Attachment Theory

Attachment theory (4,5) has been recognized as “…the most widely accepted and validated approach in developmental psychology” (6), and its relevance to other health professions, including medicine, psychology, social work, and occupational therapy (7–9), has been highlighted. Studies demonstrate associations between one's individual attachment pattern and health behaviors, including engagement in physical activity (3,10,11); however, attachment theory has received scant attention in the exercise science and exercise physiology literatures.

According to attachment theory (4,5), attachment patterns are based on internal working models, which are internalized cognitive, emotional, and behavioral schema developed from infancy. The availability of attuned early caregiving is key to the development of a secure attachment pattern. In adulthood, this secure pattern is associated with positive perceptions of the self as being worthy of care and of others as being trustworthy and reliable (12). Less optimal caregiving conditions (i.e., caregivers not attuned to the infant's needs), contribute to the development of 1 of 2 insecure attachment patterns: anxious attachment (sometimes referred to as ambivalent, insecure-resistant, or preoccupied attachment); or avoidant attachment (also known as dismissing or insecure-avoidant attachment). Some individuals demonstrate both anxious and avoidant characteristics which, in adulthood, is referred to as fearful attachment (12,13).

Anxious attachment is typically associated with a negative view of the self, and people who are more anxiously attached present as more distressed and dependent on others, are prone to catastrophizing, and have lower self-esteem (12,14). In contrast, avoidant attachment is characterized by more negative perceptions of others with the related preference for self-reliance and minimization of emotional needs (12). Those with a fearful attachment pattern view both the self and others negatively (12,15).

Attachment Theory and Health

Attachment insecurity is associated with fewer adaptive coping skills and social behaviors, lower levels of self-efficacy, and difficulties with affect regulation (16). Insecure attachment is also associated with several negative health and lifestyle behaviors, including poor nutrition, physical inactivity, reduced use of health care services, and poor compliance with lifestyle recommendations (11). The implications of attachment theory on physical health have been specifically addressed in practice areas such as ageing (17), cancer (18,19), renal transplant (20), diabetes (21,22), coronary artery disease (23), chronic pain (24,25), and other chronic conditions (26). Attachment theory has similarly been implicated in various psychological conditions including borderline personality disorder (27,28), depression (29), history of suicidal ideation (30), psychosis (31), infant mental health (32,33), postnatal depression (34), substance misuse (35), and quality of life (36).

Different attachment patterns have also been linked to intervention outcomes, highlighting the potential benefits of interventions being tailored according to the client's attachment patterns. For example, in a study of clients with coronary artery disease and depression symptoms, only those with secure attachment patterns observed a significant reduction in depression symptoms, independent of treatment assignment (23).

Although it is theoretically possible to modify attachment patterns, we do not suggest this becomes a goal, since, unlike mental health professionals such as psychologists, this is outside the scope of practice for exercise scientists and clinical exercise physiologists. Instead, being aware of clients' and practitioners' attachment patterns has implications for the development of the therapeutic alliance, client motivation and, therefore, overall intervention outcomes. This narrative review (37) aims to provide an overview of attachment theory and the evidence relating it to physical activity and exercise and consider its relevance specifically to the fields of exercise science and exercise physiology. In the absence of attachment-related research in exercise science and exercise physiology, attention is given to the broader attachment literature, which highlights the potential of attachment theory to inform discipline-specific practice, education, and research.

Methodology

An initial systematic approach to identify available evidence linking attachment theory with either exercise science or exercise physiology, included a search of 4 databases (ERIC, PsycARTICLES, PsycINFO, and MEDLINE) using the terms [‘exercise' OR ‘exercise science' OR ‘exercise physiology'] AND [‘attachment' OR ‘attachment theory'] as key words (and selecting English only). Only 1 book, titled Attachment in Sport, Exercise and Wellness (38), identified through this search strategy, was considered representative of the search focus. Although relevant to exercise and attachment theory, this book focused on the implications of attachment theory to exercise professionals, in general, and was not specific to either exercise scientists or clinical exercise physiologists who work in public health settings.

Based on the paucity of relevant research specific to exercise science and exercise physiology, a decision was made to undertake this narrative review. A narrative review accommodates exploration of the potential implications of an understanding of attachment theory for exercise scientists and clinical exercise physiologists in supporting client physical activity participation (37). Drawing from current sport, physical activity, and health science literature, the following section explores the potential insights and understanding attachment theory may provide exercise scientists and clinical exercise physiologists in (a) individual health-related responses, (b) sport and physical activity motivation, (c) key practices and processes, (d) the impact of personal attachment patterns of practitioners, as well as highlight, recommendations for future research. A summary of key articles relevant to exercise science and exercise physiology has been provided in Table 1.

