Changes in attachment representations during psychological therapy

Fluctuations in adult attachment among experienced mothers during re-transitioning to motherhood

Transition to motherhood encompasses intensive caring for another and thus may activate adult attachment. The current study aimed to examine the fluctuations in adult attachment among the rarely examined population of experienced mothers during their re-transition to motherhood. A sample of 186 Israeli women was followed at the third trimester of pregnancy (T1), 2 months (T2) and 5 months (T3) after giving birth. Participants completed questionnaires regarding their background variables and adult attachment. The findings showed that while anxious attachment remained stable, avoidant attachment decreased from the end of pregnancy to 8 weeks and 5 months after delivery. Despite its relative stability, adult attachment may fluctuate during significant life transitions in a way that is adjusted to the demands of the changing reality. This fluctuation may occur even when individuals have already experienced a life transition.

Measuring Change in Attachment Insecurity Using Short Forms of the ECR-R: Longitudinal Measurement Invariance and Sensitivity to Treatment

Attachment insecurity is important for psychotherapy both as an aspect influencing the therapeutic process as well as potential outcome variable of a treatment. Two German short forms of the Experiences in Close Relationships - Revised (ECR-R) have been proposed to assess individual differences in attachment anxiety and avoidance. In this research, we examined whether these questionnaires are suitable for measuring change in attachment anxiety and avoidance by testing longitudinal measurement invariance in two independent clinical samples (N1 = 493, N2 = 273) using a pre-post design. Results indicated that strict longitudinal measurement invariance can be assumed for both measures. Thus, changes in scale scores before and after treatment can be interpreted as changes in the latent dimensions of attachment anxiety and avoidance. Both questionnaires were also sensitive to treatment in that attachment insecurity was overall reduced after therapy. Although both measures appear to be generally suitable for investigating treatment effects, they exhibited consistent problems with structural validity across samples that should be reexamined in future research.

Attachment to robots and therapeutic efficiency in mental health

Previous studies in the mental health context have demonstrated that interactions with social robots can improve the mood and cognitive capacities of their users, and enhance their quality of life. In this Perspective article, our goal is to systematize the possible roles of social robots and to point out that different roles require different levels of attachment. We argue that the attachment between the client and the (robot) therapist is a fundamental ingredient of any helping relationship and that the full potential of using social robots in mental health settings can only be realized if the strength of attachment is appropriately correlated with the type of relationship established.

Pre-event attachment anxiety and avoidance predict posttraumatic stress symptom severity - Results from a longitudinal population-based study

Attachment-related anxiety and avoidance have been identified as risk factors for psychopathology following traumatic events. However, the predictive value of pre-event attachment orientations for PTSD symptoms in the general population remains unclear. Attachment anxiety and avoidance, as well as symptoms of anxiety and depression, were assessed in autumn 2010 (T0) in 270 adult members of a Dutch research panel. PTSD symptoms were assessed in April (T1), August (T2), and December (T3) 2012 for events occurring within one year before T1. The predictive value of attachment orientations for severity and remission of PTSD cluster and total scores was estimated by latent growth curve analyses controlling for gender, age, and pre-event psychopathology. Attachment anxiety predicted higher posttraumatic stress severity at T1, while attachment avoidance predicted lower initial posttraumatic stress levels, together adding 7.4 % independently explained variance. Higher attachment anxiety was related to more remission of PTSD total scores (6.0 % independently explained variance) which might be understood as an effect of regression to the mean. In conclusion, insecure attachment orientation predicts PTSD symptoms in the general population. Our results advocate the significance of pre-traumatic factors for the prediction of posttraumatic stress and the consideration of attachment orientations in clinical work with trauma survivors.

Attachment as a predictor of dropout in mentalization-based treatment

OBJECTIVES

Although treatments of patients with borderline personality disorder (BPD) were historically associated with relatively high dropout rates, dropout rates in contemporary evidence-based treatments for BPD are typically substantially lower. However, only a few studies have investigated dropout rates in mentalization-based treatment (MBT), and even fewer have investigated predictors of dropout in this type of treatment. In this study, we investigated dropout rates in two types of MBT (day hospital MBT [MBT-DH] and intensive outpatient MBT [MBT-IOP]) using data from a recent multicenter randomized clinical trial. Given the central importance of attachment considerations in MBT, we also investigated the relationship between dropout in these two treatments and attachment dimensions.

DESIGN

Within a multicenter randomized clinical trial, 114 BPD patients were randomized to MBT-DH (n = 70) or MBT-IOP (n = 44).

METHODS

Dropout in both types of MBT was investigated using descriptive analyses, and its association with attachment anxiety and attachment avoidance, as measured by the Experiences in Close Relationships questionnaire at baseline, was investigated using regression analyses.

RESULTS

Dropout rates were relatively low (10.5% across both types of MBT) and did not significantly differ between groups (11.4% in MBT-DH, 9.1% in MBT-IOP). Attachment avoidance and attachment anxiety did not impact dropout, nor did their interaction or the interaction with the type of MBT.

CONCLUSIONS

Low dropout rates in both types of MBT indicate a high level of engagement of patients in both programmes. Attachment dimensions were not associated with dropout, consistent with the principle that MBT is tailored to each individual's needs. More research is needed, however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature.

Attachment-Related Differences in Emotion Regulation in Adults: A Systematic Review on Attachment Representations

In recent years, there has been an increase in the prevalence of mental disorders connected with affective dysregulation and insecure attachment. Therefore, it is even more important to understand the interplay between an individual's attachment representation and patterns of emotion regulation. To our knowledge, this is the first systematic review to examine this association. PsycInfo, PsyArticles, and PubMed were searched for studies that examined attachment-related differences in emotion regulation in adults. To examine the unconscious attachment representation, only studies using the Adult Attachment Interview or the Adult Attachment Projective Picture System were included. Thirty-seven peer-reviewed studies (with a total of 2006 subjects) matched the PICO criteria. Emotion regulation was measured via four objective approaches: autonomic nervous system, brain activity, biochemistry, or nonverbal behavior. Across all measurements, results reveal a significant correlation between attachment representation and emotion regulation. Secure attachment correlates consistently with balanced emotion regulation, whereas it is impaired in insecure and dysfunctional in unresolved attachment. Specifically, unresolved individuals display counterintuitive responses and fail to use attachment as a resource. Insecure-dismissing attachment is associated with an emotionally deactivating strategy, while on a physiological, biochemical, and nonverbal level, emotional stress is still present. There is still a lack of studies examining preoccupied individuals. In addition to interpreting the results, we also discuss the risk of bias, implications for psychotherapy and coaching, and an outlook for future research.

