Attachment Issues in Attachment Issues in Clinical Practice: Issues for Clinical Practice: Issues for

Research Research Dr Ken MaDr Ken Ma

Consultant Child and Adolescent Psychiatrist Consultant Child and Adolescent Psychiatrist Coventry CAMHSCoventry CAMHS

Coventry and Warwickshire Partnership TrustCoventry and Warwickshire Partnership Trust

Outline of PresentationOutline of Presentation

Brief overview of attachment theoryBrief overview of attachment theory Assessment of attachmentAssessment of attachment Why attachment may be important as a clinical Why attachment may be important as a clinical

research variableresearch variable Why attachment may be important as a Why attachment may be important as a

sociological/ political research variablesociological/ political research variable Attachment in clinical research - some Attachment in clinical research - some

findingsfindings

John Bowlby (1907-1990)John Bowlby (1907-1990)

What is Attachment Theory? (1)What is Attachment Theory? (1) Conceived by Bowlby to explain an important Conceived by Bowlby to explain an important

evolutionary function of the child-caregiver relationship.evolutionary function of the child-caregiver relationship. Gene survival promoted by selection of Gene survival promoted by selection of attachment attachment

behavioursbehaviours leading to increased child-caregiver leading to increased child-caregiver proximityproximity..

When a child is When a child is attachedattached to someone, he or she is:to someone, he or she is:

……strongly disposed to seek proximity to and contact strongly disposed to seek proximity to and contact with a specific figure and to do so in certain situations, with a specific figure and to do so in certain situations, notably when he is frightened, tired or ill.notably when he is frightened, tired or ill.

Bowlby, Bowlby, Attachment and Loss, Vol.1 AttachmentAttachment and Loss, Vol.1 Attachment , 1969, p.371, 1969, p.371

What is Attachment Theory? (2)What is Attachment Theory? (2)

The attachment figure thus acts as a The attachment figure thus acts as a ‘secure base’‘secure base’ for for the child, especially in times of stress.the child, especially in times of stress.

The child can thus successfully explore outside world The child can thus successfully explore outside world implications for social, emotional and cognitive implications for social, emotional and cognitive development.development.

Attachment in AdulthoodAttachment in Adulthood

Now generally agreed the Now generally agreed the attachment systemattachment system is operative is operative throughout lifespan. throughout lifespan.

Attachment behaviours change.Attachment behaviours change. Physical proximity important in childhood.Physical proximity important in childhood. As child grows, availability/ trustworthiness of As child grows, availability/ trustworthiness of

attachment figures becomes internalised psychologically attachment figures becomes internalised psychologically cognitive-emotional representations. cognitive-emotional representations.

Internal working models (IWMs)Internal working models (IWMs) of self and attachment of self and attachment figures develop. figures develop.

Different ways of measuring attachment in childhood and Different ways of measuring attachment in childhood and adulthood.adulthood.

Measuring Attachment in Infancy - Measuring Attachment in Infancy - the Strange Situation Procedure the Strange Situation Procedure

Ainsworth Ainsworth et al. et al. (1978)(1978)

Mary Ainsworth Mary Ainsworth

(1913-1993)(1913-1993)

The Strange SituationThe Strange Situation

Laboratory session lasting 20 minutes with 12-Laboratory session lasting 20 minutes with 12-mth-old infant, caregiver and experimenter.mth-old infant, caregiver and experimenter.

Responses of infant to separation from Responses of infant to separation from caregiver (moderate stress) and reunion with caregiver (moderate stress) and reunion with caregiver are assessed.caregiver are assessed.

Four broad categories are observed.Four broad categories are observed. Role of temperament/ genetic influences?Role of temperament/ genetic influences?

SS ClassificationSS ClassificationInfant attachment Infant attachment categorycategory

Observations of Observations of infant in SSinfant in SS

Putative Putative caregiver stylecaregiver style

Secure (B)Secure (B)

(Organised) (Organised)

Protests when caregiver Protests when caregiver disappears. Protest continues disappears. Protest continues on return, but soon pacified on return, but soon pacified and resumes exploratory play. and resumes exploratory play.

