Attachment Issues in

Clinical Practice: Issues for

Research
Dr Ken Ma
Consultant Child and Adolescent Psychiatrist
Coventry CAMHS
Coventry and Warwickshire Partnership Trust
 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
John Bowlby (1907-1990)
 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

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

Mary Ainsworth
(1913-1993)
 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?
 SS Classification
Infant attachment Observations of Putative
category infant in SS caregiver style
Protests when caregiver Secure.
Secure (B) disappears. Protest continues Consistent.
on return, but soon pacified
(Organised) and resumes exploratory play.
Responsive.

Little protest on separation.

Avoidant (A) On caregiver’s return, hovers Broadly rejecting.
warily by, inhibited play.
(Organised)
Protests, and hard to pacify on Inconsistent.
Ambivalent (C) caregiver’s return. Clings,
buries head in lap, pushes
(Organised) away toys offered.
Freezes on separation, seems Unresolved loss and trauma in
Disorganised (D) unable to sustain any organised caregiver.
pattern of behaviour on return.
Behaviours may appear “Frightened and frightening”.
bizarre, stereotyped, ‘autistic’.
 Measuring Attachment in Adulthood
The Parenting Tradition vs. the Romantic
Attachment Tradition
(after Bartholomew & Shaver, 1998)
 Parenting Tradition Romantic Attachment
Tradition

Orientation Psychodynamic focus on clinical Social/ personality psychology.

problems.
Preferred Interviews and behavioural Simpler (incl. self-rated)
method of measures in small groups of questionnaires in larger
assessment participants. populations.
Also interview measures.
Focus Caregiver-child relationships. Close social/ romantic
State of mind with respect to relationships (friendships,
attachment. dating relationships, marriage).
Across the lifespan. Initially in young adults, now
Age groups extending at least into
adolescence.
The SS ASQ (Hazan & Shaver, 1988)
Examples of RSQ (Griffin & Bartholomew, 1994)
measures Adult Attachment Interview
ECR-R (Fraley, Waller & Brennan,
(AAI) 2000)
Kobak’s Q-Sort IPPA (Armsden & Greenberg, 1987)
 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.
 Categories on the AAI (1)
AAI category Corresponding SS Typical discourse style
category

Secure Secure (B) Narrative coherence. Valuing of

attachment but objectivity evident.
autonomous (F)
Able to give examples to support
statements.

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

Few supporting examples.

Ambivalent (C) Incoherent, vague and rambling.

Preoccupied (E) Preoccupied with past experiences.
Speaker can appear angry, passive or
fearful.

Unresolved- Disorganised (D) Striking lapses in monitoring of

reasoning during discussion of loss
disorganised (U)
or abuse.
 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.
 The Relationship Scales Questionnaire
(RSQ) –
An Example of a Romantic Attachment
Tradition questionnaire

Kim Bartholomew
http://www.sfu.ca/psyc/faculty/bartholomew/
 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.
 Bartholomew’s four-category model
- as assessed using RQ/RSQ
Positive IWM of Negative IWM of
Self (low Self (high
dependence) dependence)
Positive IWM of Secure Preoccupied
Others (low Comfortable with Preoccupied with
intimacy and autonomy relationships, high
avoidance) emotional reactivity

Negative IWM of Dismissing Fearful

Dismissive of Afraid of intimacy and
Others (high rejection; believes self to
attachment; counter-
avoidance) dependent be worthy of rejection;
high emotional reactivity
 AAI versus Self-Report Measures

AAI Self-report measures

Advantages Regarded as ‘gold Quick, easy to

standard’ by many. administer.
Able to tap into Can be used in large-
unconscious. scale research.
Construct validity
unquestioned.
Disadvantages Long. Construct validity
Impractical to use in questioned by those on
clinical settings/ large- the ‘other side’
scale research.  really measuring
Extensive and expensive attachment?
training required.
 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!
 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?
Attachment in Clinical Research
- Some Findings
 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.
 Depression
 Association with preoccupied/ unresolved
strategies (Fonagy et al., 1996 - 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.
 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).
 Borderline Personality Disorder

 High proportion with a U/E classification -

Fonagy et al., 1996; Barone, 2003.
 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.
 Compliance with Treatment

Ciechanowski et al. 2000

 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.
 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).
 What about the attachment
strategies of healthcare staff?
 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

 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!
THANK YOU!
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, 10-16.

Ma, K. (2006) Attachment theory in adult psychiatry. Part 1:

Conceptualisations, measurement and clinical research
findings. Advances in Psychiatric Treatment, 12, 440-9.