TABLE 1. Key articles relevant to attachment and either exercise science or exercise physiology.

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TABLE 1. Continued.

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Individual Health-Related Responses

An increasing body of literature supports the value of attachment theory when understanding the health behaviors across numerous populations (42). In the health literature, a range of emotional (e.g., catastrophizing, depression) and behavioral (e.g., underuse or overuse of health services, adherence to treatment) responses have been identified with implications for physical, emotional, and mental health (40). These behaviors have been increasingly linked with adult attachment patterns. Securely attached individuals have consistently been found to exhibit behaviors that support their health and well-being. For example, when seeking health advice, they have an increased sense of internal resilience, trust in the health care provider, and compliance with recommended treatments (40).

In contrast, an insecure attachment has been linked to an increased physiological response to stress (related to increased perceived stress, impaired regulation of stress physiology, and decreased modulation of stress); increased use of external regulators of affect (substance misuse, unhealthy eating behaviors, and risky sexual practices); and altered use of protective factors (help-seeking, social support, treatment adherence, and symptom attention) (40). The consequence of these associations is theorized to be poorer physical and mental health for insecurely attached adults (anxious, avoidant, or fearful attachment types) compared to their more securely attached counterparts.

Those with an anxious attachment pattern have been suggested to display forms of learned helplessness (a lack of belief in their own capacity to manage their health condition) and believe that health outcomes are beyond their personal control (40,42). They display poor abilities to self-regulate and instead compulsively seek support from others to sooth their anxiety (40). Notably, attachment anxiety has also been linked with decreased satisfaction with weight and nutrition, increased reporting of somatic symptoms, reduced exercise engagement, and impaired ability to implement lifestyle change (48,49). For example, Ciechanowski et al. (2002) found that women receiving diabetes treatment who reported either more anxious or fearful attachment patterns demonstrated more symptom reporting compared to those who were securely attached (50). Further, anxiously attached individuals consumed significantly more treatment resources compared to those reporting other attachment patterns.

In contrast, individuals displaying avoidant attachment patterns are more self-reliant as they perceive others to be unreliable and untrustworthy (40). These clients often underplay their health condition and reject attempts to empathize or help (40). Attention and care provided by health professionals may be viewed as threatening, which may result in rejection of health advice and recommendations (40). Consistent with these beliefs, avoidant attachment is associated with fewer visits to health professionals and poorer adherence to treatment recommendations (22,49,50). For example, Ciechanowski et al. (2002) showed women with avoidant and fearful attachment patterns sought significantly less treatment for diabetes than the anxiously attached group (50).

Individuals with fearful attachment patterns tend to respond in a disorganized manner (49). Although they seek empathetic, reliable, effective responses from health professionals, they have deep mistrust in the health professionals' ability to provide this support (40). In practice, this presents as a client actively displaying help-seeking behaviors, often from several practitioners, before dismissing recommendations and support as ineffective. The intermittent treatment-seeking behavior of the fearful group from multiple providers further increases their risk of delayed or inappropriate treatment (51,52).

In a summary of health-related implications, Meredith (2009) noted that insecurely attached individuals are less able to internally manage the distress associated with physical illness, less able to acquire and sustain support from family, friends, and health professionals, and more susceptible to experiencing poor outcomes from treatment interventions leading to a higher likelihood of chronic health conditions (9). For exercise scientists and clinical exercise physiologists, understanding how clients have previously engaged with other health care professionals, either successfully or unsuccessfully, may lead to more effective, personalized interventions.

Sport and Physical Activity Motivation

Over the last decade, there has been increased interest into how the attachment patterns of coach-athlete dyads influence coach-athlete relationship, as well as athlete motivation, performance, and wellbeing (43–47). Consistently, a secure attachment pattern among athletes has been positively correlated with a stronger perceived relationship between athlete and coach, as well as improved performance and overall wellbeing (43–47).

Similarly, studies exploring the relationship between individual attachment pattern and physical activity have consistently found a secure attachment pattern to predict increased physical activity motivation and engagement (3,37,53,54). Increasing evidence has revealed associations between attachment pattern and treatment adherence/compliance (20). Since exercise only works if one adheres to the prescription, treatment adherence and motivation are factors directly transferable to the success or otherwise of interventions delivered by exercise scientists and clinical exercise physiologists. Exercise scientists and clinical exercise physiologists might benefit from evidence in the sport and physical activity literature (3,37,42) which advocates for sport and exercise professionals to adopt an attachment lens to support client motivation to engage in physical activity.