Attachment patterns and autobiographical episodic memory functioning: A systemic review of adult studies to advance clinical psychological science

Patterns of insecure attachment are associated with psychopathology but the mechanisms involved remain poorly understood. Cognitive science proposes that attachment patterns are influenced by the autobiographical memory system and in turn influence its ongoing functioning. Disturbances in autobiographical memory represent cognitive risks for later emotional difficulties. We systemically reviewed 33 studies (in 28 articles) examining the association between attachment patterns and autobiographical episodic memory (AEM) in individuals from the age of 16 (i.e., from young to older adulthood). Attachment patterns were associated with key areas of AEM phenomenology, including intensity and arousal; detail, specificity, and vividness; coherence and fragmentation; and accuracy and latency. These associations appeared to be moderated by contextual and individual factors; mediated by emotional regulation and schema-based processing; linked to mental health outcomes. Attachment patterns may also influence the impact of certain AEM-based manipulations. We conclude by providing a critical discussion and a research agenda for bringing together attachment, memory, and emotion, with a view to promote mechanism-driven treatment innovation in clinical psychology.

Attachment Style and Self-Experience: The Association Between Attachment Style and Self-Reported Altered Self-Experience in Patients With Psychotic Disorders, Unaffected Siblings, and Healthy Controls

ABSTRACT

The present study aimed to examine the cross-sectional association between attachment style and self-reported disturbed self-awareness (disturbed sense of mineness of experiences) and depersonalization (disturbed sense of first-person perspective) in patients with psychotic disorders, unaffected siblings, and healthy controls. Data pertain to a subsample of the GROUP (Genetic Risk and Outcome of Psychosis) study. We found positive associations between anxious attachment and disturbed self-awareness and depersonalization across participants with different psychosis vulnerability. We also found a positive association between avoidant attachment and depersonalization, although on a trend level. Findings indicate that attachment style is associated with self-reported disturbed self-awareness and depersonalization over and above the influence of psychotic or depressive experiences in people across the vulnerability spectrum of psychosis. This supports the importance of attachment style, self-awareness, and depersonalization as potential targets in prevention and treatment interventions in patients with psychotic disorders or those with increased vulnerability.

The association between attachment style and social functioning in patients with non-affective psychotic disorders, unaffected siblings and healthy controls

OBJECTIVE

In patients with psychotic disorders, insecure attachment styles and impaired social functioning are highly prevalent. Our aim was to explore the multi-cross-sectional and longitudinal associations between attachment style and social functioning.

METHODS

This study was performed in a subsample of 119 patients with non-affective psychotic disorders, 128 unaffected siblings and 66 healthy controls within the Genetic Risk and Outcome of Psychosis (GROUP) Study. Attachment style (using the Psychosis Attachment Measure) and three social functioning domains, namely withdrawal, interpersonal behaviour and pro-social activities as measured with the Social Functioning Scale (SFS) were assessed on two moments in time. Generalized linear mixed models and linear regression models were used. Bonferroni correction for multiple testing was applied.

RESULTS

In the patient group, a significant negative association was found between avoidant attachment and pro-social functioning. In the sibling and control group, we found significant negative associations between avoidant attachment and the social functioning domains withdrawal and interpersonal behaviour. We also found a significant negative association between anxious attachment and the social functioning domain withdrawal in siblings. Higher levels of insecure anxious attachment at baseline predicted a reduction of the social functioning domain interpersonal behaviour in siblings over a period of three years on a trend level.

CONCLUSIONS

Findings indicate that levels of insecure attachment are elevated in patients with psychotic disorders and have a negative association with social functioning in both patients, siblings and controls. These findings warrant specific attention for attachment style in the treatment of patients with psychotic disorders and individuals with an increased vulnerability for developing psychosis.

Love Addiction, Adult Attachment Patterns and Self-Esteem: Testing for Mediation Using Path Analysis

Love addiction is a dysfunctional relational modality that takes on the addiction characteristics and which, for the individuals who suffer from it, can have a negative and pervasive impact on various areas of functioning. The objective of this research was the analysis the factors that can be associated with love addiction, particularly focusing on adult attachment patterns and self-esteem. A sample group of 300 individuals who declared themselves to have a romantic relationship was involved in this research (M_age = 37.83 years, SD = 12.937). They completed an online survey including the Love Addiction Inventory-Short form, Relationship Questionnaire, and Rosenberg Self-Esteem Scale. Results showed significant and positive associations between preoccupied and fearful adult attachment and love addiction. Furthermore, these relationships were totally mediated by self-esteem. Gender and age were controlled as potential covariates and showed significant effects in influencing the levels of self-esteem and love addiction. Such findings may provide useful information for orienting future research and supporting an effective clinical practice.

Exploring the Relationship Between Attachment and Pathological Personality Trait Domains in an Outpatient Psychiatric Sample

ABSTRACT

The current study investigates the relationship between insecure attachment and pathological personality trait domains in a sample of psychiatric outpatients. Participants ( N = 150) completed measures for attachment and personality. Bivariate correlations and multiple regression analyses investigated the extent to which insecure attachment and personality pathology were associated. Insecure attachment positively correlated with overall personality pathology, with attachment anxiety having a stronger correlation than attachment avoidance. Distinct relationships emerged between attachment anxiety and negative affectivity and attachment avoidance and detachment. Insecure attachment and male sex predicted overall personality pathology, but only attachment anxiety predicted all five trait domains. Insecure attachment might be a risk factor for pathological personality traits. Assessing attachment in clinical contexts and offering attachment-based interventions could benefit interpersonal outcomes.

Attachment mediates the link between childhood maltreatment and loneliness in persistent depressive disorder

BACKGROUND

A central concept of attachment theory is that early experiences with close attachment figures shape the way we interact with and relate to other social partners throughout life. As such, early experiences of childhood maltreatment (CM) have been suggested as a key precursor of adult insecure attachment representations. As CM has been linked to feelings of loneliness in adulthood, this study examines whether insecure attachment could explain the relationship between CM and loneliness. Also, the moderating role of a diagnosis of persistent depressive disorder (PDD) is investigated, a disorder characterized by high levels of CM and loneliness.

METHOD

60 patients with PDD (DSM-5) and 60 gender- and age-matched non-clinical control participants (NC) completed self-report questionnaires measuring attachment, loneliness, and CM. Mediation analyses (PDD as a moderator) were performed.

RESULTS

PDD patients reported higher levels of CM, attachment anxiety, attachment avoidance, and loneliness than NC. CM was positively associated with loneliness in both groups. Mediation analyses demonstrated that the relationship between CM and loneliness was mediated by avoidant, but not anxious attachment, regardless of a diagnosis of PDD.

LIMITATIONS

Caution when interpreting these results is crucial as the study lacked a clinical control group, relied on self-report measures, and the cross-sectional design limits the ability to draw causal inferences.

CONCLUSIONS

All constructs studied were present to a greater degree in PDD. Above, findings provide initial evidence that avoidant attachment may explain the relationship between CM and loneliness. Potentially, adult avoidant attachment may lead to and maintain feelings of loneliness, regardless of PDD.

