Supportive Care in Cancer

, Volume 27, Issue 11, pp 4317–4325 | Cite as

Spiritual well-being mediates the association between attachment insecurity and psychological distress in advanced cancer patients

  • Katharina ScheffoldEmail author
  • Rebecca Philipp
  • Sigrun Vehling
  • Susan Koranyi
  • Dorit Engelmann
  • Frank Schulz-Kindermann
  • Martin Härter
  • Anja Mehnert-Theuerkauf
Original Article



The diagnosis of a terminal disease bears existential challenges, which activate the attachment system. Attachment insecurity, as well as existential resources, such as spiritual well-being, influences patients’ extent of psychological distress. Knowledge about the interrelation of these constructs is limited. Based on current research, we assume spiritual well-being to mediate the association of attachment insecurity and psychological distress.


We obtained data from the baseline measurement of a randomized controlled trial in advanced cancer patients. Patients were sampled from the University Medical Centers of Hamburg and Leipzig, Germany. Main outcome measures included the Patient Health Questionnaire (PHQ-9), the Death and Dying Distress Scale (DADDS), the Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Scale (FACIT-Sp), and the Experience in Close Relationships Scale (ECR-M16) for assessing attachment insecurity. We tested the mediation hypothesis with two regression analyses using bootstrapping procedure.


A total of 190 patients were included. Spiritual well-being mediated the association of attachment insecurity and depression (R2 = 11%), as well as death anxiety (R2 = 15%), in fearful-avoidant attached patients. Neither dismissingly nor preoccupied attached patients differ in terms of spiritual well-being and psychological distress in comparison with secure attached patients.


Spiritual well-being plays a relevant role in advanced cancer patient’s mental health through mediating the association of attachment and psychological distress. Developing a better understanding of the interdependency of the constructs of spiritual well-being and attachment can help to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Trial registration



Advanced cancer Attachment Spiritual well-being Depression Death anxiety 


Compliance with ethical standards

The study protocol was approved by local ethics committees in both study centers (Hamburg reference number: PV4435; Leipzig reference number: 143–14–14042014). All patients provided written informed consent prior to participation and could withdraw their informed consent at all times without having any disadvantage in their medical or psychological treatment

Conflict of interest

This research was supported by the German Cancer Aid. The authors declare not having any financial relationship with the organization. The authors have full control of all primary data and agree to allow the journal to review the data if requested.