Secure.Secure.

Consistent.Consistent.

Responsive. Responsive.

Avoidant (A)Avoidant (A)

(Organised) (Organised)

Little protest on separation. Little protest on separation. On caregiver’s return, hovers On caregiver’s return, hovers warily by, inhibited play. warily by, inhibited play.

Broadly rejecting.Broadly rejecting.

Ambivalent (C)Ambivalent (C)

(Organised) (Organised)

Protests, and hard to pacify on Protests, and hard to pacify on caregiver’s return. Clings, caregiver’s return. Clings, buries head in lap, pushes buries head in lap, pushes away toys offered. away toys offered.

Inconsistent.Inconsistent.

Disorganised (D)Disorganised (D) Freezes on separation, seems Freezes on separation, seems unable to sustain any organised unable to sustain any organised pattern of behaviour on return. pattern of behaviour on return. Behaviours may appear Behaviours may appear bizarre, stereotyped, ‘autistic’. bizarre, stereotyped, ‘autistic’.

Unresolved loss and trauma in Unresolved loss and trauma in caregiver. caregiver.

““Frightened and frightening”.Frightened and frightening”.

Measuring Attachment in AdulthoodMeasuring Attachment in Adulthood The Parenting Tradition vs. the Romantic The Parenting Tradition vs. the Romantic

Attachment TraditionAttachment Tradition(after Bartholomew & Shaver, 1998)(after Bartholomew & Shaver, 1998)

Parenting TraditionParenting Tradition Romantic Attachment Romantic Attachment TraditionTradition

OrientationOrientation Psychodynamic focus on clinical Psychodynamic focus on clinical problems. problems.

Social/ personality psychology. Social/ personality psychology.

Preferred Preferred method of method of assessmentassessment

Interviews and behavioural Interviews and behavioural measures in small groups of measures in small groups of participants.participants.

Simpler (incl. self-rated) Simpler (incl. self-rated) questionnaires in larger questionnaires in larger populations.populations.

Also interview measures. Also interview measures.

FocusFocus Caregiver-child relationships.Caregiver-child relationships.

State of mind State of mind with respect to with respect to attachment. attachment.

Close social/ romantic Close social/ romantic relationships (friendships, relationships (friendships, dating relationships, marriage). dating relationships, marriage).

Age groupsAge groups Across the lifespan. Across the lifespan. Initially in young adults, now Initially in young adults, now extending at least into extending at least into adolescence. adolescence.

Examples of Examples of measuresmeasures

The SSThe SS

Adult Attachment Interview Adult Attachment Interview (AAI)(AAI)

Kobak’s Q-Sort Kobak’s Q-Sort

ASQ (Hazan & Shaver, 1988)ASQ (Hazan & Shaver, 1988)

RSQ (Griffin & Bartholomew, 1994)RSQ (Griffin & Bartholomew, 1994)

ECR-R (Fraley, Waller & Brennan, ECR-R (Fraley, Waller & Brennan, 2000)2000)

IPPA (Armsden & Greenberg, 1987) IPPA (Armsden & Greenberg, 1987)

The Adult Attachment Interview The Adult Attachment Interview (Main & Goldwyn, 1998)(Main & Goldwyn, 1998)

Semi-structured interview about early attachment history.Semi-structured interview about early attachment history. Measures adolescent’s / adult’s state of mind with respect to Measures adolescent’s / adult’s state of mind with respect to

attachment, e.g. current representations of childhood attachment, e.g. current representations of childhood relationships with caregivers.relationships with caregivers.

Questions designed to ‘surprise the unconscious’.Questions designed to ‘surprise the unconscious’. Focus on both Focus on both content content and and discourse discourse style.style. Both categorical and continuous data.Both categorical and continuous data. Four categories similar to those in SS.Four categories similar to those in SS. Very detailed (!) coding manual.Very detailed (!) coding manual. High correspondence between adult’s AAI category and High correspondence between adult’s AAI category and

infant’s subsequent category infant’s subsequent category validity. validity.

