1. Attachment Issues in Clinical Practice: Issues for Research
Dr Ken Ma
Consultant Child and Adolescent Psychiatrist
Coventry CAMHS
Coventry and Warwickshire Partnership Trust

2. 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

3. John Bowlby ( )
John Bolwby

4. 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

5. 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.

6. 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.

7. Measuring Attachment in Infancy - the Strange Situation Procedure
Ainsworth et al. (1978)
Mary Ainsworth
( )

8. 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?

9. SS Classification Infant attachment category
Observations of infant in SS
Putative caregiver style
Secure (B)
(Organised)
Protests when caregiver disappears. Protest continues on return, but soon pacified and resumes exploratory play.
Secure.
Consistent.
Responsive.
Avoidant (A)
Little protest on separation. On caregiver’s return, hovers warily by, inhibited play.
Broadly rejecting.
Ambivalent (C)
Protests, and hard to pacify on caregiver’s return. Clings, buries head in lap, pushes away toys offered.
Inconsistent.
Disorganised (D)
Freezes on separation, seems unable to sustain any organised pattern of behaviour on return. Behaviours may appear bizarre, stereotyped, ‘autistic’.
Unresolved loss and trauma in caregiver.
“Frightened and frightening”.

10. Measuring Attachment in Adulthood The Parenting Tradition vs
Measuring Attachment in Adulthood The Parenting Tradition vs. the Romantic Attachment Tradition (after Bartholomew & Shaver, 1998)

11. Romantic Attachment Tradition
Parenting Tradition
Romantic Attachment Tradition
Orientation
Psychodynamic focus on clinical problems.
Social/ personality psychology.
Preferred method of assessment
Interviews and behavioural measures in small groups of participants.
Simpler (incl. self-rated) questionnaires in larger populations.
Also interview measures.
Focus
Caregiver-child relationships.
State of mind with respect to attachment.
Close social/ romantic relationships (friendships, dating relationships, marriage).
Age groups
Across the lifespan.
Initially in young adults, now extending at least into adolescence.
Examples of measures
The SS
Adult Attachment Interview (AAI)
Kobak’s Q-Sort
ASQ (Hazan & Shaver, 1988)
RSQ (Griffin & Bartholomew, 1994)
ECR-R (Fraley, Waller & Brennan, 2000)
IPPA (Armsden & Greenberg, 1987)

12. The Adult Attachment Interview (Main & Goldwyn, 1998)
Semi-structured interview about early attachment history.
Measures adolescent’s / adult’s 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 adult’s AAI category and infant’s subsequent category  validity.

13. Categories on the AAI (1)
AAI category
Corresponding SS category
Typical discourse style
Secure autonomous (F)
Secure (B)
Narrative coherence. Valuing of attachment but objectivity evident. Able to give examples to support statements.
Dismissing (Ds)
Avoidant (A)
Brief discourse, can be idealising. Few supporting examples.
Preoccupied (E)
Ambivalent (C)
Incoherent, vague and rambling. Preoccupied with past experiences. Speaker can appear angry, passive or fearful.
Unresolved-disorganised (U)
Disorganised (D)
Striking lapses in monitoring of reasoning during discussion of loss or abuse.

14. 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.

15. The Relationship Scales Questionnaire (RSQ) – An Example of a Romantic Attachment Tradition questionnaire
Kim Bartholomew

16. 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.
I’m not sure that I can always depend on others to be there when I need 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 with me.

17. Bartholomew’s four-category model - as assessed using RQ/RSQ
Positive IWM of
Self (low dependence)
Negative IWM of Self (high dependence)
Positive IWM of Others (low avoidance)
Secure
Comfortable with intimacy and autonomy
Preoccupied
Preoccupied with relationships, high emotional reactivity
Negative IWM of Others (high avoidance)
Dismissing
Dismissive of attachment; counter-dependent
Fearful
Afraid of intimacy and rejection; believes self to be worthy of rejection; high emotional reactivity

18. AAI versus Self-Report Measures
Advantages
Regarded as ‘gold standard’ by many.
Able to tap into unconscious.
Construct validity unquestioned.
Quick, easy to administer.
Can be used in large-scale research.
Disadvantages
Long.
Impractical to use in clinical settings/ large-scale research.
Extensive and expensive training required.
Construct validity questioned by those on the ‘other side’
 really measuring attachment?

19. 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!

20. 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?

21. Attachment in Clinical Research - Some Findings

22. 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.

23. Depression
Association with preoccupied/ unresolved strategies (Fonagy et al., n=82 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.

24. 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).

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

26. 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.

27. Compliance with Treatment
Ciechanowski et al
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.

28. 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?
Goodwin’s Service Attachment Questionnaire (Goodwin et al., 2003).

29. What about the attachment strategies of healthcare staff?

30. 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

31. 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!

32. THANK YOU!

33. 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,
Ma, K. (2006) Attachment theory in adult psychiatry. Part 1: Conceptualisations, measurement and clinical research findings. Advances in Psychiatric Treatment, 12,