staff attachment styles: a pilot study investigating the influence of adult attachment styles on...

Staff Attachment Styles: A Pilot Study Investigating theInfluence of Adult Attachment Styles on StaffPsychological Mindedness and Therapeutic Relationships

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Katherine Berry, Rakhi Shah, Amy Cook, Ellie Geater,Christine Barrowclough, and Alison WeardenUniversity of Manchester

The attachment styles of psychiatric staff are likely to impact on their

capacity to form positive therapeutic relationships with patients with

psychosis. Twenty staff completed a measure assessing levels of

attachment anxiety and avoidance. Staff and patients completed a

measure of patients’ interpersonal problems and staff completed the

Five-Minute Speech Sample, which was used to derive ratings of

psychological mindedness and therapeutic relationships. Higher staff

avoidance was associated with greater discrepancies in staff and

patient ratings of patients’ interpersonal problems and poorer staff

psychological mindedness. Lower staff anxiety and avoidance were

associated with positive therapeutic relationships. Findings warrant

replication in larger samples, but suggest that staff attachment style

may be important in the development of better quality staff and

patient relationships. & 2008 Wiley Periodicals, Inc. J Clin Psychol 64:

355--363, 2008.

Keywords: psychiatric staff; adult attachment; psychological mind-

edness; therapeutic relationships; psychosis

Introduction

Psychiatric staff play key roles in the lives of people with psychosis. An importantpart of their role involves developing a good understanding of patients’ needs andforming positive therapeutic relationships with individuals who are often difficult toengage (Berghofer, Schmidl, Rudas, Steiner, & Schmitz, 2002). One factor that mightdetermine the capacity of psychiatric staff to understand patients’ needs and formpositive therapeutic relationships is their own attachment style. Research has

We thank all participants who took part in the studies from Greater Manchester NHS trusts.

Correspondence concerning this article should be addressed to: Katherine Berry, School of PsychologicalSciences, University of Manchester, Rutherford House, Manchester Science Park, Lloyd Street North,Manchester, M15 6SZ, UK; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(3), 355–363 (2008) & 2008 Wiley Periodicals, Inc.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10 .1002/ jc lp .20456

suggested that earlier attachment experiences influence social perceptions and thequality of interpersonal relationships in adulthood (Mallinckrodt, 2000). Adultattachment styles can be conceptualized in terms of two dimensions of attachmentanxiety and attachment avoidance, which have been shown to underlie self-reportmeasures of attachment. Attachment anxiety is associated with a negative self-imageand an excessive need for approval from others, coupled with a fear of rejection andabandonment. Attachment avoidance is associated with a negative image of others,social withdrawal, and either an excessive need for self-reliance or a fear ofdepending on others (Brennan, Clark, & Shaver, 1998). Previous studies havedemonstrated associations between attachment insecurity and less sensitive andresponsive care giving in romantic relationships (Simpson, Rholes, & Nelligan,1992), and associations between insecure therapist attachment styles and pooreralliance in counselling relationships (Dunkle & Friedlander, 1996).One possible reason why insecure attachment styles might have a negative impact

on therapeutic relationships is that distortions in social perception associated withincreasingly anxious or avoidant attachment patterns may result in staff failing tounderstand and therefore respond to patients’ interpersonal needs. Previous researchwith patients with psychosis has suggested that staff and patients have differentperceptions of patients’ interpersonal needs (Startup, 1998), and in nonclinicalsamples, there is some evidence to suggest better understanding of partners’attributes predicts satisfaction in romantic relationships (Swann, De La Ronde,& Hixon, 1994). One measure of differences in perceptions is discrepancies in scoreson an interpersonal problem inventory.The ability to understand and know how best to respond to patients’ needs is