The Relevance of Internal Working Models of Self and Others for Equine-Assisted Psychodynamic Psychotherapy

Attachment characteristics play a key role in mental health and in understanding mental disorders. The aim of this study was to gain insight into the role the attachment characteristics can play in treatment effects in adult patients with intrapsychic and interpersonal problems who underwent Equine-assisted Short-term Psychodynamic Psychotherapy (ESTPP). In the first part of the study, we compared the effects of ESTPP to treatment-as-usual from a previous dataset regarding psychological dysfunction. For this, an explorative experimental non-randomized pre-treatment and 1-year post-treatment design was used. A mixed model revealed a significant decline in psychological dysfunction for both conditions, with no significant difference between the two. In the second part of the study, we examined the course of ESTPP effects over the period of 1 year when controlled for attachment styles and, subsequently, for internal working models of self and others. To this end, measurements were taken at baseline, 2 months waiting time, one-week intensive module, 6 months, and one year after the start of the treatment. Mixed models accounted for repeated measures showed significant improvements in psychological dysfunction, remoralization, and depression for ESTPP patients over time. The study implies that models of self and others may be used to predict the course of effects, which is relevant in determining what works for whom. In particularly, duration and intensity of therapy and a focus on the Model of Self seem relevant for shaping a more personalized treatment. ESTPP seems beneficial for patients with low pre-treatment attachment security.

Attachment insecurity partially mediates the relationship between childhood trauma and depression severity in bipolar disorder

BACKGROUND

Childhood trauma is associated with greater depression severity among individuals with bipolar disorder. However, the mechanisms that explain the link between childhood trauma and depression severity in bipolar disorder remain poorly understood. The mediational role of attachment insecurity in childhood and adulthood was assessed in the current study.

METHODS

Participants with bipolar disorder (N = 143) completed measures of childhood trauma (Childhood Trauma Questionnaire), attachment insecurity (Experiences in Close Relationships Scale) and depression severity (Hamilton Depression Rating Scale) as part of the Prechter Longitudinal Study of Bipolar Disorder. A sequential mediation model was tested using path analysis: the direct and indirect effects of childhood trauma on depression severity with attachment insecurity (attachment anxiety and avoidance) in childhood (mother and father) and adulthood (partner) as mediators were estimated.

RESULTS

The final path model demonstrated an excellent fit to the data (comparative fit index = 0.996; root mean square error of approximation = 0.021 [90% confidence interval = 0.000-0.073]). Supporting the hypothesised sequential mediation model, maternal attachment anxiety in childhood and romantic attachment avoidance in adulthood partially mediated the relationship between childhood trauma and depression severity; this effect accounted for 12% of the total effect of childhood trauma on depression severity.

CONCLUSION

Attachment insecurity in childhood and adulthood form part of the complex mechanism informing why people with bipolar disorder who have a history of childhood trauma experience greater depression severity. Addressing attachment insecurity represents a valuable psychotherapeutic treatment target for bipolar disorder.

Evaluating the psychometric properties of the German adaptation of the client attachment to therapist scale

Background

The present study examines the psychometric properties of the German adaptation of the Client Attachment to Therapist Scale (CATS). The validity of the scale as originally proposed has recently been brought into question, as patients were identified as “pseudosecure”.

Methods

We examined the measure’s factorial structure, as well as reliability and validity towards related measures using a clinical sample of N = 354 participants.

Results

We found the original model, consisting of 36 items to be lacking in terms of model fit and construct validity. A shortened 12-item version exhibited markedly improved model fit and reliability. Correlations to related constructs demonstrated that none of the scale’s validity was lost by shortening it. Furthermore, we showed scalar invariance across groups of age and sex.

Conclusions

The shortened CATS-S can be recommended for future use in clinical research in German-speaking populations as a valid, reliable, and economical alternative to the longer version.

Attachment insecurity moderates the link between maternal childhood neglect and postpartum bonding to the infant

Mothers who experienced childhood neglect are at increased risk of parenting difficulties in adulthood, but adult attachment relationships may be protective. Eighty-eight postpartum women seeking outpatient psychiatric care completed self-report measures on adverse childhood experiences, adult attachment, mental health symptoms, and bonding. Beyond the effects of maternal mental health on bonding, childhood neglect predicted bonding difficulties only in mothers with more insecure attachments, suggesting adult attachment as a potential point of intervention to reduce the intergenerational transmission of risk.

Attachment Style Moderates Polygenic Risk for Incident Posttraumatic Stress in U.S. Military Veterans: A 7-Year, Nationally Representative, Prospective Cohort Study

BACKGROUND

Posttraumatic stress disorder (PTSD) develops consequent to complex gene-by-environment interactions beyond the precipitating trauma. To date, however, no known study has used a prospective design to examine how polygenic risk scores (PRSs) interact with social-environmental factors such as attachment style to predict PTSD development.

METHODS

PRSs were derived from a genome-wide association study of PTSD symptoms (N = 186,689; Million Veteran Program cohort). We evaluated combined effects of PRS and attachment style in predicting incident PTSD in a 7-year, nationally representative cohort of trauma-exposed, European-American U.S. military veterans without PTSD (N = 1083). We also conducted multivariate gene-by-environment interaction and drug repositioning analyses to identify loci that interact with multiple environmental factors and potential pharmacotherapies that may be repurposed for this disorder.

RESULTS

Veterans with higher PTSD PRS were more likely to have an incident-positive screen for PTSD over 7 years. A gene-by-environment interaction was also observed, such that higher PRS only predicted incident PTSD in veterans with an insecure attachment style and not those with a secure attachment style. At an individual locus level, the strongest gene-by-environment interaction was observed for the rs4702 variant of the FURIN gene with cumulative lifetime trauma burden. Drug repositioning revealed that genes implicated in PRS are perturbated by the drug doxylamine.

CONCLUSIONS

Attachment style moderates polygenic risk for the development of PTSD in European-American veterans. These findings may inform PTSD prevention and treatment for veterans with high polygenic risk for PTSD and suggest a potential pharmacotherapeutic target for risk genes moderated by social-environmental factors.

Childhood interpersonal trauma and paranoia in psychosis: The role of disorganised attachment and negative schema

Paranoia is associated with significant distress and is associated with childhood trauma. Understanding the mechanisms responsible for this association is important for informing psychological interventions. Theoretical proposals suggest that negative schema and insecure attachment may be important mechanisms in the development of paranoia. Disorganised attachment may be particularly relevant. The current study is the first to examine whether the relationship between childhood interpersonal trauma and paranoia is mediated by disorganised attachment, and the impact of disorganised attachment on negative self and negative other schema. A large online sample of 242 people with self-reported psychosis completed measures of childhood trauma, attachment, self and other schema, paranoia and psychosis symptomatology. Path analysis indicated that childhood interpersonal trauma was associated with disorganised attachment, which in turn was associated with negative self-schema, negative other schema, and paranoia. Negative schema about others, but not self, was associated with paranoia. Disorganised attachment and negative other schema fully mediated the relationship between trauma and paranoia. Negative other schema partially mediated the association between disorganised attachment and paranoia. Results were found when controlling for depression, hallucinations and age. Results suggest that interventions that aim to modify disorganised attachment patterns and negative schema about others can potentially alleviate the impact of trauma on paranoia. Findings provide justification for longitudinal studies to confirm the direction of effects, and intervention studies that aim to manipulate disorganised attachment and negative schema about others and observe the impact of this on paranoia.