Self-determination theory (55) is a motivation framework regularly explored within physical activity literature (37,42). Given the social relationship constructs of self-determination theory (autonomy, relatedness, and competence) which have been suggested to predict one's level of motivation, authors suggest attachment theory and self-determination integrate particularly well and may be key for practitioners facilitating physical activity motivation for their clients (37,42). Carr (2011) further highlighted this potential, suggesting practitioners may be able to support a secure attachment relationship with their clients by ensuring all 3 psychological needs of autonomy, relatedness, and competence were met throughout the intervention (37). Accordingly, authors posited that exercise professionals may be viewed by their client as a ‘secure attachment figure' facilitating trust and security and enhancing motivation (37).

In relation to the achievement goal framework described by Elliot and McGregor (2001), Carr (2011) highlighted the potential importance of the exploration system put forward by attachment theory (37,55). Literature has suggested that insecurely attached individuals demonstrate reduced feelings of competence and self-esteem, and a higher need to avoid failure, which leads to reduced interest in exploratory experiences, an element crucial to human motivation (3,37). Research examining the relationship between autonomy, competence, and relatedness with exercise attendance, adherence, and drop out identified the need for competence was strongly associated with exercise attendance (57). Given the frequent performance-based climate often encouraged in sport and exercise, it could be argued these environments may not initially be supportive of individuals possessing insecure attachment styles. Instead, alternative forms of physical activity may be considered in the initial stages as the client develops confidence and self-efficacy. Gaining an understanding of a client's attachment pattern may provide guidance on the type of physical activity recommended for long-term sustainability.

Another body of literature relevant to exercise scientists and clinical exercise physiologists is the relationship between attachment and activity engagement. Research in work-related task engagements suggests that avoidantly attached individuals seek productive task engagement as a coping strategy to avoid unwanted interactions with others, as well as to sooth anxiety experienced because of unmet attachment needs (58,59). For those showing anxious attachment patterns, individuals also show increased levels of task engagement; however, this was motivated, instead, by the desire to attract attention and approval from others (58,59). People with insecure attachment patterns were found to overcommit and have trouble reducing their workload when required (58,59). Although research in this space is not specific to physical activity participation, understanding an individual's motivation to engage in activities and the potential negative aspects of these behaviors (e.g., overtraining) is relevant to exercise professionals. Due to the importance of motivation and task engagement to physical activity and exercise interventions, further research into integration of attachment theory with current motivational frameworks relevant to exercise science and exercise physiology is warranted.

Key Practices and Processes

As previously discussed, there is a growing body of literature suggesting insecure attachment styles are linked to poorer mental and physical health conditions that are also associated with physical inactivity (52). Although causation cannot be inferred (e.g., does an insecure attachment pattern result in reduced physical activity, and therefore increased prevalence of chronic health conditions), an understanding of attachment theory may inform key practice and processes of exercise scientists and clinical exercise physiologists (e.g., therapeutic alliance) to better support the health of their clients.

When seeking health advice, securely attached individuals report greater trust in the health care provider (60). Further, they are more likely to form emotional bonds and negotiate meaningful goals with their health practitioner, and to report higher ratings of therapeutic alliance leading to greater adherence to treatment recommendations (61,62).

Because those with an anxious attachment pattern present as more helpless and less able to self-regulate, they are most likely to present as reliant on the practitioner (40). Thus, it has been recommended that practitioners working with individuals with anxious attachment patterns set clear boundaries, while remaining empathetic, attentive, consistent, reliable, and calm (8,40).

The self-reliance of individuals displaying avoidant attachment patterns, and their discomfort with empathy, attention, or offerings of assistance, suggest that adherence can best be supported by exercise scientists and clinical exercise physiologists who are flexible to meet the client where they are in their health journey, respect their autonomy to make their own health decisions, and recognize their need for personal space (8,40).

Individuals with fearful attachment patterns desire but reject support in a distressing pull-push manner (40). Practitioners working with this population need to set clear boundaries and expectations and be alert to the client's need for autonomy while remaining calm and demonstrating empathy (8,40). It has also been suggested that practitioners work collaboratively with the client's mental health support team where indicated (8).

As described above, adopting an attachment lens may assist exercise scientists and clinical exercise physiologists to recognize the need to respond differently to the client based on their interpersonal and emotional needs, thereby supporting the therapeutic alliance and client's commitment to engage sustainably in physical activity. Awareness of individual attachment-related nuances may improve the quality of the service offered by exercise scientists and clinical exercise physiologists, ostensibly leading to better client outcomes (8,40).

