Attachment Theory and Psychosis

Current Perspectives and Future Directions

Katherine Berry, Sandra Bucci, Adam N. Danquah

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781317352518
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Attachment Theory and Psychosis: Current Perspectives and Future Directions is the first book to provide a practical guide to using attachment theory in the assessment, formulation and treatment of a range of psychological problems that can arise as a result of experiencing psychosis.

Katherine Berry, Sandra Bucci and Adam N. Danquah, along with an international selection of contributors, expertly explore how attachment theory can inform theoretical understanding of the development of psychosis, psychological therapy and mental health practice with service users with psychosis. In the first section of the book, contributors describe the application of attachment theory to the understanding of paranoia, voice-hearing, negative symptoms, and relationship difficulties in psychosis. In the second section of the book, the contributors consider different approaches to working therapeutically with psychosis and demonstrate how these approaches draw on the key principles of attachment theory. In the final section, contributors address individual and wider organisation perspectives, including a voice-hearer perspective on formulating the relationship between voices and life history, how attachment principles can be used to organise the provision of mental health services, and the influence of mental health workers' own attachment experiences on therapeutic work. The book ends by summarising current perspectives and highlighting future directions.

Written by leading mental health practitioners and researchers, covering a diverse range of professional backgrounds, topics and theroetical schools, this book is significant in guiding clinicians, managers and commissioners in how attachment theory can inform everyday practice. Attachment Theory and Psychosis: Current Perspectives and Future Directions will be an invaluable resource for mental health professionals, especially psychologists and other clinicians focusing on humanistic treatments, as well as postgraduate students training in these areas.

1

Introduction

Katherine Berry, Sandra Bucci and Adam N. Danquah

Background

Attachment theory is a life span theory, which proposes that early relationships with significant others have a profound impact on later interpersonal relationships (Bowlby, 1969). The theory is based on the assumption that early experiences lead to the formation of what John Bowlby, the theory’s founder, termed ‘internal working models’, consisting of mental representations of the self, others and relationships with those others. Individuals interpret experiences in light of these working models, which guide and influence the way they interact with, and behave towards, others. Attachment is embedded in the evolutionary need for safety and security (Bowlby, 1969). From an evolutionary perspective, caregiving relationships, and closeness to the caregiver in particular, ensure protection in a dangerous world, and thus promote safety and a felt sense of security. There is evidence that childhood experiences influence attachments to others in adult life, and that adult attachment style predicts social functioning, interpersonal difficulties and mental health (Bartholomew & Horowitz, 1991; Berry, Wearden, Barrowclough & Liversidge, 2006; Platts, Tyson & Mason, 2002).

Given the role of attachment in interpersonal functioning and mental health problems, a number of researchers have argued that attachment theory can help extend existing models and conceptualisations of psychosis (Berry, Wearden & Barrowclough, 2007; Gumley, Barker, Schwannauer & Lawrie, 2015; Korver-Nieberg et al., 2015; Read & Gumley, 2008; Berry & Bucci, 2016; Berry, Varese & Bucci, 2017). When asked about the relevance of attachment theory to understanding psychosis, Bowlby replied it, ‘had nothing to contribute to schizophrenia’ (Khar, 2012, p. 10). Whether this statement reflected the modesty of a man whose work is so central to the understanding of mental health and personality development or thinking from different times, it is clear that thinking has moved on within the field. The link between developmental adversity and psychosis is well established (Varese et al., 2012) and attachment has been identified as a key potential mediating factor in this relationship (Berry, Barrowclough, & Wearden, 2008; Read & Gumley, 2008).

The well-known attachment theorist Jeremy Holmes (personal communication) suggests that attachment theory can be an invaluable framework for conceptualising psychosis. He observed that the kinds of insecure attachment – i.e. dismissiveness, preoccupation and disorganisation – in their extreme form, can respectively tip into paranoia, confusion and fragmentation. With such a framework, we are moved from a description of symptoms to the developmental origin and relational function of otherwise inexplicable behaviour. Increasing understanding of the mediating role dissociation plays between psychosis and its traumatic origins (Pearce et al., 2017) is proving a particularly promising line of enquiry regarding the contribution of attachment, so closely tied are dissociative or psychotic phenomena and the processes of disorganised attachment (Liotti & Gumley, 2008).

