A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research
Introduction
Attachment theory conceptualises ‘the propensity of human beings to make strong affectional bonds to particular others … and the many forms of emotional distress and personality disturbance…… to which unwilling separation and loss give rise’ (Bowlby, 1977, p. 201). Although attachment theory has had a significant impact on theories and research concerning the nature of human relationships (Cassidy, 1999), there is limited research investigating its relevance to psychosis (Dozier, Stovall, & Albus, 1999). This is surprising as interpersonal difficulties are one of the hallmarks of the diagnosis and are associated with a significant degree of psychological distress (Penn et al., 2004).
The primary aims of this review are to assess the contribution that attachment theory can make to the understanding and treatment of psychosis, and identify questions for further research. In order to provide a context for the main body of the review, we will begin by summarising the key concepts of Bowlby's theory and different models and measures of adult attachment. Next, we will describe current theories of the role of psychosocial factors in psychosis (see reviews by Bentall et al., 2001, Garety and Freeman, 1999, Penn et al., 1997), assess the extent to which attachment theory can enhance theoretical developments, summarise the existing literature investigating attachment styles and psychosocial factors in psychosis, and recommend future research. We will conclude by discussing the clinical implications of attachment theory, as well as highlighting the conceptual and methodological limitations that will need to be addressed in applying the theory to the study of psychosis.
The review incorporates studies involving samples with psychosis or other forms of severe and enduring mental health problems that were found from a search of the PsycInfo database for the years 1985 to 2004, entering the term ‘attachment’. Articles that were cited in these studies in relation to the topics of attachment and psychosis were then followed up from reference lists, and expert sources in attachment theory and interpersonal theories of psychosis were consulted. We also included selected studies identified by the search terms ‘parental bonding’ and ‘schizophrenia’, in order to highlight the main findings of investigations of retrospective memories of parental bonding in this group. Our review extends previous reviews of the relevance of attachment theory to adult mental health (Dozier et al., 1999, Goodwin, 2003, Platts et al., 2002) by focusing specifically on the understanding of psychosis and psychotic symptoms.
Section snippets
Definition of attachment
Attachment is defined as a type of affectional bond, which the individual forms with a specific person, who is approached in times of distress. The bond is conceptualised as persistent and emotionally significant, is associated with a desire for close proximity to the attachment figure and results in distress following involuntary separation (Bowlby, 1973, Bowlby, 1980, Bowlby, 1982). The attachment relationship is hypothesised to provide a ‘secure base’, which enables the individual to engage
Attachment theory and psychosocial models of psychosis
Attachment theory provides a framework for conceptualising the role of social cognition, interpersonal experiences and regulation of affect in the development of both interpersonal functioning and psychological distress (Mallinckrodt, 2000). Psychosocial models of psychosis highlight the importance of negative beliefs about the self and the social world in terms of both vulnerability and maintenance (Penn et al., 1997). According to these models, past interpersonal relationships and traumas are
Overview of studies investigating attachment in psychosis
The majority of the existing studies investigating attachment styles in psychosis have been carried out by Dozier and colleagues. This group of authors have investigated attachment states of mind in schizophrenia and other forms of severe mental health problems, including schizoaffective disorder, bipolar disorder and major depression. These studies all used the AAI and Kobak's (in press) Q-sort method of classifying responses to assess degree of attachment security, and the individual's use of
The nature of attachment representation in psychosis
A pre-requisite condition to establishing the relevance of attachment theory to the study of psychosis, is evidence of high levels of insecure attachment in individuals with the diagnosis. Three of Dozier and colleagues' studies have compared the nature of attachment representations in psychiatric and control samples, or in different diagnostic subgroups. Two studies found significantly higher levels of attachment insecurity in the psychiatric group, and individuals with a diagnosis of
Attachment style and social cognitive models of psychosis
Cognitive models of psychosis emphasise the importance of self and other schemata, which involve negative beliefs about the self and how one can expect to be treated by others, in the development and maintenance of psychosis. These theories propose that childhood adversities, particularly those associated with close interpersonal relationships; or significant later interpersonal traumas lead individuals to develop beliefs about themselves as being vulnerable and others as being a source of
How can attachment theory inform the understanding of specific symptoms in psychosis?
We next consider how attachment theory can help inform our understanding of mechanisms underlying specific symptoms associated with psychosis, including: paranoia; voice hearing; and negative symptoms.
Trower and Chadwick (1995) propose a distinction between ‘poor me’ paranoia, which is associated with a belief that persecution is undeserved and is related to high self-esteem, and ‘bad me’ paranoia, which is associated with a belief that persecution is deserved and is related to low self-esteem.
Clinical implications
In a population where a significant proportion of patients are difficult to engage (Frank & Gunderson, 1990), attachment theory has considerable potential relevance for clinical work with individuals with psychosis, adding to our understanding of how interpersonal styles might impede engagement with services and therapies (Slade, 1999). Moreover, attachment theory generates hypotheses about the types of therapeutic interactions that would modify attachment styles or maximise the potential for
Conceptual issues
It has been argued that attachment theory is useful in increasing our understanding of the development and course of psychosis and specific symptoms associated with diagnosis. However, further research is needed to address a number of conceptual issues that relate to both attachment theory in general, and the role of attachment styles in psychosis. There is a lack of clarity about how flexible working models are and under what conditions they change, including the role that attachment style
Methodological limitations
Existing studies investigating attachment theory and attachment styles in psychosis in particular have methodological limitations which need to be addressed through future research. The majority of studies carried out by Dozier and colleagues have sampled individuals with a range of different diagnoses, often with a relatively small proportion of individuals with a diagnosis of psychosis, and the extent to which different samples reported overlap is not clear. The authors' findings therefore
Conclusions
This review has argued that attachment theory has the potential to provide a useful theoretical framework for conceptualising the influence of social cognitive, interpersonal and affective factors on the development and course of psychosis, thus integrating and enhancing current psychological models. Moreover, insights derived from attachment theory have significant clinical implications, in terms of informing both psychological formulations and interventions with individuals with specific
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