disease Activity and Depressive Symptoms in Ulcerative Colitis

Inflammatory Bowel Diseases, 2005

Background: Among people with ulcerative colitis, depression occurs more frequently when inflamma... more Background: Among people with ulcerative colitis, depression occurs more frequently when inflammation is active. We hypothesized that individual differences in interpersonal style affect the risk that active disease will be accompanied by depressive symptoms.

Research paper thumbnail of Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak

Emerging Infectious Diseases, 2006

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to ... more Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.

Research paper thumbnail of Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak

Emerging Infectious Diseases, 2006

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to ... more Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.

Research paper thumbnail of Failures in interpersonal psychotherapy (IPT): factors related to treatment resistances

Journal of Clinical Psychology, 2011

Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan an... more Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan and across cultures. However, even when delivered with fidelity, some patients drop out and others do not improve sufficiently. Attention to IPT treatment attrition, dropout, nonresponse, or failure can elucidate its limitations and the opportunities to improve its effectiveness. Studies of factors known to moderate and negatively predict IPT depression treatment response are reviewed along with recommended modifications to improve outcomes. Although the risk of treatment failure always exists, it is possible to enhance treatment effectiveness by attending to the therapeutic alliance, strategically addressing depression, and adapting IPT to patient characteristics. These include adding pharmacotherapy, extending the course of treatment, and targeting specific symptoms or interpersonal vulnerabilities. Case examples illustrate several of these points.

Research paper thumbnail of Attachment and Psychosomatic Medicine: Developmental Contributions to Stress and Disease

Objective: The object of this study was to evaluate the evidence linking attachment insecurity to... more Objective: The object of this study was to evaluate the evidence linking attachment insecurity to illness. Attachment theory describes lifelong patterns of response to threat that are learned in the interaction between an infant and his or her primary caregiver. Despite its biopsychosocial domain, attachment theory has only recently been applied to psychosomatic medicine. Method: MEDLINE and PsychInfo databases were searched from 1966 to 2000 for English language papers with key words "attachment" and "object relations." Papers and their cited references were reviewed if they were directly related to physical illness, symptoms, or physiology. A hypothetical causal model was developed. Results: Direct and indirect evidence from survey studies supports an association between attachment insecurity and disease. Animal studies and human experiments suggest that attachment contributes to individual differences in physiological stress response. There is also less robust support for insecure attachment leading to symptom reporting and to more frequent health risk behaviors, especially substance use and treatment nonadherence. Evidence supports the prediction from attachment theory that the benefits of social support derive more from attachment relationships than nonattachment relationships. Conclusions: Although the available data are suggestive rather than conclusive, the data can be organized into a model that describe attachment insecurity leading to disease risk through three mechanisms. These are increased susceptibility to stress, increased use of external regulators of affect, and altered help-seeking behavior. This model warrants further prospective investigation. Key words: Attachment, disease model, stress, development, biopsychosocial.

Research paper thumbnail of Psychobiological subtypes of ulcerative colitis: pANCA status moderates the relationship between disease activity and psychological distress

The American journal of gastroenterology, 2006

Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. ... more Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions. In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination, and endoscopy using the St. Mark's index, and depressive symptoms and health anxiety were measured with self-report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated. In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation = 0.48, p < 0.001) ...

Research paper thumbnail of Halpern, J. and Maunder, R.G. Acute and chronic workplace stress in emergency medical technicians and paramedics

Research paper thumbnail of Concerns of patients with inflammatory bowel disease: results from a clinical population

The American Journal of Gastroenterology, 2001

Research paper thumbnail of Using attachment theory to understand illness behavior

This article examines a model of illness as a stressor that activates an individual's characteris... more This article examines a model of illness as a stressor that activates an individual's characteristic attachment behaviors. These behaviors are the result of the attachment system, a mammalian trait that exists in order to maximize the odds of survival of an infant born without the necessary maturation for immediate independence. Attachment concepts, such as attachment style, coherence, and reflective functioning, are briefly explained, followed by examples of their application to the psychological management of patients with medical or surgical illness. Attachment theory provides a unique, simple, and pragmatically useful model for understanding the particular ways that individuals can feel and react when stressed by illness, and how the professional may help manage that distress.

