Presentation on theme: "Attachment Issues in Clinical Practice: Issues for Research"— Presentation transcript:
1Attachment Issues in Clinical Practice: Issues for Research Dr Ken MaConsultant Child and Adolescent PsychiatristCoventry CAMHSCoventry and Warwickshire Partnership Trust
2Outline of Presentation Brief overview of attachment theoryAssessment of attachmentWhy attachment may be important as a clinical research variableWhy attachment may be important as a sociological/ political research variableAttachment in clinical research - some findings
4What 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
5What 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.
6Attachment 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.
7Measuring Attachment in Infancy - the Strange Situation Procedure Ainsworth et al. (1978)Mary Ainsworth( )
8The Strange SituationLaboratory 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?
9SS Classification Infant attachment category Observations of infant in SSPutative caregiver styleSecure (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”.
10Measuring Attachment in Adulthood The Parenting Tradition vs Measuring Attachment in Adulthood The Parenting Tradition vs. the Romantic Attachment Tradition (after Bartholomew & Shaver, 1998)
11Romantic Attachment Tradition Parenting TraditionRomantic Attachment TraditionOrientationPsychodynamic focus on clinical problems.Social/ personality psychology.Preferred method of assessmentInterviews and behavioural measures in small groups of participants.Simpler (incl. self-rated) questionnaires in larger populations.Also interview measures.FocusCaregiver-child relationships.State of mind with respect to attachment.Close social/ romantic relationships (friendships, dating relationships, marriage).Age groupsAcross the lifespan.Initially in young adults, now extending at least into adolescence.Examples of measuresThe SSAdult Attachment Interview (AAI)Kobak’s Q-SortASQ (Hazan & Shaver, 1988)RSQ (Griffin & Bartholomew, 1994)ECR-R (Fraley, Waller & Brennan, 2000)IPPA (Armsden & Greenberg, 1987)
12The 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.
13Categories on the AAI (1) AAI categoryCorresponding SS categoryTypical discourse styleSecure 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.
14Categories 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.
15The Relationship Scales Questionnaire (RSQ) – An Example of a Romantic Attachment Tradition questionnaireKim Bartholomew
16The 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.
17Bartholomew’s four-category model - as assessed using RQ/RSQ Positive IWM ofSelf (low dependence)Negative IWM of Self (high dependence)Positive IWM of Others (low avoidance)SecureComfortable with intimacy and autonomyPreoccupiedPreoccupied with relationships, high emotional reactivityNegative IWM of Others (high avoidance)DismissingDismissive of attachment; counter-dependentFearfulAfraid of intimacy and rejection; believes self to be worthy of rejection; high emotional reactivity
18AAI versus Self-Report Measures AdvantagesRegarded as ‘gold standard’ by many.Able to tap into unconscious.Construct validity unquestioned.Quick, easy to administer.Can be used in large-scale research.DisadvantagesLong.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?
19Attachment in Clinical Research - The ‘Why Measure It?’ Question Better understanding of aetiology of psychopathologyAttachment 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 disorderAttachment 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!
20Attachment 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?
22Attachment 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 factorsPostulated association between ‘maximising’ attachment strategies and “internalising” psychopathology, and between ‘minimising’ attachment strategies and “externalising” psychopathology.
23DepressionAssociation 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.
24AnxietyAssociation 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).
25Borderline Personality Disorder High proportion with a U/E classification - Fonagy et al., 1996; Barone, 2003.
26Patterns 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.
27Compliance with Treatment Ciechanowski et al276 tertiary care type I diabetes patients.RSQ.Dismissing attachment associated with significantly higher HbA1c.Dozier et al., 1990Those patients with insecure attachment less compliant with psychotropic medication.
28Healthcare 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).
29What about the attachment strategies of healthcare staff?
30Attachment 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
31Conclusions 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!
33Cassidy, 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,