Is there an elephant in the room? A study of convergences and divergences of adult attachment measures commonly used in clinical studies

Objective: In view of the persisting conceptual confusion related to the convergence of attachment measures, we investigated several common measures within a clinical and a non-clinical sample, tested the convergence/divergence of different measures, and tried to find a dimensional model. Method: 175 patients with panic disorder/agoraphobia and 143 matched non-clinical individuals completed seven self-report attachment measures/ clinical self-reports and were interviewed by applying the Adult Attachment Interview (AAI), the Adult Attachment Rating (AAR) and the Adult Attachment Projective (AAP). Results: The categorical and most dimensional attachment measures differentiated between the samples. The convergence of the categorical measures was low, whereas we found moderate to high correlations between similar scales in the dimensional self-report measures. Expectedly, the convergence of dimensional and categorical attachment measures was low. In a factorial (exploratory as well as confirmatory) model, four independent dimensions were extracted reflecting self-rated attachment anxiety and avoidance, the categories of the AAI and those of the AAP, indicating significant differences between the measures. Discussion: Measures of adult attachment are only partially convergent, underlining the need for clarification of which aspect of attachment is actually being assessed in individual clinical investigations. The question remains whether the different measures are in fact related to one construct.

The role of attachment and dissociation in the relationship between childhood interpersonal trauma and negative symptoms in psychosis

Negative symptoms have an adverse impact on quality of life and functioning in psychosis. Service users with psychosis have identified negative symptoms as a priority for their recovery. Despite this, there is a lack of effective and targeted psychological interventions for negative symptoms and their underlying mechanisms remain poorly understood. Childhood trauma is a robust risk factor for positive symptoms in psychosis, but the association with negative symptoms is less well established. Our aim was to examine the association between childhood interpersonal trauma and negative symptoms and the psychological mediators of this relationship. Two hundred and forty participants experiencing psychosis completed validated self-report measures of childhood trauma, attachment, dissociation, compartmentalization, and symptoms. Mediation analyses showed that disorganized attachment and dissociative experiences mediated the association between childhood trauma and negative symptoms, when analysed individually and in a combined model. Models adjusted for age and positive and depressive symptoms. Avoidant attachment and compartmentalization were independently associated with negative symptoms but not childhood trauma and thus were not significant mediators. Childhood trauma was not independently associated with negative symptoms. This paper is the first to present empirical data to support a model implicating attachment and dissociation as important psychological processes in the link between childhood trauma and negative symptoms. These exploratory findings suggest that it may be beneficial to consider these relationships in trauma-informed formulations and interventions. Further longitudinal research is required to establish causality and test theoretical models of mechanisms in the pathway to negative symptoms.

Romantic Attachment and Difficulties in Emotion Regulation on Dyadic Adjustment: A Comprehensive Literature Review

In romantic relationships, individual differences are determinant factors for relational quality. Specifically, romantic attachment (RA) and difficulties in emotional regulation influence each other and may have predictive potential for the perceived dyadic adjustment (DA) level. This paper aims to identify the developmental parallel between behavioral patterns built since childhood and the construction of the emotional regulation skills that characterize them. Our analysis was based on the attachment theory and the concepts of romantic relationship and DA. In this way, we sought to further the understanding of relationship dynamics, beyond the usual focus on a single element and on associative relationships, and by exploring other effects among the different dimensions of relational functioning. In particular, we explored the predictive ability of emotional regulation patterns (more flexible individual characteristics) in discriminating between RA styles (more perennial influences), and their impact on the quality of romantic relationships, in the anticipation of dyadic adjustment variations.

Failure to resolve loss and compromised mentalizing in female inpatients with major depressive disorder

Attachment and mentalizing are central concepts in research on the etiology, course, and treatment of depression. The goal of this cross-sectional study was to clarify the unique value of these constructs in characterizing the presence, severity, and chronicity of depression. We examined 50 female inpatients suffering from Major Depressive Disorder (MDD) in comparison to 47 matched healthy controls regarding their attachment states of mind, mentalizing capacities, and clinical variables indicating depression severity and chronicity (e.g. illness duration, number of hospitalizations). In the group of depressed patients, unresolved attachment with regard to loss was significantly overrepresented. Dimensionally, patients were more disorganized and more insecure, whereas there was no difference on the dismissing-preoccupied dimension between the two groups. Mentalizing was significantly lower in patients than in healthy controls. Logistic regression analysis revealed attachment insecurity, mentalizing deficits, and unresolved loss to be incrementally relevant to predict MDD. Correlations with clinical parameters in the group of depressed patients showed positive associations between mentalizing deficits, attachment insecurity, and variables indicating illness chronicity. Our findings highlight the relevance of the inability to resolve or reappraise loss experiences in depressive states.

Alexithymia is a mediating factor in the relationship between adult attachment and severity of depression and social anxiety

BACKGROUND

Major depressive disorder (MDD) and social anxiety disorder (SAD) are commonly occurring conditions, either alone or together (MDD-SAD). Recent research linked insecure attachment and alexithymia to MDD and/or SAD, indicating that the way affected individuals relate interpersonally and their ability to identify and communicate emotions are pertinent issues. The current study investigated the mediating role of alexithymia in the relationship between insecure attachment and severity of MDD and SAD symptoms.

METHOD

Using the SCID-I, participants (N=159) were identified as MDD-only (n=43), MDD-SAD (n=56), or a healthy control (n=60). Participants completed measures of adult attachment, depression, social anxiety and alexithymia (defined as difficulty identifying and describing feelings). A two-step mediation analysis approach recommended by Shrout and Bolger determined if alexithymia mediates the relationship between attachment-depression and attachment-social anxiety.

RESULTS

While alexithymia was high in MDD-only and MDD-SAD groups, individuals with MDD-SAD had significantly greater difficulty describing feelings. Alexithymia was a full mediator between attachment avoidance and depression, but only a partial mediator between attachment anxiety and depression. Meanwhile, alexithymia was a partial mediator for both attachment dimensions and social anxiety.

LIMITATIONS

Causal inferences regarding insecure attachment, alexithymia, and MDD and SAD cannot be assumed given the cross-sectional data. The 'externally oriented thinking' component in alexithymia was also excluded from analyses due to low reliability.

CONCLUSION

The results suggest emotional awareness and expression play a role in the illness severity for MDD and SAD-particularly in those with high attachment avoidance, offering a possible target for treatment and prevention strategies.