Research paper thumbnail of Physicians’ difficulty with emergency department patients is related to patients’ attachment style

Social Science & Medicine, 2006

Doctors experience 10-20 percent of patient interactions as being personally difficult, but the s... more Doctors experience 10-20 percent of patient interactions as being personally difficult, but the sources of difficulty are incompletely understood. In particular, physician-perceived difficulty has not been studied from the perspective of an established model of interpersonal relationships. Our objective was to determine whether a relationship exists between patients' attachment style and the degree of difficulty experienced by their attending physician in an Emergency Department in Pretoria, South Africa. Patients of an Emergency Department (n=165) completed the Experiences in Close Relationships-Revised Questionnaire to measure attachment anxiety and attachment avoidance. Their physicians (n=26), blind to the attachment measure, rated perceived difficulty using the Difficult Doctor-Patient Relationship Questionnaire. Four categories of attachment style were identified by cluster analysis of attachment scores. Patients were divided into difficult and non-difficult groups using a cut-off score. Two percent of patients with a secure attachment style were experienced as difficult, whereas the prevalence of difficulty in the insecure styles was 'preoccupied' 17 percent, 'dismissing' 19 percent and 'fearful' 39 percent (χ 2 =16.383, df=3, p=0.0009), supporting the hypothesis that the physician's perception of patient difficulty is related to the patient's attachment style. The degree to which physicians serve attachment functions for patients in crisis merits further investigation.

Research paper thumbnail of Downtime after Critical Incidents in Emergency Medical Technicians/Paramedics

BioMed Research International, 2014

Effective workplace-based interventions after critical incidents (CIs) are needed for emergency m... more Effective workplace-based interventions after critical incidents (CIs) are needed for emergency medical technicians (EMT)/paramedics. The evidence for a period out of service post-CI (downtime) is sparse; however it may prevent posttraumatic stress disorder (PTSD) and burnout symptoms. We examined the hypothesis that downtime post-CI is associated with fewer symptoms of four long-term emotional sequelae in EMT/paramedics: depression, PTSD, burnout, and stress-related emotional symptoms (accepted cut-offs defined high scores). Two hundred and one paramedics completed questionnaires concerning an index CI including downtime experience, acute distress, and current emotional symptoms. Nearly 75% received downtime; 59% found it helpful; 84% spent it with peers. Downtime was associated only with lower depression symptoms, not with other outcomes. The optimal period for downtime was between <30 minutes and end of shift, with >1 day being less effective. Planned testing of mediation of the association between downtime and depression by either calming acute post-CI distress or feeling helped by others was not performed because post-CI distress was not associated with downtime and perceived helpfulness was not associated with depression. These results suggest that outcomes of CIs follow different pathways and may require different interventions. A brief downtime is a relatively simple and effective strategy in preventing later depression symptoms.

Research paper thumbnail of The Experience of the 2003 SARS outbreak as a traumatic stress among frontline health-care workers in Toronto: lessons learned

SARS, 2005

The outbreak of severe acute respiratory syndrome (SARS) in the first half of 2003 in Canada was ... more The outbreak of severe acute respiratory syndrome (SARS) in the first half of 2003 in Canada was unprecedented in several respects. Understanding the psychological impact of the outbreak on healthcare workers, especially those in hospitals, is important in planning for future outbreaks of emerging infectious diseases. This review draws upon qualitative and quantitative studies of the SARS outbreak in Toronto to outline the factors that contributed to healthcare workers&amp;amp;amp;amp;#39; experiencing the outbreak as a psychological trauma. Overall, it is estimated that a high degree of distress was experienced by 29-35% of hospital workers. Three categories of contributory factors were identified. Relevant contextual factors were being a nurse, having contact with SARS patients and having children. Contributing attitudinal factors and processes were experiencing job stress, perceiving stigmatization, coping by avoiding crowds and colleagues, and feeling scrutinized. Pre-existing trait factors also contributed to vulnerability. Lessons learned from the outbreak include: (i) that effort is required to mitigate the psychological impact of infection control procedures, especially the interpersonal isolation that these procedures promote; (ii) that effective risk communication is a priority early in an outbreak; (iii) that healthcare workers may have a role in influencing patterns of media coverage that increase or decrease morale; (iv) that healthcare workers benefit from resources that facilitate reflection on the effects of extraordinary stressors; and (v) that healthcare workers benefit from practical interventions that demonstrate tangible support from institutions.

