1. Attachment styles, symptoms and interpersonal relationships in psychosis Katherine Berry University of Manchester Christine Barrowclough, Alison Wearden

2. Outline Background literature Method Key Results Discussion of findings Clinical implications Caveats and further developments

3. Background Interpersonal difficulties and psychosis (Penn et al., 2004). Limitations of traditional CBT models and interventions (Gumley & Schwannauer, 2006). Attachment theory - Theory of human relationships. - Attachment ‘from the cradle to the grave’ (Bowlby, 1979). - Universal need to form close affectional bonds. - Homeostatic mechanism for regulating distress.

4. Earlier interpersonal experiences influence interpersonal functioning and methods of regulating distress via ‘attachment working models’ (Bowlby, 1980). Sensitive and responsive care giving leads to secure attachment (Ainsworth et al., 1978). Insensitive or unresponsive care giving leads individual to meet attachment needs by escalating or deactivating affect (Shaver & Mikulincer. 2002).

5. Conceptualisations and assessment of adult attachment - Narrative approach: Attachment states of mind and Adult Attachment Interview (AAI; Main et al., 1985). - Self-report tradition: Conscious thoughts, feelings and behaviour in close relationships in adulthood and questionnaire measures (e.g. Hazan & Shaver, 1987; Bartholomew & Horowitz, 1991).

6. Adult attachment dimensions (Brennan et al., 1998) High levels of attachment anxiety - negative self-image - an overly demanding interpersonal style - fear of rejection - tendency to exaggerate or be overwhelmed by negative affect High levels of attachment avoidance - negative image of others - interpersonal hostility - social withdrawal - defensive minimisation of affect and importance of social relationships

7. Stability of attachment styles over time - Retrospective and longitudinal studies: Relative stability, but not complete consistency over periods of several months to 30 years (e.g. Scharfe & Bartholmew, 1994; Waters et al, 2000). - Role of life events (e.g. loss, formation of relationships and interpersonal traumas) in influencing stability (Waters et al., 2000).

8. - Insecure adult attachment styles and psychopathology (Goodwin, 2003). - Insecure adult attachment styles and interpersonal difficulties (Berry et al., 2006). - Insecure attachment styles and difficulties in therapeutic relationships (Daniel, 2006). - Attachment styles influence methods of regulating distress and psychotic experiences highly distressing (Bendall et al., 2006). - Role of trauma and negative interpersonal events in models of psychosis (Larkin & Morrison, 2006). Why study attachment styles in psychosis?

9. Nature of attachments in psychosis - Greater insecurity on AAI in schizophrenia compared to affective diagnoses (Dozier, 1990; Dozier et al., 1991). - Some evidence of higher levels of avoidant attachment on AAI in schizophrenia (Dozier et al., 1991), but findings not consistent (Dozier, 1990; Dozier, et al., 1994). - Higher levels of avoidant attachment on self-report measures in schizophrenia, but findings not specific (Mickelson et al., 1997).

10. Parental bonding studies - Retrospective memories of parents as high in ‘affectionateless control’ (e.g. Parker et al., 1982; Willinger et al., 2002). - But findings not specific to schizophrenia (Winther Helgeland & Torgersen, 1997). Attachment and schizotypy research - Attachment anxiety and positive schizotypy - Attachment avoidance and both positive and negative schizotypy - Avoidant attachment and paranoia (Berry et al., 2006; Berry et al., 2007)

11. Attachment and interpersonal difficulties in psychosis - Avoidant attachment on AAI and greater rejection of treatment providers, less self-disclosure and poorer use of treatment (Dozier, 1990). - Avoidant and preoccupied attachment on AAI and higher emotional over involvement in relatives (Dozier et al., 1991). - Avoidant attachment on AAI and greater off task behaviour and confusion in staff-patient interactions (Dozier et al., 2001).

12. - Avoidant attachment and greater rejection of relatives in relative-patient interactions (Dozier et al., 2001). - Insecure attachment on Adult Attachment Scale, ‘sealing over’ recovery style and poorer engagement with services (Tait et al., 2004).