Although the empirical evidence for the role of attachment difficulties in psychosis has lagged behind these theoretical speculations, over the past decade there has been an exceptional growth in research measuring attachment styles or patterns in psychosis. Studies show an association between insecure attachment and psychotic phenomena (Berry, Barrowclough & Wearden, 2008) and, moreover, that dismissing and disorganised patterns predominate (Harder, 2014). A number of hypotheses have been proposed to account for these relationships (e.g. Liotti & Gumley, 2008), though the area is still contested. What is now less controversial is the relational dimension to psychosis. Apart from contributing to re-humanising psychotic experience, more light is being shed on how to engage with people whose early attempts at connection have been thwarted and yet who – it is now clear – continue to try to connect all the same. In line with such understanding, there has been increased interest in using attachment theory to inform psychological therapies and mental health care more generally for people with psychosis. Given these developments, it is timely to synthesise and showcase current thinking in the field by drawing together theories, research findings and therapeutic work from a range of well-established researchers and clinicians. In this introductory chapter, we aim to provide an outline of the structure of the book and summarise the content of each chapter. Before doing so, we will describe the basic concepts of attachment theory in order to provide a context for the chapters that follow.

Basic concepts

Attachment relationships are distinguished from other types of social relationships in that there is a persistent and emotionally significant affectional bond, which is formed with a specific person, who is approached in times of distress. Theorists have suggested that caregivers’ mental representations about their own childhood attachment experiences are important in influencing the quality of the attachment relationship formed with their own child (Main, Kaplan & Cassidy, 1985). Attachment relationships can be distinguished from other types of relationships and are defined in terms of both a desire for close proximity to the attachment figure and evidence of distress following involuntary separation (Bowlby, 1973; 1980; 1982; Weiss, 1991). Attachment behaviours are defined as any form of behaviour that results in the individual regaining or retaining contact with his or her attachment figure; such behaviours can be triggered by environmental threats, distress, illness, or fatigue (Bowlby, 1973; 1980; 1982). The attachment relationship is further hypothesised to provide a ‘secure base’, which enables one to engage in exploration, develop and gain independence (Ainsworth, Blehar, Waters & Wall, 1978).

Bowlby (1973; 1980; 1982) proposed that as a result of their interactions with caregivers during infancy and childhood, individuals develop mental representations of the self in relation to significant others and expectations about how others behave in social relationships. These working models are hypothesised to guide attention, interpretation, memory and predictions about future interpersonal interactions. They are characterised in terms of cognitive elements, which reflect beliefs about whether the individual him or herself is worthy of attention and whether other people are reliable, and also represent emotions associated with interpersonal experiences, such as happiness, fear and anger.

The Strange Situation procedure for assessing attachment security in infancy was crucial in providing empirical support for Bowlby’s theory and measuring individual differences in the quality of attachment relationships. The procedure involves a laboratory-based observation of the infant’s response to two brief separations from, and reunions with, his or her caregiver (Ainsworth et al., 1978). Responses are traditionally classified in terms of three patterns of behaviours: secure, insecure-avoidant and insecure-ambivalent. The different patterns of responses are hypothesised to relate to different attachment working models and methods of regulating distress (Ainsworth et al., 1978). The caregiver’s sensitivity to distress appears to be a significant factor in determining attachment classification (Weinfield, Sroufe, Egeland & Carlson, 1999). In the case of insecure attachment, the child’s emotions are ineffective in eliciting contingent responses in caregivers, so the child learns to either inhibit (avoidant attachment) or exaggerate their emotional needs and expressions (ambivalent attachment). The sensitivity of the caregiver has been associated with a number of factors including: his or her own mental health; sources of stress and support inside and outside the family (Belsky & Nezworski, 1988; Cummings & Cicchetti, 1990); his or her own attachment style (van Ijzendoorn, 1995); and infant characteristics, such as temperament (Rutter, 1995; Weinfield et al., 1999).

