Attachment Issues in Clinical Practice: Issues for Research

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Attachment Issues in Clinical Practice Issues
for Research

• Dr Ken Ma
• Consultant Child and Adolescent Psychiatrist
• Coventry CAMHS
• Coventry and Warwickshire Partnership Trust

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Outline of Presentation

• Brief overview of attachment theory
• Assessment of attachment
• Why attachment may be important as a clinical
  research variable
• Why attachment may be important as a
  sociological/ political research variable
• Attachment in clinical research - some findings

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• John Bowlby (1907-1990)

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What is Attachment Theory? (1)

• Conceived by Bowlby to explain an important
  evolutionary function of the child-caregiver
  relationship.
• Gene survival promoted by selection of attachment
  behaviours leading to increased child-caregiver
  proximity.
• When a child is attached to someone, he or she
  is
• strongly disposed to seek proximity to and
  contact with a specific figure and to do so in
  certain situations, notably when he is
  frightened, tired or ill.
• Bowlby, Attachment and Loss, Vol.1
  Attachment, 1969, p.371

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What is Attachment Theory? (2)

• The attachment figure thus acts as a secure
  base for the child, especially in times of
  stress.
• The child can thus successfully explore outside
  world ? implications for social, emotional and
  cognitive development.

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Attachment in Adulthood

• Now generally agreed the attachment system is
  operative throughout lifespan.
• Attachment behaviours change.
• Physical proximity important in childhood.
• As child grows, availability/ trustworthiness of
  attachment figures becomes internalised
  psychologically ? cognitive-emotional
  representations.
• Internal working models (IWMs) of self and
  attachment figures develop.
• Different ways of measuring attachment in
  childhood and adulthood.

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Measuring Attachment in Infancy - the Strange
Situation Procedure

• Ainsworth et al. (1978)
• Mary
  Ainsworth
• (1913-1993)

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The Strange Situation

• Laboratory session lasting 20 minutes with
  12-mth-old infant, caregiver and experimenter.
• Responses of infant to separation from caregiver
  (moderate stress) and reunion with caregiver are
  assessed.
• Four broad categories are observed.
• Role of temperament/ genetic influences?

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SS Classification
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Measuring Attachment in Adulthood The Parenting
Tradition vs. the Romantic Attachment
Tradition(after Bartholomew Shaver, 1998)
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(No Transcript)
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The Adult Attachment Interview (Main Goldwyn,
1998)

• Semi-structured interview about early attachment
  history.
• Measures adolescents / adults state of mind
  with respect to attachment, e.g. current
  representations of childhood relationships with
  caregivers.
• Questions designed to surprise the unconscious.
• Focus on both content and discourse style.
• Both categorical and continuous data.
• Four categories similar to those in SS.
• Very detailed (!) coding manual.
• High correspondence between adults AAI category
  and infants subsequent category ? validity.

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Categories on the AAI (1)
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Categories on the AAI (2)

• Participants with the U classification are also
  assigned one of the other categories that best
  captures underlying attachment strategies, i.e.
  U/F, U/Ds and U/E.

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The Relationship Scales Questionnaire (RSQ) An
Example of a Romantic Attachment Tradition
questionnaire

• Kim Bartholomew
• http//www.sfu.ca/psyc/faculty/bartholomew/

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The RSQ

• 30 descriptive items. Self-rated/ other-rated.
• Interviewees score each item on scale of 1-5 to
  show level of agreement.
• Examples
• I find it difficult to depend on other people.
• Im not sure that I can always depend on others
  to be there when I need them.
• I worry that others dont value me as much as I
  value them.
• I often worry that romantic partners wont want
  to stay with me.

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Bartholomews four-category model - as assessed
using RQ/RSQ
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AAI versus Self-Report Measures
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Attachment in Clinical Research - The Why
Measure It? Question

• Better understanding of aetiology of
  psychopathology
• Attachment insecurity may be a (significant) risk
  factor for psychopathology, in both childhood and
  adulthood.
• Attachment security may be a resilience factor in
  adversity.
• Attachment system likely to be activated in times
  of stress, e,g. psychiatric/ physical disorder
• Attachment pattern may predict pattern of
  help-seeking, healthcare utilisation and
  compliance.
• It may also influence the therapeutic alliance or
  patient-clinician relationship in ways that will
  help/ hinder treatment (process research).
• Attachment pattern of clinician may similarly be
  important.
• However, attachment is not the be-all and end-all!