13. Limitations of existing literature - Majority of research one group of authors using AAI. - No research investigating associations between self-reported attachment and specific types of interpersonal difficulties. - No research investigating associations between self-reported attachment and therapeutic alliance; key factor influencing outcomes (Neale & Rosenheck, 1995). - Majority of studies not controlled for severity of symptoms.

14. Research questions Are attachment anxiety and avoidance associated with severity of and specific types of interpersonal problems (overly intrusive and hostile interpersonal styles)? Are attachment anxiety and avoidance associated with difficulties in therapeutic alliance? Are associations between attachment and interpersonal relationships maintained when severity of symptoms are controlled?

15. Method Participants 96 patients and their key workers Inclusion criteria - Documented ICD-10 diagnosis of schizophrenia, schizotypal or delusional disorder (World Health Organisation, 1992) - Able to give informed consent - English speaking - Same key worker for at least 3 months

16. Measures - Psychosis Attachment Measure (PAM; Berry et al., 2006) - Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987) - Inventory of Interpersonal Problems (IIP-32; Barkham et al., 1996) - Items from Social Behaviour Schedule (SBS; Wykes & Sturt, 1986) - Patient and key worker versions of Working Alliance Inventory (WAI; Tracey & Kokotovic, 1989 )

17. Developing attachment measure Two dimensions of anxiety and avoidance. Derived from literature characterising attachment dimensions and existing measures. 16 items referring to self-identified thoughts, feelings, and behaviours in interpersonal relationships, but not romantic relationships.

18. Psychometric properties Replicated 2-factor solution obtained in non-clinical sample (Berry et al., in 2007). Internal consistency (anxiety alpha =.82; avoidance alpha =.76) One-month test re-test reliability (anxiety ICC =.71; avoidance = ICC.56)

19. Hypothesis: Attachment and interpersonal problems Attachment anxiety Attachment avoidance Interpersonal problems.58*** <.001.28**.01

20. Hypothesis: Attachment anxiety and overly demanding behaviour (OD) ODNo ODt (d.f.)p value Mean attachment anxiety (s.d.) 1.33 (.85).84 (.65)2.82 (77).006**

21. Hypothesis: Attachment avoidance and interpersonal hostility (IH) IHNo IHt (d.f.)p value Mean attachment avoidance (s.d.) 1.87 (.72)1.47 (.55)2.77 (77).007**

22. Hypothesis: Attachment avoidance and poorer therapeutic relationships Attachment anxiety Attachment avoidance Patient working alliance -.11.313 -.44*** <.001 Key worker working alliance.18.109 -.33**.003

23. Controlling for severity of symptoms Associations between attachment and interpersonal problems were still significant (anxiety: r =.57, p <.001; avoidance: r =.=25, p =.029). Associations between attachment anxiety and overly demanding behaviour where still significant [F (1, 76) 6.46, p =.013], as where associations between attachment avoidance and interpersonal hostility [F (1, 76) 4.59, p =.035]. Associations between attachment avoidance and patient-rated (r = -.35, p =.02) and key worker-rated (r = -.25, p =.025) alliance were still significant

24. Discussion of findings Associations between attachment and interpersonal problems - Replicate findings in non-clinical samples (e.g. Berry et al., 2006). - Specific associations between attachment anxiety and overly demanding behaviour and attachment avoidance and hostility. - Associations independent of severity of symptoms. - Implications for models of interpersonal difficulties in Psychosis.

25. Associations between attachment avoidance and working alliance - Consistent with previous findings (e.g. Dozier, 1990; Tait et al., 2004). - Associations independent of severity of symptoms. - Implications for understanding staff-patient relationships in psychosis. - No evidence of associations between attachment anxiety and therapeutic alliance consistent with less robust relationships in previous research (Daniel, 2006).

26. Clinical implications Assessment of attachment experiences and attachment styles in clinical practice. Identification of people with avoidant attachment and additional support and supervision to staff.