Replication Studies on Significant Differences in Personality Profiles of Securely and Insecurely Attached Psychotherapists and Dentists

This study contributes to the therapist variable in general and the personality profile of securely and insecurely attached psychotherapists and other healthcare professionals in particular. In a preceding study, it has been found that insecurely attached psychotherapists differ in nine personality styles from securely attached ones. The aim of the present study was to replicate these findings and to investigate whether they also apply to other health professions such as dentists. About 891 subjects from two German professional societies for hypnosis were surveyed online with a personality questionnaire [Personality Styles and Disorder Inventory (PSDI)] and an attachment questionnaire [Relationship Scale Questionnaire (RSQ)]. Since these subjects were interested in hypnosis and used it in their practice (HYP), 150 dentists without a hypnosis context (NONHYP) were studied as a control group with the same survey. The results of the preceding attachment study could be replicated: Insecurely attached healthcare professionals differed significantly from securely attached ones in the same nine (plus one, i.e., 10) personality styles if they use psychological methods including hypnosis. If they do not use psychological methods (like the NONHYP dentists), they differ in half of the personality styles. No within-sample and no between-sample differences have been found in the assertive/antisocial (AS) personality style. No within-sample differences have also been found in the conscientious/compulsive (ZW) and the intuitive/schizotypal (ST) personality styles. However, large between-sample differences were obvious in ZW and the ST. Both of the samples of the dentist were much more compulsive than the two psychotherapeutic samples. In addition, both of the HYP samples were much more schizotypal than the NONHYP samples. The latter is the general signature of those individuals who are interested in hypnosis and were metaphorically termed homo hypnoticus. It seems that AS, ZW, and ST are independent of attachment.

Does attachment predict the outcome of cognitive processing therapy for posttraumatic stress disorder in adolescent patients with interpersonal traumatization?

The attachment has emerged as a significant predictor of psychotherapy outcome. However, studies on trauma-focused treatments and adolescent samples are sparse. We analyzed the data of 43 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related posttraumatic stress disorder (PTSD) who were undergoing developmentally adapted cognitive processing therapy (D-CPT) within a multicenter, randomized clinical trial (German Clinical Trials Register; identifier: DRKS00004787). Besides clinician-rated posttraumatic stress symptoms (PTSS), attachment-related (AR) anxiety and AR avoidance were assessed using self-reports before and after treatment as well as at three-month and six-month follow-ups. Baseline attachment did not predict any changes in PTSS severity. Averaging across all assessment points, overall higher posttraumatic avoidance was associated with greater baseline AR avoidance in D-CPT. In terms of change in attachment during the trial, a greater reduction of attachment insecurities was associated with a greater reduction of PTSS severity. Results are compared with those of the control group, a wait-list condition with treatment advice (WL/TA; N = 42). AR anxiety was more often a significant variable in the models in WL/TA, whereas AR avoidance was in D-CPT. Our study does furnish initial insights into the role of attachment during trauma-focused treatment with abused adolescents and young adults.Trial registration: German Clinical Trials Register identifier: DRKS00004787.

Evaluation of a short version of the Experiences in Close Relationships-Revised questionnaire (ECR-RD8): results from a representative German sample

BACKGROUND

Attachment insecurity is a prominent risk factor for the development and course of psychiatric and psychosomatic disorders. The Experiences in Close Relationships - Revised (ECR-R) questionnaire is a widely used self-report to assess attachment related anxiety and avoidance. However, its length has the potential to restrict its use in large, multi-instrument studies. The aim of this study was to develop and evaluate a brief version of the ECR-R, and provide norm values for the German population.

METHODS

A screening version of the original ECR-R was developed through principal components analysis of datasets from several previous studies. In a representative sample of 2428 randomly selected individuals from the German population, we compared fit indices of different models by means of confirmatory factor analyses (CFA). We investigated the convergent validity of the screening version in an independent convenience sample of 557 participants. Correlations between the short and the full scale were investigated in a re-analysis of the original German ECR-R evaluation sample.

RESULTS

CFA indicated a satisfactory model fit for an eight-item version (ECR-RD8). The ECR-RD8 demonstrated adequate reliability. The subscales correlated as expected with another self-report measure of attachment in an independent sample. Individuals with higher levels of attachment anxiety, but especially higher levels of attachment avoidance were significantly more likely to not be in a relationship, across all age groups. Correlations between the short and the full scale were high.

CONCLUSIONS

The ECR-RD8 appears to be a reliable, valid, and economic questionnaire for assessing attachment insecurity. In addition, the reported population-based norm values will help to contextualize future research findings.

Long-term changes in attachment patterns after psychotherapy in outpatients with Axis I and personality disorders vs. Axis I disorders only

BACKGROUND

Adult attachment can be self-reported by rating anxiety of deception and avoidance of emotional closeness. There are few studies of changes in adult attachment patterns after psychotherapy.

AIM

This study investigated how attachment anxiety and avoidance mean scores changed from pre-treatment to follow-up in patients with Axis I disorders only vs. patients with Axis I and comorbid personality disorders (comorbid group) after outpatients psychotherapy.

METHOD

Of 156 patients with pre-treatment evaluation, 64 (41%) participated in follow-up 6 years later. Axis I and personality disorder interviews were performed at pre-treatment and follow-up, and the participants self-reported attachment patterns at both time points.

RESULTS

At both pre-treatment and follow-up, the Axis I group had significantly lower attachment avoidance scores than the comorbid group, while no significant between-group differences were observed for attachment anxiety. After adjustment, neither the Axis I nor the comorbid group showed any significant reductions in attachment anxiety or avoidance over time. The pre-treatment attachment scores were the only significant predictors of the follow-up scores.

CONCLUSION

Neither attachment anxiety nor avoidance were amenable to change over time. These findings may be associated with the psychotherapy given. Pre-treatment attachment scores were the only significant predictors of these scores at follow-up. © 2020 John Wiley & Sons, Ltd.

Get secure soon: attachment in abused adolescents and young adults before and after trauma-focused cognitive processing therapy

Severe posttraumatic stress symptoms (PTSS) are connected to a variety of health-related and interpersonal problems, among them are the insecure attachment orientations. However, psychotherapy seems to improve not only PTSS but also attachment insecurities. In a large multicenter, randomized clinical trial, the attachment characteristics and PTSS of 85 adolescents and young adults (aged 14-21 years) with clinically relevant abuse-related PTSS were assessed at study entry, at the end of treatment, and 3 months after the end of treatment. Participants were randomized either to a developmentally adapted cognitive processing therapy (D-CPT) or to a wait-list with treatment advice (WL/TA). The purpose of the study was to analyze the association between PTSS and attachment at study entry as well as changes in attachment during the trial. We found that attachment-related avoidance (AR avoidance) was positively associated with PTSS from both self-reports and clinician ratings, whereas attachment-related anxiety (AR anxiety) was only related to self-reported PTSS (Pearson correlation coefficients between 0.37 and 0.46). Changes in AR anxiety occurred in both conditions at some point during the study (baseline to 3-month follow-up effect size was d = 0.60 for D-CPT and d = 0.44 for WL/TA) whereas for AR avoidance, only participants in D-CPT improved significantly (baseline to 3-month follow-up effect size was d = 0.75). The results indicate that PTSS and attachment are connected. Positive changes in attachment insecurities brought about by trauma-focused psychotherapy seem possible.Trial registration: German Clinical Trials Register (DRKS); Germanctr.de; identifier: DRKS00004787; date of registration: 18 March 2013.