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Attachment in Sociological/ Political Research -
Systemic Influences on the Healthcare System

• Wider systemic issues.
• Healthcare utilisation and expenditure - e.g.
  heartsink patients.
• Attachment may predict political leaning (e.g. Ds
  and neo-fascism).
• Attachment security of policy makers?

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Attachment in Clinical Research - Some Findings
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Attachment and Psychopathology - Some General
Points

• Majority of studies thus far cross-sectional.
• Poor diagnostic clarity.
• Different measures used make studies difficult to
  compare ? one explanation for contradictory
  results.
• Questions of causality on the whole not answered
  as yet.
• Relative balance of genetic and social/
  environmental factors
• Postulated association between maximising
  attachment strategies and internalising
  psychopathology, and between minimising
  attachment strategies and externalising
  psychopathology.

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Depression

• Association with preoccupied/ unresolved
  strategies (Fonagy et al., 1996 - n82 pts, 85
  controls Cole-Detke Kobak, 1996)
• Association with preoccupied/ fearful attachment
  (Carnelly et al., 1994 Haaga et al., 2002 Reis
  Grenyer, 2004) all using self-report measures.

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Anxiety

• Association with anxious-ambivalent attachment
  longitudinally (Warren et al., 1997) and with
  preoccupied/ unresolved attachment
  cross-sectionally (Fonagy et al., 1996)
• Twaite Rodriguez (2004) - attachment partially
  mediated link between childhood abuse and PTSD
  following 9/11 (self-report measure).

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Borderline Personality Disorder

• High proportion with a U/E classification -
  Fonagy et al., 1996 Barone, 2003.

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Patterns of Help-Seeking

• Ciechanowski et al. (2002)
• N 701 adult female primary care HMO pts.
• RSQ.
• Preoccupied and fearful patients reported more
  physical symptoms, but no differences between
  groups in medical co morbidity.
• Patients with preoccupied attachment had the
  highest primary care costs and utilisation.
• Those with fearful attachment had the lowest.

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Compliance with Treatment

• Ciechanowski et al. 2000
• 276 tertiary care type I diabetes patients.
• RSQ.
• Dismissing attachment associated with
  significantly higher HbA1c.
• Dozier et al., 1990
• Those patients with insecure attachment less
  compliant with psychotropic medication.

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Healthcare Staff as Attachment Figures

• Can staff act as attachment figures for
  vulnerable clients whose attachment system is
  activated?
• If so, what are the implications?
• Compliance with management.
• Formation of therapeutic alliance - especially
  with patients with dismissing attachment
  strategies.
• How to assess attachment to staff/ services?
• Goodwins Service Attachment Questionnaire
  (Goodwin et al., 2003).

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What about the attachment strategies of
healthcare staff?
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Attachment Strategies of Healthcare Staff

• Healthcare is a stressful preoccupation!
• Dozier et al. (1994)
• 18 psychiatric case managers - those with
  preoccupied attachment may intervene more
  actively with clients ? ?dominance of counter
  transference issues.
• What are the implications?
• Relevance for supervision?
• Influence on outcome of treatment?
• Implications for managers

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Conclusions and Implications

• Which measure is used depends on what one is
  trying to measure.
• There are a number of areas where the
  consideration of attachment might provide fresh,
  valuable insight.
• Please consider self-report measures!

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• THANK YOU!

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• Cassidy, J. Shaver, P. (eds) (1999) Handbook
  of Attachment Theory, Research and Clinical
  Implications. New York Guilford.
• Ma, K. (2007) Attachment theory in adult
  psychiatry. Part 2 Importance to the
  therapeutic relationship. Advances in
  Psychiatric Treatment, 13, 10-16.
• Ma, K. (2006) Attachment theory in adult
  psychiatry. Part 1 Conceptualisations,
  measurement and clinical research findings.
  Advances in Psychiatric Treatment, 12, 440-9.