27. Use of attachment theory in formulations of interpersonal difficulties - Emphasis on adaptive nature of insecure attachment styles. - Emphasis of self-perpetuating nature of insecure styles and how other people can get drawn into maintaining them. - Less stigmatising for patients. - Help reduce staff criticism and possible role in maintaining problematic interactions (e.g. Berry et al., 2009).

28. Using attachment theory to inform interventions - Anxious attachment: Increasing self-efficacy in relation to coping with distress and confidence in the reliability of others (Bartholomew et al., 2001). - Avoidant attachment: Reducing negative models of others by developing trusting relationships despite initial hostility (Bartholomew et al., 2001).

29. - Maximising engagement and clinical effectiveness by varying therapeutic approaches in accordance with patients’ attachment styles (Tyrell et al., 1999). - But match or mismatch? - Importance of maintaining and developing staff and patient relationships across range of interventions (Berry & Drake, 2010).

30. Caveats and further developments Generalisation to more diverse samples. Cross-sectional study and direction of associations. Stability of attachment styles over time and influence of symptoms and ‘trauma of psychosis’ on attachment styles (Berry et al., 2008). Reporting biases, common method variance and importance of considering discrepancies in staff and patient perceptions (Berry et al., 2008).

31. Role of staff attachment style in staff and patient relationships (Berry et al., 2008). Organisation of attachment working models in psychosis: General attachment styles versus attachment to specific others (Berry et al., 2007). Associations between insecure attachment and range of psychiatric conditions (Goodwin, 2003). Associations between AAI and self-report measures in psychosis.

32. Extent to which staff and patient relationships can be conceptualised as attachment relationships. Attachment to services, including influence of individual attachment styles (Blackburn et al. in press). Avoidance of ‘parental blaming’ and fact adult attachment style is likely to be influenced by a range of interpersonal experiences.

33. Conclusions Adult attachment potentially important predictor of interpersonal difficulties in psychosis. Extend previous research by replicating AAI findings using self-report measure and assessing effects controlling for symptoms. Largest most comprehensive study of attachment in psychosis since Dozier and colleagues’ work. Findings support reliability and validity of PAM.

34. References Berry, K., Band, R., Corcoran, R., Barrowclough, C. & Wearden, A. (2007). Attachment styles, interpersonal relationships and schizotypy in a non-clinical sample. Psychology and Psychotherapy, 80, 563-576. Berry, K., Barrowclough, C. & Wearden, A. (2008). Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis. Behaviour Research and Therapy, 46, 1275-1282. Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study investigating the use of psychological formulations to modify psychiatric staff perceptions of service users with psychosis. Behavioural and Cognitive Psychotherapy, 37, 39-48. Berry, K., Barrowclough, C. & Wearden, A. (in press). Adult attachment, perceived earlier experiences of care giving and trauma in people with psychosis. Journal of Mental Health.

35. Berry, K., Barrowclough, C. & Wearden, A. (2007). A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research. Clinical Psychology Review, 27, 458-475. Berry, K. & Drake, R. (2010). The relevance of attachment theory for psychiatric rehabilitation and implications for practice. Advances in Psychiatric Treatment, 16, 308-315. Berry, K., Wearden, A. & Barrowclough, C. (2007). Adult attachment styles and psychosis: An investigation of associations between general attachment styles and attachment relationships with specific others. Social Psychiatry and Psychiatric Epidemiology, 42, 972-976. Berry, K, Wearden, A., Barrowclough, C. & Liversidge, T. (2006). Attachment styles, interpersonal relationships and psychotic phenomena in a non-clinical student sample. Personality and Individual Differences, 41, 707-718. Berry, K, Shah, R., Cook, A., Geater, E., Barrowclough, C. & Wearden, A. (2008). Staff attachment styles: A pilot study investigating the influence of adult attachment styles on staff psychological mindedness and therapeutic relationships. Journal of Clinical Psychology, 64, 355-363. Blackburn, C., Berry, K. & Cohen, K. (in press). Factors correlated with client attachment to mental health services. Journal of Nervous and Mental Disease.