Measuring Attachment and Parental Bonding in Psychosis and its Clinical Implications, 2014

Link: doi: 10.1017/S2045796014000730

Authors: Mathews, S., Onwumere, J., Bissoli, S., Ruggeri, M., Kuipers, E. & Valmaggia, L.

Quotes and Thoughts:

“A secure attachment style is associated with a capacity to manage distress, comfort with autonomy and the ability to form relationships with others, whereas insecure attachment can lead to dysfunctional relationships, emotional and behaviour avoidance.”

—So basically secure attachment is one form of strengthening resiliency. Nice!

“Conversely, if the caregiver is perceived as unavailable, unresponsive and insensitive to proximity-seeking attempts, an individual will either make use of hyperactivating strategies (e.g., eliciting care from an attachment partner through clinging and controlling responses) which can lead to the development of an insecure–ambivalent attachment style or deactivating strategies (e.g., distancing oneself from an attachment partner to handle a stressful situation alone) that can lead to the development of an insecure–avoidant attachment style (Shaver & Mikulincer, 2002; Mikulincer & Shaver, 2007). A fourth disorganised attachment style is said to reflect individuals who make use of both hyperactivating and deactivating strategies which is thought to represent fearful interactions with caregivers (Main & Solomon, 1986; 1990).”

—I like the terms “hyperactivating” and “deactivating” strategies. I feel like they offer more information on the purpose of the action. Sometimes I’m frustrated by terminology used in theoretical models because I just want clarity, not jargon. These two terms seem very helpful in that they feel like they offer info in a clear way to me.

“Although secure and insecure attachment strategies are functional in their developmental context (Fraley, 2002), difficulties in caregiver bonding and attachment-related adverse childhood experiences (e.g., trauma or loss) have been linked to increased risk of later psychopathology in clinical groups (Greenberg, 1999; Morgan & Fisher, 2007; Read et al. 2009; Read & Gumley, 2010).”

“Two recent comprehensive systematic reviews of the attachment and psychosis literature (Gumley et al. 2014; Korver-Nieberg et al. 2014) have pointed towards the importance of understanding the influence that attachment styles may play in the aetiology, trajectory and recovery of psychosis.”

—I so appreciate that they are talking about recovery from altered states here too. Looking at what influences an experience is important but keeping in mind ways to make sure it’s helpful to the person is key.

“They found small to moderate associations between attachment styles and outcomes, including positive and negative symptoms, depression and quality of life; and suggested that an insecure–avoidant attachment style may be a risk factor for problematic recovery following psychosis. Furthermore, they found that both insecure–anxious and insecure–avoidant attachment styles are associated with psychotic phenomenology and with an indication that insecurely attached individuals are more vulnerable to developing maladaptive coping strategies in relation to their recovery from psychosis (Gumley et al. 2014; Korver-Nieberg et al. 2014).”

—Again coping and resiliency linked here with successful outcomes.

“Parker et al. identified four quadrants with different attachment styles and demonstrated that the ‘affectionless control’ style (characterised by low care and high protection) was overexpressed in psychotic participants.”

—I’m interested to get more into the definition of “affectionless control” because I’m curious of whether the phrasing tends to blame parents as was the case in the past. There are so many things that can interfere with caregiver connection so hopefully they include more than just a character assination of the parent.

“Their findings suggested that patients with insecure attachment styles when compared with patients with secure attachments had a significantly earlier age of psychosis onset and longer admissions (Ponizovsky et al. 2007).”

—Interesting.

“The results suggested that patients with psychosis were more likely to rate both parents as being less caring and fathers as being more overprotective. Furthermore, patients who rated both parents as being low caring and overprotective also tended to have an earlier age of initial hospitalisation for psychosis and at nine months following discharge, were also more likely to be readmitted (Parker et al. 1982). These findings were also replicated in study, which assessed 62 patients with a diagnosis of schizophrenia using the PBI. The results indicated that the patients who perceived their parents positively tended to experience fewer relapses (Warner & Atkinson, 1988).”

—I would note these are client perceptions. I would be so curious to see the same test administered after several years of family work. Not that I’m doubting the persons initial report I just often find that our recollection can sometimes initially focus on the hurtful memories and after working through some the recollection is often more positive. Not at all trying to discount either. Havign both to compare to is wonderful info to discuss with the person and family.

“Results also indicated that first episode psychosis service users reported higher levels of attachment anxiety, discomfort with closeness and a greater need for approval in peer relations compared with controls.

“Patients who were more reliant on hyperactivating strategies reported more psychotic symptoms than those using deactivating strategies. However, they found that patients with dismissing attachment styles, who made use of deactivating strategies, experienced more delusions, hallucinations and suspiciousness, and were rated by case workers as presenting as ‘more psychotic’ (Dozier & Lee, 1995).”