  1. 1.
    Kissane DW (2012) The relief of existential suffering. Arch Intern Med 172(19):1501–1505. CrossRefPubMedGoogle Scholar
  2. 2.
    Bowlby J (1977) The making and breaking of affectional bonds. I. Aetiology and psychopathology in the light of attachment theory. An expanded version of the fiftieth Maudsley lecture, delivered before the Royal College of Psychiatrists, 19 November 1976. Br J Psychiatry 130(3):201–210. CrossRefPubMedGoogle Scholar
  3. 3.
    Nicholls W, Hulbert-Williams N, Bramwell R (2014) The role of relationship attachment in psychological adjustment to cancer in patients and caregivers: a systematic review of the literature. Psycho-Oncology 23(10):1083–1095. CrossRefPubMedGoogle Scholar
  4. 4.
    Scheffold K, Philipp R, Koranyi S, Engelmann D, Schulz-Kindermann F, Härter M, Mehnert A (2018) Insecure attachment predicts depression and death anxiety in advanced cancer patients. Palliat Support Care 16(3):308–316. CrossRefPubMedGoogle Scholar
  5. 5.
    Ciechanowski P, Sullivan M, Jensen M, Romano J, Summers H (2003) The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain. Pain 104(3):627–637. CrossRefPubMedGoogle Scholar
  6. 6.
    Hunter JJ, Maunder RG (2001) Using attachment theory to understand illness behavior. Gen Hosp Psychiatry 23(4):177–182. CrossRefPubMedGoogle Scholar
  7. 7.
    Brennan KA, Clark CL, Shaver PR (1998) Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS (eds) Attachment theory and close relationships. Guilford Press, New York, pp 46–76Google Scholar
  8. 8.
    Bartholomew K, Horowitz LM (1991) Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 61(2):226–244CrossRefGoogle Scholar
  9. 9.
    Peteet JR, Balboni MJ (2013) Spirituality and religion in oncology. CA Cancer J Clin 63(4):280–289. CrossRefPubMedGoogle Scholar
  10. 10.
    Vehling S, Lehmann C, Oechsle K, Bokemeyer C, Krüll A, Koch U, Mehnert A (2011) Global meaning and meaning-related life attitudes: exploring their role in predicting depression, anxiety, and demoralization in cancer patients. Support Care Cancer 19(4):513–520. CrossRefPubMedGoogle Scholar
  11. 11.
    Scheffold K, Mehnert A, Müller V, Koch U, Härter M, Vehling S (2014) Sources of meaning in cancer patients - influences on global meaning, anxiety and depression in a longitudinal study. Eur J Cancer Care (Engl) 23(4):472–480. CrossRefGoogle Scholar
  12. 12.
    Canada AL, Murphy PE, Fitchett G, Peterman AH, Schover LR (2008) A 3-factor model for the FACIT-Sp. Psycho-Oncology 17(9):908–916. CrossRefPubMedGoogle Scholar
  13. 13.
    Lo C, Zimmermann C, Gagliese L, Li M, Rodin G (2011) Sources of spiritual well-being in advanced cancer. BMJ Support Palliat Care 1(2):149–153. CrossRefPubMedGoogle Scholar
  14. 14.
    Sherman AC, Merluzzi TV, Pustejovsky JE, Park CL, George L, Fitchett G, Jim HSL, Munoz AR, Danhauer SC, Snyder MA, Salsman JM (2015) A meta-analytic review of religious or spiritual involvement and social health among cancer patients. Cancer 121(21):3779–3788. CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Loetz C, Müller J, Frick E, Petersen Y, Hvidt NC, Mauer C (2013) Attachment theory and spirituality: two threads converging in palliative care? Evid Based Complement Alternat Med 2013:740291. CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Hiebler-Ragger M, Falthansl-Scheinecker J, Birnhuber G, Fink A, Unterrainer HF (2016) Facets of spirituality diminish the positive relationship between insecure attachment and mood pathology in young adults. PLoS One 11(6):e0158069. CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Lo C, Hales S, Rydall A et al (2015) Managing Cancer And Living Meaningfully: study protocol for a randomized controlled trial. Trials 16:391. CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Scheffold K, Philipp R, Engelmann D, Schulz-Kindermann F, Rosenberger C, Oechsle K, Härter M, Wegscheider K, Lordick F, Lo C, Hales S, Rodin G, Mehnert A (2015) Efficacy of a brief manualized intervention Managing Cancer and Living Meaningfully (CALM) adapted to German cancer care settings: study protocol for a randomized controlled trial. BMC Cancer 15:592. CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Wade DT, Vergis E (1999) The Short Orientation-Memory-Concentration Test: a study of its reliability and validity. Clin Rehabil 13(2):164–170CrossRefGoogle Scholar
  20. 20.
    Lo C, Walsh A, Mikulincer M, Gagliese L, Zimmermann C, Rodin G (2009) Measuring attachment security in patients with advanced cancer: psychometric properties of a modified and brief Experiences in Close Relationships scale. Psycho-Oncology 18(5):490–499. CrossRefPubMedGoogle Scholar
  21. 21.
    Philipp R, Vehling S, Scheffold K, Grünke B, Härter M, Mehnert A, Oechsle K, Schulz-Kindermann F, Lo C (2017) Attachment insecurity in advanced cancer patients: psychometric properties of the German version of the brief Experiences in Close Relationships scale (ECR-M16-G). J Pain Symptom Manag 54(4):555–562. CrossRefGoogle Scholar
  22. 22.