Personal Attachment Patterns of Professionals

With growing evidence of the implications of the attachment pattern of the client for engagement and outcomes, it would be remiss not to consider the attachment pattern of the exercise scientist and exercise physiologist. Since attachment theory supports growing self-awareness, exercise scientists and clinical exercise physiologists who understand their own attachment patterns may gain insights into their own behaviors and relational preferences, and why better outcomes might be observed with some clients yet not others, when using the same therapeutic approach. In addition, such insight may suggest ways to tailor client/practitioner interactions to achieve more optimal outcomes with all clients.

While not yet investigated in the exercise science or exercise physiology literature, research within the profession of psychology shows that clinician attachment styles can potentially impact the therapeutic alliance, countertransference, and overall intervention outcomes (61). For example, Rubino and colleagues (2000) found that psychologists with a more anxious attachment style were likely to respond with less empathy, while psychologists (regardless of attachment style) responded with more empathy to clients with fearful and anxious attachment patterns (41). Further, a study by Bucci and colleagues (2016) found that therapists with a fearful attachment style were rated by clients as having a poorer therapeutic alliance (39). To further develop the therapeutic alliance, and enhance client satisfaction and intervention outcomes, there is a need to better understand the implications of the exercise professional's attachment pattern for the exercise professional's preferences and behaviors.

Recommendations for Future Research

Attachment insecurity has been linked with a range of mental and physical health conditions, and is associated with behaviors, cognitions, and emotions relevant to exercise science and exercise physiology. Based on this body of information, a key advantage of adopting an attachment theory perspective in clinical areas of exercise science and exercise physiology is that it provides a comprehensive developmental model providing insights to: the origins of a range of illness-related emotional and behavioral responses; the origins of behaviors often perceived clinically as barriers to sustainable engagement in exercise and physical activity; why different approaches may work more effectively or achieve better outcomes with some clients than others. It may also: improve capacity for practitioners to predict individual needs and preferences of clients; improve identification of subgroups who might benefit from more tailored group intervention approaches; and support goal setting and the developing therapeutic alliance. Thus, attachment theory could represent a valuable clinical reasoning tool for exercise scientists and clinical exercise physiologists.

Despite the growing bodies of literature, the implications of adult attachment theory for the clinical and professional practices of exercise science and exercise physiology have to date, been ignored. This literature gap highlights an opportunity for further research to improve the practice of exercise prescription. The information presented in this review suggests that attachment theory offers a developmentally sound theoretical basis for empirical investigations in a large range of practice and professional areas. Our top 3 future research priorities are detailed to explore the potential role of attachment theory in the field of exercise science and exercise physiology.

First, we suggest foundational research is required to explore the knowledge and practice currently used by exercise scientists and clinical exercise physiologists within their practice regarding attachment theory and how this informs the development and delivery of exercise interventions. This research will include examining clinician/client interactions so a model of best practice to employ attachment theory when working with clients can be developed. Given the evidence of the implementation of attachment theory in other health professions (7–9, 43–47), and the absence of evidence specific to exercise science and exercise physiology, examining current knowledge and practice appears a necessary first step.

Second, researchers must develop and evaluate the effectiveness of attachment theory education for the exercise science and clinical exercise physiology profession, either within the current tertiary curricula or as a professional development activity. Attachment theory offers a well-accepted model used within several health professions for understanding the ways that individuals can feel and react when stressed by illness, as well as how professionals may help manage that distress (40). Understanding the theoretical foundations and application of attachment theory in assessment and treatment is, therefore, required for exercise scientists and clinical exercise physiologists to incorporate safely and ethically. Educational evaluation outcomes should include acceptability, knowledge gain, confidence to apply theoretical concepts, and relevance to current practice.

Finally, research is needed to evaluate the association between practice and treatment outcomes when attachment theory is used by exercise scientists and clinical exercise physiologists in clinical practice. An additional implication for this research is to establish how the various attachment subgroups within study samples may obtain differential outcomes from exercise programs. It is plausible that an exercise program offered to a large group of clients that demonstrates no significant change overall, is more accurately revealed to be beneficial for people with one attachment pattern, while being of no assistance (or even detrimental) for those with a different pattern. Attachment style is rarely if ever considered as an explanatory variable in determining the effectiveness of exercise interventions and, based on the theoretical considerations described in this paper, warrants attention. Including assessment of attachment style in exercise trials, and using this variable in moderation or mediation analyses, may advance the field of exercise prescription. Such findings could inform more client-centerd and tailored physical activity and exercise interventions.

Within this article, we propose a paradigm shift in how exercise scientists and clinical exercise physiologists engage with their clients to facilitate sustained participation in physical activity and exercise interventions. Importantly, we further propose a research framework to evaluate the application of attachment theory to professional exercise practice including the impact on the therapeutic alliance, exercise adherence, client motivation, and overall treatment outcomes.