Research paper thumbnail of Attachment Insecurity, Responses to Critical Incident Distress, and Current Emotional Symptoms in Ambulance Workers

Stress and Health, 2012

Ambulance workers are exposed to critical incidents that may evoke intense distress and can resul... more Ambulance workers are exposed to critical incidents that may evoke intense distress and can result in long-term impairment. Individuals who can regulate distress may experience briefer post-incident distress and fewer longterm emotional difficulties. Attachment research has contributed to our understanding of individual differences in stress regulation, suggesting that secure attachment is associated with effective support-seeking and coping strategies, and fewer long-term difficulties. We tested the effect of attachment insecurity on emotional distress in ambulance workers, hypothesizing that (1) insecure attachment is associated with symptoms of current distress and (2) prolonged recovery from acute post-critical incident distress, coping strategies and supportive contact mediate this relationship. We measured (1) attachment insecurity, (2) acute distress, coping and social contact following an index critical incident and (3) current symptoms of post-traumatic stress, depression, somatization and burnout and tested the hypothesized associations. Fearful-avoidant insecure attachment was associated with all current symptoms, most strongly with depression (R = 0.38, p<0.001). Fearful-avoidant attachment insecurity was also associated with maladaptive coping, reduced social support and slower recovery from social withdrawal and physical arousal following the critical incident, but these processes did not mediate the relationship between attachment insecurity and current symptoms. These findings are relevant for optimizing post-incident support for ambulance workers.

Research paper thumbnail of Facilitating Adjustment to Inflammatory Bowel Disease: A Model of Psychosocial Intervention in Non-Psychiatric Patients

Psychotherapy and Psychosomatics, 1999

There is no consensus about the most appropriate psychosocial interventions for people with infla... more There is no consensus about the most appropriate psychosocial interventions for people with inflammatory bowel disease (IBD) or the most appropriate criteria by which to select which patients might benefit from the available interventions. Nonetheless the perception that stress and other subjective factors contribute to suffering in IBD is persistent and professionals are often called upon to offer appropriate support. A model of normal psychosocial adjustment to IBD and the interventions which can improve difficulties with adjustment will facilitate rational therapeutic intervention and needed research in this area. A model of normal adjustment to IBD is developed from a synthesis of the empirical literature and clinical experience in a tertiary care medical/surgical IBD centre and is used to identify potential points of psychosocial intervention. Normal adjustment to IBD can be understood as a process involving the interaction of a triad of adaptive challenges: illness uncertainty, loss and change, and suffering. Each of these challenges requires different criteria of psychosocial assessment and may lead to different interventions. Although the interventions available for improving adjustment to IBD have not been exhaustively investigated, the existing data support the value of further study. The model of psychosocial adjustment presented here provides a synthesis of the existing data and a starting point for further research.

Research paper thumbnail of Insecure Attachment in a Subgroup with Ulcerative Colitis Defined by ANCA Status

Digestive Diseases and Sciences, 2000

This study is the first test of the novel hypothesis that perinuclear anti-neutrophil cytoplasmic... more This study is the first test of the novel hypothesis that perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) marks an etiological division between stress-susceptible and stress-neutral ulcerative colitis. Subjects were 47 UC patients with known p-ANCA status (19 p-ANCA-positive, 28 p-ANCA-absent). Controls were 77 university students. Subjects and controls completed the Reciprocal Attachment Questionnaire. Subjects were categorized as avoidant/nonavoidant and anxious/nonanxious based

Research paper thumbnail of Identifying, describing, and expressing emotions after critical incidents in paramedics

Journal of Traumatic Stress, 2012

For paramedics, critical incidents evoke intense emotions and may result in later psychological d... more For paramedics, critical incidents evoke intense emotions and may result in later psychological difficulties. We examined 2 ways to deal with emotions after critical incidents: (a) identifying emotions, and (b) describing and expressing emotions, and their association with recovery from acute stress and psychological symptoms. We surveyed 190 paramedics, examining how impaired capacity to identify and describe emotions (alexithymia) and voluntary expression of emotions during contacts with others in the first 24 hours after the incident were associated with recovery from acute stress and current symptoms of PTSD, depression, burnout, and somatization. Overall alexithymia was not associated with recovery, but the component of difficulty identifying feelings was associated with prolonged physical arousal (χ(2) = 10.1, p = .007). Overall alexithymia and all its components were associated with virtually all current symptoms (correlation coefficients .23-.38, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .05). Voluntary emotional expression was unrelated to current symptoms. Greater emotional expression was related to greater perceived helpfulness of contacts (χ(2) = 56.8, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). This suggests that identifying emotions may be important in managing occupational stress in paramedics. In contrast, voluntary emotional expression, although perceived as helpful, may not prevent symptoms. These findings may inform education for paramedics in dealing with stress.