likely to be associated with the concept of psychological mindedness. Psychologicalmindedness refers to the person’s ability to recognize associations between thoughts,feelings and actions, and therefore understand the causes of his own and others’behavior (Beitel & Cecero, 2003). Beitel and Cecero (2003) found that insecureattachment styles were associated with poorer psychological mindedness in a sampleof students, but to our knowledge there are no studies investigating associationsbetween attachment style and psychological mindedness in samples of psychiatricstaff.There are different methods of conceptualizing and measuring therapeutic

relationships. High expressed emotion (EE) refers to affective attitudes andbehaviors towards patients characterized by critical comments, hostility, andemotional over-involvement. The construct has traditionally been applied to thestudy of familial relationships, but has also been found to characterize staff andpatient relationships (Van Audenhove & Van Humbeeck, 2003). Conventionally EEis rated from the Camberwell Family Interview (CFI; Leff & Vaughn, 1985), whichcan take up to 2 hours to administer and a similar length of time to rate. Analternative briefer method of rating EE is the Five-Minute Speech Sample (FMSS),which has been shown to have good correlations with the CFI (Magana, Goldstein,Karno, Milkowitz, Jenkins, & Falloon, 1986). Previous research has found a lowfrequency of high EE in dyads of psychiatric staff and patients with psychosis usingthe FMSS (Tattan & Tarrier, 2000). The FMSS rates EE on the basis of a number ofdifferent dimensions, including initial statements (positive, negative, or neutral), theoverall relationship (positive, negative, or neutral), number of critical comments andemotional over-involvement. A broader distribution of patient and staff dyads hasbeen found when relationships are categorized according to the overall quality ofrelationships. There is evidence to suggest that a positive relationship, inferred from

356 Journal of Clinical Psychology, March 2008

Journal of Clinical Psychology DOI: 10.1002/jclp

either direct reports of a positive relationship or expression of interest in the patient,is associated with better outcomes than a neutral or negative relationship (Tattan &Tarrier, 2000). There is evidence that insecure attachments to parents are associatedwith critical or over-involved parenting styles with one’s own children (Diamond &Doane, 1994), but there are no studies investigating the influence of staff attachmentstyles on either EE or the overall quality of staff-patient relationships in people withpsychosis.This preliminary study aims to investigate how staff attachment style is associated

with patient and staff discrepancies in the understanding of interpersonal problems,staff psychological mindedness and therapeutic relationships in a sample of psychiatricstaff and patients with psychosis. We predict associations between high staffattachment anxiety and avoidance and greater discrepancies between staff and patientperceptions of patients’ interpersonal problems. We also predict positive associationsbetween staff attachment anxiety and avoidance and poorer psychological mind-edness. Finally, we predict that low levels of staff attachment anxiety and avoidancewill be associated with better quality of staff and patient relationships.

Method

Participants and Procedure

Twenty staff was recruited from psychiatric services in Greater Manchester and wereall participating in a larger related study investigating patient attachment styles andinterpersonal relationships. Patient inclusion criteria for the larger study were adocumented International Statistical Classification of Diseases and Related HealthProblems, 10th Revision (ICD-10) diagnosis of schizophrenia, schizotypal ordelusional disorder (World Health Organisation, 1992), ability to give informedconsent, English speaking, and having the same mental health worker for at least 3months. Exclusion criteria were a history suggestive of organic disorder and aprimary diagnosis of substance use disorder or mood disorder. Once patientsconsented to participate in the research, their key worker, defined as the mentalhealth professional who had the most frequent contact with them, was asked tocomplete measures of patients’ interpersonal functioning. All staff who wereinterviewed for the larger study over a 6-month period were also asked to complete ameasure of their own attachment style. No staff who were approached about theresearch refused to participate.