“Scores on the two attachments dimensions varied depending on the type of relationship and the authors concluded that factors that influence variability in attachment relationships should be considered in treatment plans as it may be possible to support individuals with insecure attachment styles to develop more positive relationships with others (Berry et al. 2007b).”

—A main goal of therapy if I’m not mistaken. Seems odd to me that they had to say “it may be possible.” Of course it’s possible.

“They found that higher levels of attachment anxiety and attachment avoidance predicted both symptom severity and difficulties in therapeutic relationships (Berry et al. 2006).”

—Super interesting. I’d be curious about a study that looked at different styles of therapist personality for impact on fit with the client experiencing different attachment styles.

“In a sample of 36 patients with schizophrenia or schizoaffective disorders compared with their siblings, Willinger et al. (2002) found that patients had a greater tendency to describe their mothers as being less caring and more overprotective towards them compared with descriptions from their healthy siblings.

—I definitely flinch a little with mothers being identified as the blamed object. There has been so much blame put on families and especially mothers in the history of research on altered states. I’m not saying that there aren’t times where mothers have harmed children, I’m just noting that there are also so many other factors to be aware of too. Also I flinch at the term “healthy siblings.” Yuck.

“Interestingly, a study examining 12 monozygotic and 19 same-sex zygotic twin pairs discordant for DSM-III-R schizophrenia found that patients reported higher levels of parental overprotection than their probands, raising the question of whether the differences in parental bonding could be explained by the presence of a psychotic disorder (Onstad et al. 1994).”

—Super interesting! I had to look up “proband” [“a person serving as the starting point for the genetic study of a family (used especially in medicine and psychiatry).” Thanks Google!]. This is a common comment from parents. That they had to respond differently to one child as opposed to the others due to the identified patients experiences of altered states. This would be a very cool topic for a dissertation.

“More specifically it has been suggested that the attachment experience of individuals with psychosis is an important construct for understanding how social information is processed and how mentalisation skills are developed within this population (Korver-Nieberg et al. 2014). Gumley's systematic review of attachment and psychosis found that individuals with psychosis who had a secure attachment had better engagement and greater treatment adherence, whereas insecure attachment was found to be related to disengagement with treatment services and avoidant attachment was related to help-seeking difficulties, poorer use of treatment, longer hospital admissions and lower-rated therapeutic alliance. Their findings also suggested that the attachment system is activated in the relationships that individuals develop with their service providers and as such, highlight attachment theory as a useful framework in which to consider recovery within individuals with psychosis. These authors further note the importance of services being aware of how these systems may be activated within individuals as a means to provide ‘an attuned response to the needs of individuals’ and establish ‘a safe haven and secure base for recovery’ (Gumley et al. 2014).”

“The studies reviewed in this paper suggest that insecure attachment representations are evident at different illness phases including during the at-risk mental state (Couture et al. 2007; Gajwani et al. 2013). They are linked to a poorer quality of interpersonal relationships and less integrated recovery styles (Berry et al. 2007b; Gumley et al. 2014). Thus, insecure attachment styles may serve as a vulnerability factor for both the development and persistence of psychosis. Recent data from at-risk psychosis populations (e.g., O'Brien et al. 2006; Tienari et al. 2004; McFarlane & Cook, 2007) attests to the important role played by family relationships in the expression and course of psychosis symptomatology. However, as most attachment studies are cross-sectional, it is equally possible that having a more severe course of illness can render individuals more likely to develop and/or recall difficulties in attachment relationships.”

—Well put.

“In conclusion, reports of caregiver attachment difficulties may play an important role in the development of psychosis. The narrative review speaks to the importance of greater attention being given to the assessment and understanding of attachment needs and difficulties that are experienced and reported during the early years, and it emphasises the need to develop interventions that seek to compensate for these difficulties. Secure attachment may confer advantages in facilitating how individuals make sense of their experiences and their readiness to engage with therapeutic interventions and seek help. In contrast, individuals presenting with insecure attachment representations may find the reciprocal process of engagement with clinicians threatening or overwhelming, and consequently may disengage from services to regulate affect. An understanding of attachment representations may therefore be relevant to understanding differences in recovery trajectories in the first few years after treatment for psychosis is initiated, particularly in understanding the role help seeking may play in accelerating or forestalling relapse (Gumley et al. 2010; Onwumere et al. 2011).”

Discussion topics:

Do you feel your own therapy work was very much influenced by your attachment style? By your parents attachment styles to their own parents?

What type of therapist personality (quiet, talkative, stoic, lots of hand movement, etc) do you feel is the best fit for your own individual attachment style? What do you think is your current therapist’s attachment style? Would you feel comfortable talking to them about it?

Look ups:

The Parental Bonding Instrument (PBI, Parker et al. 1979)

“To date only the PAM was developed specifically to measure attachment styles in individuals with psychosis (Berry et al. 2008).”

(Onstad et al. 1994).