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

AAI categoryAAI category Corresponding SS Corresponding SS categorycategory

Typical discourse styleTypical discourse style

Secure Secure autonomous (F)autonomous (F)

Secure (B) Secure (B) Narrative coherence. Valuing of Narrative coherence. Valuing of attachment but objectivity evident. attachment but objectivity evident. Able to give examples to support Able to give examples to support statements.statements.

Dismissing (Ds)Dismissing (Ds) Avoidant (A) Avoidant (A) Brief discourse, can be idealising. Brief discourse, can be idealising. Few supporting examples. Few supporting examples.

Preoccupied (E)Preoccupied (E) Ambivalent (C) Ambivalent (C) Incoherent, vague and rambling. Incoherent, vague and rambling. Preoccupied with past experiences. Preoccupied with past experiences. Speaker can appear angry, passive or Speaker can appear angry, passive or fearful. fearful.

Unresolved-Unresolved-disorganised (U)disorganised (U)

Disorganised (D) Disorganised (D) Striking lapses in monitoring of Striking lapses in monitoring of reasoning during discussion of loss reasoning during discussion of loss or abuse.or abuse.

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

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

The Relationship Scales Questionnaire The Relationship Scales Questionnaire (RSQ) –(RSQ) –

An Example of a Romantic Attachment An Example of a Romantic Attachment Tradition questionnaireTradition questionnaire

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

The RSQThe RSQ

30 descriptive items. Self-rated/ other-rated.30 descriptive items. Self-rated/ other-rated. Interviewees score each item on scale of 1-5 to show Interviewees score each item on scale of 1-5 to show

level of agreement.level of agreement. Examples:Examples:

I find it difficult to depend on other people.I find it difficult to depend on other people. I’m not sure that I can always depend on others to be there I’m not sure that I can always depend on others to be there

when I need them.when I need them. I worry that others don’t value me as much as I value them.I worry that others don’t value me as much as I value them. I often worry that romantic partners won’t want to stay I often worry that romantic partners won’t want to stay

with me.with me.

Bartholomew’s four-category modelBartholomew’s four-category model - as assessed using RQ/RSQ- as assessed using RQ/RSQ

Positive IWM of Positive IWM of

SelfSelf (low (low dependence)dependence)

Negative IWM of Negative IWM of SelfSelf (high (high

dependence)dependence)

Positive IWM of Positive IWM of OthersOthers (low (low avoidance)avoidance)

SecureSecureComfortable with Comfortable with

intimacy and autonomyintimacy and autonomy

PreoccupiedPreoccupiedPreoccupied with Preoccupied with relationships, high relationships, high

emotional reactivityemotional reactivity

Negative IWM of Negative IWM of Others Others (high (high avoidance)avoidance)

DismissingDismissingDismissive of Dismissive of

attachment; counter-attachment; counter-dependentdependent

FearfulFearful

Afraid of intimacy and Afraid of intimacy and rejection; believes self to rejection; believes self to be worthy of rejection; be worthy of rejection;

high emotional reactivityhigh emotional reactivity

AAI versus Self-Report MeasuresAAI versus Self-Report Measures

AAIAAI Self-report measuresSelf-report measures

AdvantagesAdvantages Regarded as ‘gold Regarded as ‘gold standard’ by many.standard’ by many.

Able to tap into Able to tap into unconscious.unconscious.

Construct validity Construct validity unquestioned. unquestioned.

Quick, easy to Quick, easy to administer.administer.

Can be used in large-Can be used in large-scale research.scale research.

DisadvantagesDisadvantages Long. Long.

Impractical to use in Impractical to use in clinical settings/ large-clinical settings/ large-scale research.scale research.

Extensive and expensive Extensive and expensive training required.training required.

Construct validity Construct validity questioned by those on questioned by those on the ‘other side’ the ‘other side’

really measuring really measuring attachment?attachment?