    Löwe B, Kroenke K, Herzog W, Gräfe K (2004) Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord 81(1):61–66. CrossRefPubMedGoogle Scholar
  23. 23.
    Engelmann D, Scheffold K, Friedrich M, Hartung TJ, Schulz-Kindermann F, Lordick F, Schilling G, Lo C, Rodin G, Mehnert A (2016) Death-related anxiety in patients with advanced cancer: validation of the German version of the Death and Dying Distress Scale. J Pain Symptom Manag 52(4):582–587. CrossRefGoogle Scholar
  24. 24.
    Peterman AH, Fitchett G, Brady MJ, Hernandez L, Cella D (2002) Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy--Spiritual Well-being Scale (FACIT-Sp). Ann Behav Med 24(1):49–58CrossRefGoogle Scholar
  25. 25.
    Baron RM, Kenny DA (1986) The moderator-mediator variable distinction in social psychological research. J Pers Soc Psychol 51(6):1173–1182CrossRefGoogle Scholar
  26. 26.
    Hayes AF (2009) Beyond Baron and Kenny: statistical mediation analysis in the new millennium. Commun Monogr 76(4):408–420. CrossRefGoogle Scholar
  27. 27.
    Hayes AF (2017) Introduction to mediation, moderation, and conditional process analysis: a regression-based approach, 2nd edn. The Guilford Publications, New YorkGoogle Scholar
  28. 28.
    Hayes AF, Preacher KJ (2014) Statistical mediation analysis with a multicategorical independent variable. Br J Math Stat Psychol 67(3):451–470. CrossRefPubMedGoogle Scholar
  29. 29.
    Granqvist P, Ivarsson T, Broberg AG, Hagekull B (2007) Examining relations among attachment, religiosity, and new age spirituality using the adult attachment interview. Dev Psychol 43(3):590–601. CrossRefPubMedGoogle Scholar
  30. 30.
    Granqvist P, Mikulincer M, Shaver PR (2010) Religion as attachment: normative processes and individual differences. Personal Soc Psychol Rev 14(1):49–59. CrossRefGoogle Scholar
  31. 31.
    Mikulincer M (1998) Attachment working models and the sense of trust: an exploration of interaction goals and affect regulation. J Pers Soc Psychol 74(5):1209–1224. CrossRefGoogle Scholar
  32. 32.
    Mikulincer M, Shaver PR, Pereg D (2003) Motiv Emot 27(2):77–102. CrossRefGoogle Scholar
  33. 33.
    Ciechanowski PS (2002) Attachment theory: a model for health care utilization and somatization. Psychosom Med 64(4):660–667. CrossRefPubMedGoogle Scholar
  34. 34.
    Kunsmann-Leutiger E, Loetz C, Frick E, Petersen Y, Müller JJ (2018) Attachment patterns affect spiritual coping in palliative care. J Hosp Palliat Nurs 20(4):385–391. CrossRefPubMedGoogle Scholar
  35. 35.
    Meuti V, Aceti F, Giacchetti N, Carluccio GM, Zaccagni M, Marini I, Giancola O, Ciolli P, Biondi M (2015) Perinatal depression and patterns of attachment: a critical risk factor? Depress Res Treat 2015:105012. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Fraley RC, Shaver PR (2000) Adult romantic attachment: theoretical developments, emerging controversies, and unanswered questions. Rev Gen Psychol 4(2):132–154. CrossRefGoogle Scholar
  37. 37.
    Maunder RG, Hunter JJ (2009) Assessing patterns of adult attachment in medical patients. Gen Hosp Psychiatry 31(2):123–130. CrossRefPubMedGoogle Scholar
  38. 38.
    Ravitz P, Maunder R, Hunter J, Sthankiya B, Lancee W (2010) Adult attachment measures: a 25-year review. J Psychosom Res 69(4):419–432. CrossRefPubMedGoogle Scholar
  39. 39.
    Büssing A, Ostermann T, Koenig HG (2007) Relevance of religion and spirituality in German patients with chronic diseases. Int J Psychiatry Med 37(1):39–57. CrossRefPubMedGoogle Scholar
  40. 40.
    Büssing A, Janko A, Baumann K, Hvidt NC, Kopf A (2013) Spiritual needs among patients with chronic pain diseases and cancer living in a secular society. Pain Med 14(9):1362–1373. CrossRefPubMedGoogle Scholar
  41. 41.
    Mikulincer M, Shaver PR (2007) Boosting attachment security to promote mental health, prosocial values, and inter-group tolerance. Psychol Inq 18(3):139–156. CrossRefGoogle Scholar
  42. 42.
    Maunder RG, Hunter JJ (2016) Can patients be ‘attached’ to healthcare providers? An observational study to measure attachment phenomena in patient–provider relationships. BMJ Open 6(5):e011068. CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    LeMay K, Wilson KG (2008) Treatment of existential distress in life threatening illness: a review of manualized interventions. Clin Psychol Rev 28(3):472–493. CrossRefPubMedGoogle Scholar
  44. 44.
    Schulz-Kindermann F, Vehling S (2017) Sinnbasierte Interventionen bei fortgeschritten erkrankten Patienten. Onkologe 23(12):1011–1015. CrossRefGoogle Scholar
  45. 45.
    Hales S, Lo C, Rodin G (2010) Managing Cancer and Living Meaningfully (CALM): treatment manual: an individual psychotherapy for patients with advanced cancer. Psychosocial Oncology and Palliative Care. Princess Margaret Hospital, University Health Network, TorontoGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Medical PsychologyUniversity Medical Center Hamburg-EppendorfHamburgGermany
  2. 2.Department of Medical Psychology and Medical SociologyUniversity Medical Center LeipzigLeipzigGermany

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