Psilocybin-Assisted Group Therapy and Attachment: Observed Reduction in Attachment Anxiety and Influences of Attachment Insecurity on the Psilocybin Experience

Attachment insecurity is determined early in life, is a risk factor for psychopathology, and can be measured on two separate continuous dimensions: attachment anxiety and attachment avoidance. Therapeutic changes toward more secure attachment correlate with reduction in psychiatric symptoms. Psilocybin-assisted psychotherapy has demonstrated promise in the treatment of psychopathology, such as treatment-resistant depression and substance use disorders. We hypothesized that psilocybin-assisted psychotherapy would reduce attachment anxiety and attachment avoidance, thus increasing attachment security. We also hypothesized that baseline measures of attachment insecurity, which can reflect a diminished capacity for trust and exploration, would inform the quality of the psilocybin session. Participants were male long-term AIDS survivors with moderate-severe demoralization (n = 18). Using the Experiences in Close Relationships scale, we measured attachment insecurity at baseline as well as immediately, and 3 months, after completion of a brief group therapy course, which included a single midtreatment open-label psilocybin session conducted individually. Clinically important aspects of the psilocybin session were assessed using the revised Mystical Experience Questionnaire and the Challenging Experience Questionnaire the day following psilocybin administration. Self-reported ratings of attachment anxiety decreased significantly from baseline to 3-months post-intervention, t(16) = -2.2; p = 0.045; d _rm = 0.45; 95% CI 0.01, 0.87. Attachment avoidance did not change significantly. Baseline attachment anxiety was strongly correlated with psilocybin-occasioned mystical-type experiences, r(15) = 0.53, p = 0.029, and baseline attachment avoidance was strongly correlated with psilocybin-related challenging experiences, r(16) = 0.62, p = 0.006. These findings have important implications for the general treatment of psychopathology as well as optimizing psilocybin-assisted psychotherapy as a broadly applicable treatment modality.

Attachment style and clinical outcome within a DBT-informed Therapeutic Community

Purpose

There is evidence that attachment style and clinical outcomes are related within Therapeutic Communities (TCs). This paper aims to examine any possible relationships between self-reported adult attachment style, therapy programme engagement and measures of psychological distress and dissociation on admission and discharge within a residential TC.

Design/methodology/approach

Ex-clients of the TC were contacted by post and invited to take part in this service evaluation. Additional data were sourced from a database of routinely collected outcome measures. Of 281 ex-clients, the final sample in this study was N = 32.

Findings

When attachment style is conceptualised dimensionally, participants identified most strongly with a fearful attachment style, and least with a preoccupied or secure style. A range of attachment styles were reported. A significant association was apparent between self-reported secure attachment and reduced levels of psychological distress upon discharge from the TC. The potential for changes in client attachment patterns following TC membership is discussed.

Research limitations/implications

The small sample size and correlational nature of this study means that results should be interpreted cautiously. Nevertheless, results are of clinical relevance for inpatient or residential therapy programmes (including TCs). Such programmes should routinely assess client attachment style to ensure appropriate interventions and adaptions are implemented.

Originality/value

To the best of the authors’ knowledge, to date, this is the first known study to report on the relationship between self-reported adult attachment style and psychological outcomes specifically for women with self-defeating behaviours within a TC.

The relationship between attachment and functioning for people with serious mental illness: a systematic review

AIMS

Functional impairment is a hallmark feature of severe mental health problems (SMI). Attachment theory is a key psychological theory of interpersonal functioning and difficulties in attachment are common in SMI and may help explain functioning problems in SMI. This systematic review aimed to synthesise and critically appraise existing literature exploring associations between adult attachment style and functioning in SMI samples.

METHOD

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines we systematically searched five databases using strings of terms relating to both attachment and social functioning. Inclusion criteria were samples diagnosed with SMI and validated measure tools.

RESULTS

Ten studies met inclusion criteria. Considerable heterogeneity was found across studies in relation to construct measurement, sample size, and gender distribution. However, as predicted there was some evidence to suggest that secure attachment is associated with better functioning, and insecure attachment (specifically anxious style) is associated with impairments in functioning.

CONCLUSION

Findings highlight the importance of considering attachment in relation to functional outcome when working with people with SMI, particularly when assessing, formulating, and delivering psychological interventions.

Fostering Attachment Security: The Role of Interdependent Situations

This work adopts an Interdependence Theory framework to investigate how the features of interdependent situations that couples face in their daily life (i.e., situations in which partners influence each other’s outcomes) shape attachment security toward their current partners. An experience sampling study examined attachment tendencies and features of interdependent situations that people experience with their partner in daily life to predict satisfaction and trust in their relationship, and changes in attachment avoidance and anxiety toward their partner over time. Results revealed that encountering situations with corresponding outcomes (i.e., situations in which both partners have the same preferences) and with information certainty (i.e., situations in which there is clear knowledge of each partner’s preferences) assuage people’s insecurity. On the contrary, situations of mutual current and future interdependence (i.e., situations in which each person’s current or future outcomes are dependent on their partner’s behavior) undermined security for anxiously attached individuals. Power (i.e., the asymmetry in partners’ dependence) was not related to attachment security. This work underscores the importance of studying the role of the situations that partners experience in their daily life and the way they are related to relationship feelings and cognitions.

Family aggression and attachment avoidance influence neuroendocrine reactivity in young adult couples

Family-of-origin aggression (FOA) exposure is a chronic childhood stressor that has been linked to altered stress reactivity of the hypothalamic-pituitary-adrenal (HPA) axis in adulthood. The effects of FOA also spill over between partners in romantic couples, such that one partner's FOA history influences the other's HPA reactivity during couple interactions. However, the direction of these effects is inconsistent, with both heightened and blunted HPA reactivity observed; this heterogeneity suggests the presence of moderators. This study measured HPA reactivity during emotionally vulnerable conversations between young adult romantic partners to assess whether romantic attachment avoidance accounts for this divergence by moderating actor and partner effects of FOA on HPA. A total of 112 opposite-sex couples (224 young adults) provided information on FOA and avoidance, completed dyadic interaction procedures, and provided saliva samples to assess HPA reactivity during interactions. Multilevel structural equation models revealed that FOA did not predict either the actor's or the partner's HPA reactivity. However, FOA and avoidance interacted to produce both actor and partner effects, such that greater FOA exposure heightened HPA reactivity when avoidance was high but blunted reactivity when avoidance was low. The results support the conjecture that proximal relationship-related characteristics, such as attachment avoidance, influence whether distal relationship-related stressors, such as FOA, amplify or attenuate physiological reactivity during emotionally vulnerable interactions. Because HPA reactivity has been linked to a variety of health outcomes, identifying relationship-related buffers of associations between FOA and HPA response may inform future interventions to protect health for FOA-exposed youth. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychodynamic Based Equine-Assisted Psychotherapy in Adults with Intertwined Personality Problems and Traumatization: A Systematic Review

The growing field of equine-assisted psychotherapy (EAP), a subfield of animal-assisted psychotherapy (AAP), needs theoretically-based clinical studies. This systematic review examines the existing clinical studies in adult populations on psychodynamic psychotherapy combined with equine-assisted psychotherapy. An electronic database search was divided in two studies to identify publications on 1) EAP combined with psychodynamic psychotherapy and 2) EAP combined to personality problems and traumatization in order to compile studies by population, intervention, outcome and therapeutic assets. Study 1 revealed no relevant clinical studies on EAP with a psychodynamic background with an adult population. Study 2 revealed 12 publications to review predominantly addressing veterans with PTSD. The methodological limitations of most of the studies restrain the overall findings on outcome. However, overall positive effects for EAP, specifically on its experiential features and on finding interpersonal trust for patients, can be discerned. There is an apparent need for clinical studies meeting methodological standards on psychodynamic underpinned EAP methodologies in adults with intertwined personality problems and traumatization.