Measures

Staff attachment style. Staff attachment was measured using a questionnairespecifically designed for this program of research (Berry, Wearden, Barrowclough,& Liversidge, 2006). Items were derived from existing self-report attachmentmeasures (Brennan et al., 1998), but there were no items referring specifically toromantic relationships. Our measure has advantages over existing attachmentmeasures, as items are rated on simple and anchored, 4-point Likert scales, andunlike the majority of other self-report attachment questionnaires, it is applicable topeople who do not currently have or have not recently had a romantic partner canuse it. The attachment measure has 16 items, with 8 items assessing the construct ofavoidance and 8 items assessing the construct of anxiety, thus permittingcomparisons with previous and future studies. Total scores were calculated foreach dimension by averaging individual item scores, with higher scores reflecting

357Staff Attachment Styles


higher levels of anxiety and avoidance. The measure has been used successfullybefore in nonclinical samples, with evidence of good psychometric properties,including reasonable concurrent validity with an existing attachment questionnaire(Berry et al., 2006; Berry, Band, Corcoran, Barrowclough, & Wearden, 2007).Subscale alphas in the present staff sample were .72 for the anxiety subscale and .75for the avoidance subscale.

Patient interpersonal problems. The 32-item Inventory of Interpersonal Problems(IIP; Barkham, Hardy, & Startup, 1996) was completed by patients. It assesses arange of interpersonal problems, including aggression, poor sociability, andexcessive dependence on others. Staff also completed an informant version of themeasure with parallel items (Startup, 1998). The alpha was .85 for the self-reportversion and .84 for the informant version. The interrater reliability of the informantversion of the measure was established by asking two mental health professionals torate a sample of 10 patients with psychosis (intraclass correlation coefficient5 .77;95% confidence interval5 .33–.95). Patient and staff ratings of interpersonalproblems were only weakly associated (r5 .24, p5 .032). Dissimilarity scoresmeasuring the extent of disagreement between patient and informant ratings forinterpersonal problems were derived by subtracting patient scores from staff scores.

Staff-patient relationships and psychological mindedness. The FMSS (Maganaet al., 1986) involves asking participants to talk about their thoughts and feelingsabout the patient for a 5-minute period. Speech samples are categorized on the basisof initial statements (positive, negative, or neutral), the overall relationship (positive,negative, or neutral), number of critical comments, and emotional over-involvement.All speech samples were audio-taped and overall EE ratings and EE category ratingswere made directly from the recordings by one of the authors (KB). Ten sampleswere independently rated by an experienced EE rater (AW) and the mean interraterreliability between the two raters on each subscale was high (kappa5 .86, po.001).

We also used FMSS transcripts to rate staff psychological mindedness(Barrowclough, Gregg, & Tarrier, 2007). For each problem the staff memberidentified and attempted to explain during the FMSS, we rated to what extent theywere interpreting the problem as the result of psychological difficulties. Eachexplanation was assigned to one of three levels based on how well their causeexplained the problem in psychological terms. A high level of psychologicalmindedness (score 3) was defined as a clear attempt to describe psychologicalprocesses (beliefs or emotions) underlying the patient’s problem (e.g., ‘‘Socialsituations cause Brian lots of anxiety because he often misinterprets what peoplemeany, he tends to think people have got it in for him.’’). Some psychologicalmindedness (score 2) was defined such that most people would judge there to be arelationship between the inferred cause and the patient’s problem, but there is noexplicit reference to psychological processes mediating the link (e.g., ‘‘Elaine getsanxious a lot of time which is often to do with new staff being around or changes inroutine.’’). Little psychological mindedness (score 1) was defined as when a causallink between a cause and the patient’s problem is given or inferred; however, mostpeople would not see the former as a sufficient explanation of the outcome and thereis no attempt to suggest any mediating or extenuating factors (e.g., ‘‘Mavis finds ithard to feel comfortable around other peopleyI don’t think she’s got a lot of insightinto how people relate to her.’’). A mean psychological mindedness score was thenderived for each transcript by averaging psychological mindedness scores forexplanations. To ensure ratings were representative, only transcripts in which staff



attempted to explain at least two problems were included in the analysis.Psychological mindedness was independently rated by two raters (KB & RS) andhigh levels of interrater reliability were obtained (kappa5 .84, po.001). All ratersfor EE and psychological mindedness were blind to staff attachment scores at thetime of rating.