In addition to the three categories of attachment originally identified by Ainsworth, Main and Soloman (1986) noted that some infants displayed disorganised and disoriented responses to separation and reunion from caregivers that appeared contradictory and inconsistent with the ‘organised’ attachment patterns such as avoidant or ambivalent attachment. This disorganisation of the attachment system was conceptualised as the outcome of interactions in which the infant experiences the attachment figure as frightening, frightened, or dissociated in times of stress. The caregiver might act in ways that are confusing and unpredictable for the infant, rendering it difficult for them to develop an ‘organised’ pattern of self-protection. According to Liotti (2004), the infant experiences ‘fright without solution’ at being confronted with the biological paradox that the attachment figure, the primary source of safety and protection, is also the source of infant distress. There is evidence of associations between attachment disorganisation and parental maltreatment (Lyons-Ruth & Jacobvitz, 1999), but the development of a disorganised attachment pattern could also be influenced by more subtle (but frequent or pervasive) disruptions in parental attunement, possibly caused by a range of adverse conditions and circumstances (e.g. parental poor mental health, trauma and experiences of loss (Cyr, Euser, Bakermans-Kranenburg & van Ijzendoorn, 2010; Hesse & Main, 2006; Lyons-Ruth & Jacobvitz, 1999; van Ijzendoorn, 1995; 1999).

Bowlby emphasised that attachment is an integral part of human behaviour ‘from the cradle to the grave’ (Bowlby, 1979, p. 208). In order to provide a clearer picture of the attachment literature and different models of adult attachment, which we know is complex, we present the different models in Table 1. The Table illustrates how the different categories of attachment style in adulthood developed by different theorists map onto each other, as well as attachment categories commonly described in the childhood literature.

Table 1.1 Summary and comparison between different models of attachment

Authors associated with model or system of classifying attachment	Method of assessing attachment	Attachment patterns identified*
Ainsworth et al., (1978) Main & Soloman (1986)	Strange Situation test in infancy A laboratory-based observation of the infant’s response to two brief separations from, and reunions with, his or her caregiver	Secure Children feel confident that the attachment figure will be available, responsive and helpful in such a way that the caregiver easily soothes them in times of distress. They also use their caregiver as a safe base to explore their environment. The child will feel positive and loved as their caregiver will present as ‘sensitive’ to the child’s needs.	Ambivalent/Resistant Children will exaggerate their needs and expressions towards the attachment figure, but will reject their attempts to engage and comfort. Children are unable to use caregivers as a secure base to explore novel surroundings. This is as a result of inconsistent responses from their caregiver at times of need, meaning the child is unable to develop feelings of attachment security.	Avoidant Children are very independent of the caregiver in both the physical sense, when exploring the environment, and emotionally. They will not seek help from the caregiver and inhibit their emotional needs. The caregiver often presents as insensitive and not responsive to their needs due to withdrawing at distressing times or not being available.	NA	Disorganised Children appear afraid of their caregiver who presents in a manner that is confusing and unpredictable for the child, therefore not facilitating an ‘organised’ pattern of self-protection. Children may display behaviours such as overt displays of fear; contradictory behaviours or affects occurring simultaneously or sequentially; stereotypic, asymmetric, misdirected or jerky movements; or freezing and apparent dissociation.
Main & Goldwyn (1984)	Adult Attachment Interview in adulthood A semi-structured interview focusing on earlier experiences of being parented, including asking people to identify five adjectives to describe each parent.	Autonomous Individuals have a coherent and collaborative narrative when discussing earlier attachment experiences. They may have had positive or negativ...

Table of contents

• Cover
• Endorsement
• Half Title
• Series Information
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• 1 Introduction
• Part I Symptoms, functioning and aetiology
• Part II Therapeutic approaches
• Part III Individual and organisational perspectives
• Index