Attachment and social support mediate the association between childhood maltreatment and depressive symptoms

OBJECTIVE

To examine attachment insecurity and low social support as potential mediators of the association between childhood maltreatment (CM) types and depression severity in patients with a lifetime history of major depressive disorders (MDD).

METHOD

Participants with an acute or remitted MDD (N = 580) completed questionnaires about CM (Childhood Trauma Questionnaire), attachment (Relationship Scales Questionnaire), social support (Social Support Questionnaire), and depression severity (Beck Depression Inventory). Mediation and path models with CM types as independent variables, attachment avoidance and anxiety as mediators and depression severity as dependent variable were calculated. In addition, a sequential mediation model with attachment insecurity and social support as mediators of the association between CM and depression was tested.

RESULTS

Attachment avoidance and anxiety partially mediated the effect of CM on depression. In the path model including the different CM types, there were significant indirect effects of emotional abuse on depression via attachment anxiety and of emotional neglect on depression via attachment avoidance. Results also supported the hypothesized sequential mediation via attachment insecurity and social support.

LIMITATIONS

A cross-sectional design with a retrospective self-report measure of CM was used and the developmental timing of exposure to CM was not considered.

CONCLUSION

Our findings suggest that the effect of emotional abuse and emotional neglect on depression is partially mediated by attachment avoidance and anxiety. Further, the results support the hypothesis of a sequential mediation via attachment insecurity and social support. Accordingly, attachment insecurity is discussed as a target of psychotherapy for patients with MDD and CM.

The Role of Perceived Authenticity in Psychological Recovery from Collective Trauma

Introduction: Previous research demonstrates that perceived authenticity is positively associated with psychological health and security in the face of threats. The current research extends this work by testing whether perceived authenticity promotes recovery from the negative mental health consequences of collective trauma (e.g., a natural disaster).

Methods: We recruited a sample of undergraduates (N = 570), many of whom reported direct or indirect exposure to Hurricane Harvey, to complete surveys at two time points. We assessed exposure to the disaster, acute stress, post-traumatic stress, coping, and authenticity twice, once approximately 1 month after Hurricane Harvey (Time 1) and again approximately 9 weeks after Hurricane Harvey (Time 2).

Results: We employed multilevel modelling to explore whether authenticity would aid in recovery from collective trauma. Results showed that perceived authentic living at Time 1 predicted a variety of indicators of stress related to the hurricane at Time 2. Specifically, those participants who reported low authentic living at Time 1 reported greater levels of stress at Time 2, compared to individuals who reported higher levels of authentic living. Importantly, these effects remained even when controlling for known predictors of stress (e.g., levels of stress at Time 1 and coping strategies).

Discussion: Findings provide preliminary insight into authenticity as a part of a likely larger network of interrelated psychosocial qualities that have the potential to help one navigate recovery from trauma.

Change in dysfunctional attitudes and attachment in interpersonal psychotherapy for depressed adolescents

ABSTRACT This study examined changes in depressed adolescents' reports of dysfunctional attitudes while receiving interpersonal psychotherapy (IPT-A) and the relationship between the change in dysfunctional attitudes and change in attachment anxiety and avoidance with IPT-A. Forty adolescents (age 12-17) participated in a 16-week randomized clinical trial of 4 adaptive treatment strategies that began with IPT-A and augmented treatment for insufficient responders by adding additional IPT-A sessions or the antidepressant medication, fluoxetine. Measures of attachment anxiety and avoidance (Experience in Close Relationships Scale-Revised [ECR-R]), dysfunctional attitudes (Dysfunctional Attitudes Scale [DAS]), and depression (Children's Depression Rating Scale-Revised [CDRS-R]) were administered at baseline and weeks 4, 8, 12, and 16. Adolescents demonstrated a significant decrease in dysfunctional attitudes (DAS) over the course of treatment. Reductions in dysfunctional attitudes (DAS) were also significantly associated with reductions in attachment anxiety and avoidance (ECR-R), controlling for depression (CDRS-R). Our results suggest that change in adolescents' attachment anxiety and avoidance may be an important mechanism of change in adolescents' dysfunctional thinking patterns.

Significant Differences in Personality Styles of Securely and Insecurely Attached Psychotherapists: Data, Reflections and Implications

This is a contribution to the research on the therapist variable aiming to improve effectiveness of psychotherapy. It is shown that attachment styles shape personality styles of psychotherapists in a favorable or unfavorable manner. Data on personality (PSDI) and attachment (RSQ) styles was collected from 430 psychological psychotherapists of the DACH countries using an online survey. The 88 insecurely attached psychotherapists differed significantly from their 342 securely attached colleagues in 9 of 14 personality styles: They were - even though well within normal range - more paranoid, borderline, schizoid, dependent, negativistic, self-sacrificing, avoidant, and depressive, as well as less optimistic. This corresponds to results of other researchers. Data regarding their effectiveness was not available. It is argued that a secure attachment style predispose to be a good psychotherapist. Yet, insecurely attached psychotherapists possibly compensate their adverse traits through self-therapy, continuous education, and supervision.

Psychometric properties of the Italian version of the Experience in Close Relationship Scale 12 (ECR-12): an exploratory structural equation modeling study

The Experiences in Close Relationship Scale (ECR) is one of the most commonly used self-report instruments of adult attachment and has been widely adopted in psychotherapy research. Composed of two subscales, namely Attachment Avoidance and Anxiety, the ECR was recently shortened to a 12-items version, called the ECR-12. Given the importance of extending knowledge on its applicability in understudied populations, our aim was to validate the ECR-12 in a large sample of Italian native-speakers. A total of 1197 participants (73.2% females; mean age=28.53±11.37 years) completed the ECR-12. Each participant also completed other measures of attachment, psychopathology, interpersonal distress, coping strategies, and well-being. An Exploratory Structural Equation Modeling analysis showed an excellent fit of the data, providing support for the two-dimensional orthogonal structure of the ECR-12. In addition, the measurement model was invariant across genders. Both attachment anxiety and attachment avoidance subscales demonstrated good internal reliability, with McDonald’s Omegas and Cronbach’s Alphas above the suggested 0.8 cut-off. Finally, the Italian version of ECR-12 showed adequate convergent, concurrent, and divergent validity. Highly anxious individuals reported the highest levels of maladaptive interpersonal functioning and coping strategies, resulting in lower well-being. Interestingly, both attachment insecurity dimensions predicted higher levels of psychopathology, even after controlling for demographic variables and levels of self-reported relational difficulties. Given the good psychometric properties of the ECR-12, researchers and practitioners in Italy are encouraged to adopt the ECR-12 in their future research on adult attachment in psychotherapy.