Research paper thumbnail of The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults

Journal of Psychosomatic Research, 2006

The purpose of this study was to test predicted relationships between adult attachment and stress... more The purpose of this study was to test predicted relationships between adult attachment and stress using subjective and physiological measures. Sixty-seven healthy adults completed measures of adult attachment and perceived chronic stress. Subjective stress and the high-frequency (HF) and low-frequency (LF) spectral bandwidths of heart rate variability (HRV) were measured during a standardized stress protocol. Attachment anxiety is associated with between-subject differences in chronic perceived stress (P=.001) and subjective acute stress (P=.01). There is a main effect of attachment avoidance on between-subject differences in HF HRV (P=.004). Attachment avoidance is inversely associated with HF HRV, independent of age and variability in respiration. Attachment anxiety is associated with self-reported distress. Attachment avoidance is inversely associated with HF HRV, a marker of vagal influence on cardiac activity, but is not associated with subjective stress.

Research paper thumbnail of Adult attachment measures: A 25-year review

Journal of Psychosomatic Research, 2010

Objective: Over the past 25 years, attachment research has extended beyond infant-parent bonds to... more Objective: Over the past 25 years, attachment research has extended beyond infant-parent bonds to examine dyadic relationships in children, adolescents, and adults. Attachment has been shown to influence a wide array of biopsychosocial phenomena, including social functioning, coping, stress response, psychological well-being, health behavior, and morbidity, and has thus emerged as an important focus of psychosomatic research. This article reviews the measurement of adult attachment, highlighting instruments of relevance to-or with potential use in-psychosomatic research. Methods: Following a literature search of articles that were related to the scales and measurement methods of attachment in adult populations, 29 instruments were examined with respect to their utility for psychosomatic researchers. Results: Validity, reliability, and feasibility were tabulated on 29 instruments. Eleven of the instruments with strong psychometric properties, wide use, or use in psychosomatic research are described. These include the following: Adult Attachment Interview (George, Kaplan, and Main); Adult Attachment Projective (George and West); Adult Attachment Questionnaire (Simpson, Rholes, and Phillips); Adult Attachment Scale (and Revised Adult Attachment Scale) (Collins and Read); Attachment Style Questionnaire (Feeney); Current Relationship Interview (Crowell and Owens); Experiences in Close Relationships (Brennan, Clark, and Shaver) and Revised Experiences in Close Relationships (Fraley, Waller, and Brennan); Parental Bonding Instrument (Parker, Tupling, and Brown); Reciprocal Attachment Questionnaire (West and Sheldon-Keller); Relationship Questionnaire (Bartholomew and Horowitz); and Relationship Scales Questionnaire (Grifiin and Bartholomew). Conclusion: In addition to reliability and validity, investigators need to consider relationship focus, attachment constructs, dimensions or categories of interest, and the time required for training, administration, and scoring. Further considerations regarding attachment measurement in the context of psychosomatic research are discussed.

Research paper thumbnail of Resilience training for hospital workers in anticipation of an influenza pandemic

Journal of Continuing Education in the Health Professions, 2011

Background: Well before the H1N1 influenza, health care organizations worldwide prepared for a pa... more Background: Well before the H1N1 influenza, health care organizations worldwide prepared for a pandemic of unpredictable impact. Planners anticipated the possibility of a pandemic involving high mortality, high health care demands, rates of absenteeism rising up to 20-30% among health care workers, rationing of health care, and extraordinary psychological stress.

Research paper thumbnail of Attachment, Contemporary Interpersonal Theory and IPT: An Integration of Theoretical, Clinical, and Empirical Perspectives

Journal of Contemporary Psychotherapy, 2008

Interpersonal Psychotherapy (IPT) is an effective, pragmatic treatment for depression but interpe... more Interpersonal Psychotherapy (IPT) is an effective, pragmatic treatment for depression but interpersonal explanations of its effectiveness are not fully developed. This paper presents an integration of aspects of attachment theory and contemporary interpersonal theory which explains how interpersonal interactions contribute to a clinical understanding of depression and its treatment through IPT. We test hypotheses of interpersonal change in a case series of depressed patients treated with IPT. The results demonstrate that both attachment insecurity and interpersonal problems improve significantly over a 16 week course of treatment. Further research into the interpersonal processes that alleviate depression is needed.

Research paper thumbnail of Attachment Insecurity Moderates the Relationship Between Disease Activity and Depressive Symptoms in Ulcerative Colitis

Inflammatory Bowel Diseases, 2005

Background: Among people with ulcerative colitis, depression occurs more frequently when inflamma... more Background: Among people with ulcerative colitis, depression occurs more frequently when inflammation is active. We hypothesized that individual differences in interpersonal style affect the risk that active disease will be accompanied by depressive symptoms.

Research paper thumbnail of Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak

Emerging Infectious Diseases, 2006

Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to ... more Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.