Results

Sample Characteristics

Seventy percent (n5 14) of the staff were women, 75% were nurses (n5 15), and25% were support workers (n5 5). Staff had a mean of 11 (SD5 8.1) years ofexperience in mental health, the median days of contact with patients per month was20 (range5 4–20), and the mean number of months they had known patients was 33(SD5 21.6). There were 26 patients in this study: 61.5% men (n5 16), 80.8%patients with a diagnosis of schizophrenia (n5 21), and 19.2% with a diagnosis ofschizoaffective disorder (n5 5). The mean age of the sample was 49 years(SD5 14.9) and the mean illness duration was 25 years (SD5 13.7).1

Discrepancies in Staff and Patient Ratings of Interpersonal Problems

As predicted, staff attachment avoidance was significantly positively correlated withdiscrepancies in ratings of interpersonal problems (r5 .51, p5 .008). There was noevidence of an association between staff attachment anxiety and discrepancies ininterpersonal problem ratings (r5 .08, p5 .703).

Psychological Mindedness and Staff Attachment Style

As predicted, staff psychological mindedness was negatively correlated with staffattachment avoidance, suggesting that staff who were less psychologically mindedwere more avoidant (r5�.55, p5 .018). On the other hand, there was no significantcorrelation between psychological mindedness and anxiety (r5 .19, p5 .449).

Staff Attachment Style and Therapeutic Relationships

There were no negative initial statements, negative relationships, critical comments,or emotional over-involvement in this subsample of 20 staff who also completed theattachment measure. We therefore examined associations between staff attachmentstyle and staff and patient relationships by comparing staff who were rated as havinga positive relationship with the patient versus those who were rated as having aneutral relationship. Even in this small sample, staff who were rated as having apositive relationship with the patient had significantly lower attachment anxiety thanstaff who were rated as having a neutral relationship with the patient. Groupdifferences for avoidance also approached significance (see Table 1).

1Six staff members completed the IIP and five staff members completed the FMSS for more than one

patient. When data were analyzed including and excluding these staff members’ attachment scores, there

were no differences in significance levels. Nonindependence of the data was not therefore deemed to be a

confounding factor so these attachment scores were retained in the analyses.



Discussion

In summary, the findings of this pilot study suggest that staff avoidance is associatedwith greater discrepancies in staff and patient ratings of patients’ interpersonalproblems and poorer staff psychological mindedness. There was some preliminaryevidence from this pilot to suggest that lower staff anxiety and avoidance areassociated with more positive therapeutic relationships.Previous research suggests that patients and staff have different perceptions of

patients’ interpersonal problems (Startup, 1998). Reasons for discrepant findings arelikely to be multifaceted and in the absence of a gold standard objective measure ofinterpersonal functioning, it is difficult to establish whether it is staff or patientperceptions that are biased. However, the fact that previous research suggestsdiscrepancies in self and partner understanding of self-attributes predicts relation-ship satisfaction (Swann et al., 1994), highlights the importance of further studies toinvestigate lack of agreement between staff and patient perceptions of interpersonalproblems in samples with psychosis. The finding that staff attachment avoidance ismoderately and significantly correlated with discrepancies in ratings does imply thatstaff characteristics may influence their assessments of patients’ levels of need. Peoplewith avoidant attachment typically experience difficulties in forming close relation-ships with others, thus possibly decreasing their awareness of how other people thinkand feel in interpersonal situations. Avoidant attachment is also associated withnegative views of other people, which may result in a tendency to overestimatenegative interpersonal traits in others (Brennan et al., 1998).Findings of associations between staff attachment style and psychological