Attachment Style of Volunteer Counselors in Telephone Emergency Services Predicts Counseling Process

Telephone emergency services (TES) provide emotional support and aim to prevent suicide. The current study examines a potential change of volunteer counselors' attachment characteristics during TES training and investigates the predictive influence of counselor attachment for their competence and working alliance with callers. We recruited 261 volunteers enrolled in training for paraprofessional counseling in the German Telephone Emergency Service (TelefonSeelsorge). Participants were assessed three times during their training (mean training duration 13.3 months) and responded to questionnaires on adult attachment (Experience in Close Relationships-Revised) and their counseling competence (adapted Development of Psychotherapists Common Core Questionnaire). In addition, they indicated the quality of the working alliance (adapted Working Alliance Inventory - Short, Revised) with their client callers upon training completion. Results showed that attachment anxiety, but not attachment avoidance, significantly decreased during training. Lower attachment avoidance predicted better working alliances with callers as well as better general skillfulness. Implications for the training of volunteer telephone counselors are discussed.

Mapping evidence from systematic reviews regarding adult attachment and mental health difficulties: a scoping review

OBJECTIVE

The aim of this scoping review was to map evidence gathered through systematic reviews regarding adult attachment and mental health difficulties. This review highlights established, emerging, and inconsistent findings, suggesting areas for future research, and implications for theory and practice.

METHODS

A systematic search for meta-analyses and systematic reviews measuring adult attachment and concerning mental health difficulties was conducted. In total, 17 studies met the selection criteria.

RESULTS

Findings were presented according to four identified themes, (1) measurement of attachment; (2) measurement of mental health difficulty; (3) intrapersonal processes related to attachment and mental health difficulties; and (4) interpersonal processes related to attachment and mental health difficulties.

CONCLUSIONS

This review highlights the connection between attachment style and mental health difficulties, and suggests that relationships can facilitate both mental health and illheath. However, the mechanisms through which insecure attachment confers risk for mental health difficulties require further research.

Dyadic coping mediates the effects of attachment on quality of life among couples facing ovarian cancer

Cancer is an interpersonal stressor affecting both patient and spouse. To examine the pathways that insecure adult attachment can impact health outcomes by way of dyadic processes, this cross-sectional study used the actor-partner interdependence mediation model to examine whether common dyadic coping (CDC) mediated the associations between attachment and quality of life (QOL). Couples (N = 106) facing ovarian cancer were recruited from a comprehensive cancer center and completed self-report questionnaires. Results indicated that worse social and functional QOL were associated with both one's own and one's partner's greater insecure attachment, by way of one's own use of less CDC. Unexpectedly, greater CDC reported by one's partner was associated with one's own lower functional QOL. Although CDC has beneficial effects on QOL, CDC may also be experienced as draining. Effects of adult attachment on dyadic coping are a significant contributor to subjective health outcomes among couples facing ovarian cancer.

Attachment Styles and Posttraumatic Growth Among Suicide-Loss Survivors

Abstract. Background and aims: The world loses approximately one million people to suicide every year, leaving behind many suicide-loss survivors, family members and friends, who are significantly affected by the traumatic loss. Yet some suicide-loss survivors not only manage to cope with the loss, but actually experience posttraumatic growth (PTG). To date, no studies have fully examined the psychological processes that underlie this personal positive change. We hypothesized that attachment style would predict PTG and this association would be mediated by self-disclosure and social support. Method: A community sample of 131 suicide-loss survivors (108 women), aged 18–70, self-reported on attachment style, self-disclosure, social support, and PTG. Results: Securely attached individuals scored highest on PTG compared with other attachment styles. A structural equation model confirmed that self-disclosure and social support mediated the association between attachment and PTG. Suicide-loss survivors with secure attachment tended to self-disclose more and to perceive greater support from others than did suicide-loss survivors with insecure attachment, thus enhancing their chances of PTG. Limitations: The sample comprised mostly female participants, and the findings may not be directly generalizable to male suicide-loss survivors. Conclusion: Our results suggest that different psychological interventions should be utilized for suicide-loss survivors with particular attachment styles. Psychotherapies aiming to modify internal working models may be useful for enhancing PTG among survivors characterized by insecure attachment styles.

A Comparative Effectiveness Study of a Shortened Trauma Recovery Empowerment Model and an Attachment-Informed Adaptation

Relational challenges often associated with interpersonal trauma may hinder survivors' abilities to fully benefit from group therapy. This quasi-experimental study compared clinical outcomes of a 16-week version of the Trauma Recovery and Empowerment Model (TREM) for women and an attachment-informed adaptation (ATREM). Prior findings of TREM are extended by demonstrating that both group conditions can facilitate comparable clinical outcomes, creating options for group facilitators. Only ATREM resulted in statistically significant improvement in individual attachment avoidance, and it trended toward a slightly higher completion rate. This study provides insight into the emerging concept of group attachment.

Buffering Internalization of HIV Stigma: Implications for Treatment Adherence and Depression

BACKGROUND

One mechanism through which social stigma of HIV affects health outcomes for people living with HIV (PLWH) is through internalization of stigma. However, this transformation of social stigma in the community into internalized stigma may not be of the same magnitude for all PLWH. We examined the moderating effects of 3 personality traits-fear of negative social evaluation, attachment-related anxiety, and dispositional resilience-in transforming perceived stigma in the community into internalized stigma. Furthermore, we investigated downstream effects of these moderated associations on depressive symptoms and antiretroviral treatment (ART) adherence.

SETTING/METHODS

In study 1, data from 203 PLWH in the Southeast United States were analyzed controlling for age, sex, education, race, and time on ART. In study 2, data from 453 women in a multisite study were analyzed controlling for age, education, race, time on ART, and substance use.

RESULTS

In both studies, fear of negative evaluation and attachment-related anxiety moderated the effect of perceived HIV stigma in the community on internalized HIV stigma: People higher on those moderating variables had stronger associations between perceived stigma in the community and internalized stigma. In study 2, resilience was assessed and also moderated the effect of perceived HIV stigma in the community on internalized stigma. In moderated mediation models, fear of negative evaluation, attachment-related anxiety, and resilience moderated the indirect effect of perceived HIV stigma in the community on ART adherence and depression through internalized stigma.

CONCLUSIONS

Interventions to assuage internalization of HIV stigma should focus on bolstering attachment-related security, social competence, and resilience.