Attachment in Clinical ResearchAttachment in Clinical Research - The ‘Why Measure It?’ Question - The ‘Why Measure It?’ Question

Better understanding of aetiology of psychopathologyBetter understanding of aetiology of psychopathology Attachment insecurity may be a (significant) Attachment insecurity may be a (significant) risk factorrisk factor for for

psychopathology, in both childhood and adulthood.psychopathology, in both childhood and adulthood. Attachment security may be a Attachment security may be a resilience factorresilience factor in adversity.in adversity.

Attachment system likely to be activated in times of stress, e,g. Attachment system likely to be activated in times of stress, e,g. psychiatric/ physical disorderpsychiatric/ physical disorder Attachment pattern may predict pattern of Attachment pattern may predict pattern of help-seekinghelp-seeking, ,

healthcare utilisation and healthcare utilisation and compliancecompliance.. It may also influence the therapeutic alliance or It may also influence the therapeutic alliance or patient-patient-

clinician relationshipclinician relationship in ways that will help/ hinder in ways that will help/ hinder treatment (process research).treatment (process research).

Attachment pattern of clinicianAttachment pattern of clinician may similarly be important. may similarly be important. However, attachment is not the be-all and end-all!However, attachment is not the be-all and end-all!

Attachment in Sociological/ Political Attachment in Sociological/ Political Research Research

- Systemic Influences on the Healthcare - Systemic Influences on the Healthcare SystemSystem

Wider systemic issues.Wider systemic issues. Healthcare utilisation and expenditure - e.g. Healthcare utilisation and expenditure - e.g.

‘heartsink patients’.‘heartsink patients’. Attachment Attachment may may predict political leaning (e.g. predict political leaning (e.g.

Ds and neo-fascism). Ds and neo-fascism). Attachment security of policy makers?Attachment security of policy makers?

Attachment in Clinical Research Attachment in Clinical Research - Some Findings- Some Findings

Attachment and Psychopathology - Attachment and Psychopathology - Some General PointsSome General Points

Majority of studies thus far cross-sectional.Majority of studies thus far cross-sectional. Poor diagnostic clarity.Poor diagnostic clarity. Different measures used make studies difficult to Different measures used make studies difficult to

compare compare one explanation for contradictory results. one explanation for contradictory results. Questions of causality on the whole not answered as yet.Questions of causality on the whole not answered as yet. Relative balance of genetic and social/ environmental Relative balance of genetic and social/ environmental

factorsfactors Postulated association between ‘maximising’ attachment Postulated association between ‘maximising’ attachment

strategies and “internalising” psychopathology, and strategies and “internalising” psychopathology, and between ‘minimising’ attachment strategies and between ‘minimising’ attachment strategies and “externalising” psychopathology.“externalising” psychopathology.

DepressionDepression

Association with preoccupied/ unresolved Association with preoccupied/ unresolved strategies (Fonagy strategies (Fonagy et al.et al.,, 1996 - n=82 pts, 85 1996 - n=82 pts, 85 controls; Cole-Detke & Kobak, 1996)controls; Cole-Detke & Kobak, 1996)

Association with preoccupied/ fearful Association with preoccupied/ fearful attachment (Carnelly attachment (Carnelly et al.et al., 1994; Haaga , 1994; Haaga et al.et al., , 2002; Reis & Grenyer, 2004) all using self-2002; Reis & Grenyer, 2004) all using self-report measures.report measures.

AnxietyAnxiety

Association with anxious-ambivalent Association with anxious-ambivalent attachment longitudinally (Warren attachment longitudinally (Warren et al.et al., , 1997) and with preoccupied/ unresolved 1997) and with preoccupied/ unresolved attachment cross-sectionally (Fonagy attachment cross-sectionally (Fonagy et alet al., ., 1996)1996)

Twaite & Rodriguez (2004) - attachment Twaite & Rodriguez (2004) - attachment partially mediated link between childhood partially mediated link between childhood abuse and PTSD following 9/11 (self-report abuse and PTSD following 9/11 (self-report measure).measure).