mindedness support previous research with student samples (Beitel & Cecero,2003). Our findings extend this research by not only suggesting that correlationsbetween psychological mindedness and attachment style generalize beyond studentsamples, but that it is attachment avoidance as opposed to attachment anxiety thathas a detrimental effect on the ability to make psychological inferences about thecauses of others people’s behavior. In fact, mild levels of anxious attachment, whichis associated with hypersensitivity to cues of social rejection and abandonment(Meyer, Olivier, & Roth, 2005), may render individuals more sensitive to otherpeople’s thoughts and feelings. However, more significant levels of attachmentanxiety and hypersensitivity are, likely have an adverse effect on relationships.Although associations between staff attachment style and therapeutic relation-

ships must be interpreted with caution due to the small sample size, these findings areconsistent with associations between attachment insecurity and less sensitive andresponsive care giving in romantic relationships (Simpson et al., 1992) and poorertherapeutic alliance in counseling relationships (Dunkle & Friedlander, 1996).Moreover, previous research with psychiatric staff and patients with severe and

Table 1Mean (SD) and t Statistics for Associations Between Staff Attachment and TherapeuticRelationships

Positive relationship

(n5 6)

Neutral relationship

(n5 14) t df p Value

Attachment anxiety .29 (.20) .64 (.39) �2.06 18 .05

Attachment avoidance .88 (.39) 1.29 (.47) �1.98 18 .061



enduring mental health problems has shown that insecure staff attachment styles arerelated to insensitive and inflexible interactions, which may serve to reinforcepatients’ dysfunctional styles of relating (Dozier, Cue, & Barnett, 1994). Possibleassociations between insecure staff attachment styles and neutral relationships withpatients are particularly important, as the absence of a positive therapeuticrelationship in people with psychosis is associated with poorer outcomes (Tattan& Tarrier, 2000).This study provides a preliminary investigation of associations between staff

attachment styles, psychological mindedness, and therapeutic relationships. There area number of ways that future studies could improve on and further explore ourfindings. Replicating the study in larger samples would determine whether findingsgeneralize and would potentially result in higher incidence of high EE, thus permittingmore powerful comparisons between those scoring lower and higher on EE measures.Patient–staff discrepancies in the perception of interpersonal problems may wellmediate the association between staff attachment and patient–staff relationshipquality. Our sample is too small to conduct mediational analyzes, but future researchwith larger samples would be able to test this hypothesis. Our attachment measureassesses self-reported thoughts, feelings, and behavior in close interpersonal relation-ships; it does not measure unconscious attachment processes or attachmentrepresentations, which are assessed based on an individual’s narrative in describingrelationship experiences (Crowell, Fraley, & Shaver, 1999). As self-reportedattachment styles are not necessarily correlated with unconscious attachmentrepresentations (Crowell et al., 1999), research should explore how both constructsrelate to psychological mindedness and therapeutic relationships. It would also beimportant to incorporate measures of patient attachment styles in future research, asthere is a growing body of evidence of associations between patient attachment andthe quality of therapeutic relationships (Daniel, 2006). Moreover, there is evidencethat patient and staff attachment interact to influence the therapeutic process,although further work is needed to identify optimal matches between patient and staffattachment patterns (Zegers, Schuengel, van Ijzenfdoorn, & Janssens, 2006).Future studies should incorporate patients’ perceptions of therapeutic relationships

as staff and patient perspectives are not necessarily related (Couture, Roberts, Penn,Cather, Otto, & Goff, 2006). Although we obtained good levels of interrater reliabilitywith the measure of psychological mindedness (Barrowclough et al., 2007), it requiresfurther validation. The FMSS may also underestimate EE in psychiatric staff who maybe reluctant to criticize patients due to social desirability biases and similar biases maylead staff to underreport levels of attachment anxiety and avoidance. Despite thesecaveats, the present study is an important first step in highlighting the role of staffattachment style in perceptions of patients’ interpersonal difficulties and the nature ofstaff-patient relationships. The findings highlight the importance of increasingpsychiatric staff awareness of their own attachment styles and the way in whichthese might affect their relationships with patients.

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