Borderline Personality DisorderBorderline Personality Disorder

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

Patterns of Help-SeekingPatterns of Help-Seeking

Ciechanowski Ciechanowski et al. et al. (2002) (2002) N =701 adult female primary care HMO pts.N =701 adult female primary care HMO pts. RSQ.RSQ. Preoccupied and fearful patients reported more Preoccupied and fearful patients reported more

physical symptoms, but no differences physical symptoms, but no differences between groups in medical co morbidity.between groups in medical co morbidity.

Patients with preoccupied attachment had the Patients with preoccupied attachment had the highest primary care costs and utilisation.highest primary care costs and utilisation.

Those with fearful attachment had the lowest.Those with fearful attachment had the lowest.

Compliance with TreatmentCompliance with Treatment

Ciechanowski Ciechanowski et al. et al. 2000 2000 276 tertiary care type I diabetes patients.276 tertiary care type I diabetes patients. RSQ.RSQ. Dismissing attachment associated with significantly Dismissing attachment associated with significantly

higher HbA1c.higher HbA1c.

Dozier Dozier et alet al., 1990., 1990 Those patients with insecure attachment less Those patients with insecure attachment less

compliant with psychotropic medication.compliant with psychotropic medication.

Healthcare Staff as Attachment FiguresHealthcare Staff as Attachment Figures

Can staff act as attachment figures for vulnerable Can staff act as attachment figures for vulnerable clients whose attachment system is activated?clients whose attachment system is activated?

If so, what are the implications?If so, what are the implications? Compliance with management.Compliance with management. Formation of therapeutic alliance - especially with Formation of therapeutic alliance - especially with

patients with dismissing attachment strategies.patients with dismissing attachment strategies. How to assess attachment to staff/ services?How to assess attachment to staff/ services?

Goodwin’s Service Attachment Questionnaire Goodwin’s Service Attachment Questionnaire (Goodwin (Goodwin et al.et al., 2003)., 2003).

What about the attachment What about the attachment strategies of healthcare staff?strategies of healthcare staff?

Attachment Strategies of Healthcare StaffAttachment Strategies of Healthcare Staff

Healthcare is a stressful preoccupation!Healthcare is a stressful preoccupation! Dozier Dozier et al. et al. (1994) (1994)

18 psychiatric case managers - those with 18 psychiatric case managers - those with preoccupied attachment may intervene more preoccupied attachment may intervene more actively with clients actively with clients ?dominance of counter ?dominance of counter transference issues.transference issues.

What are the implications?What are the implications? Relevance for supervision?Relevance for supervision? Influence on outcome of treatment?Influence on outcome of treatment? Implications for managersImplications for managers

Conclusions and ImplicationsConclusions and Implications

Which measure is used depends on what one is Which measure is used depends on what one is trying to measure.trying to measure.

There are a number of areas where the There are a number of areas where the consideration of attachment might provide consideration of attachment might provide fresh, valuable insight.fresh, valuable insight.

Please consider self-report measures!Please consider self-report measures!

THANK YOU!THANK YOU!

Cassidy, J. & Shaver, P. (eds) (1999) Cassidy, J. & Shaver, P. (eds) (1999) Handbook of Attachment: Handbook of Attachment: Theory, Research and Clinical Implications. Theory, Research and Clinical Implications. New York: New York: Guilford.Guilford.

Ma, K. (2007) Attachment theory in adult psychiatry. Part 2: Ma, K. (2007) Attachment theory in adult psychiatry. Part 2: Importance to the therapeutic relationship. Importance to the therapeutic relationship. Advances in Advances in Psychiatric TreatmentPsychiatric Treatment, , 1313, 10-16., 10-16.

Ma, K. (2006) Attachment theory in adult psychiatry. Part 1: Ma, K. (2006) Attachment theory in adult psychiatry. Part 1: Conceptualisations, measurement and clinical research Conceptualisations, measurement and clinical research findings. findings. Advances in Psychiatric TreatmentAdvances in Psychiatric Treatment, , 1212, 440-9., 440-9.