Attachment in mental health institutions: a critical review of assumptions, clinical implications, and research strategies

Building high-quality interpersonal staff-client relationships with people with severe to profound intellectual disabilities and challenging behavior: Insights of professionals and relatives

Background: Staff-client relationships impact the quality of support and life of people with severe to profound intellectual disabilities and challenging behavior, but are challenging to build due to clients' intense, complex and varying support needs. The present study explores the perspectives of professionals and relatives on what affects these interpersonal relationships. Method: 17 professionals and 11 relatives participated in focus groups and interviews. Data collection and analysis was performed in collaboration with a co-researcher. Data were synthesized thematically. Results: Interpersonal relationships constituted equivalence, striving for mutual understanding, trust and exploring clients' potential. The combination of staff characteristics (enthusiasm/passion, patience, resilience, creativity/humor, flexibility) and expertise (knowledge, vulnerability/sincerity, self-reflection) enabled staff to build these relationships. The importance of involving relatives was addressed. Contextual influences included the team (cooperation, flexibility, culture), organization (cooperation, boundary conditions) and setting (predictability, interior/atmosphere). Conclusions: The findings make practical knowledge explicit and scientifically underpinned for this specific population.

The Relationship between Dog Ownership, Psychopathological Symptoms and Health-Benefitting Factors in Occupations at Risk for Traumatization

Individuals working in high-risk occupations (e.g., emergency staff) are exposed to high levels of occupational stress including traumatic events. Correspondingly, several studies report high rates of mental health problems among these occupations. Pet ownership has been associated with better mental health. However, to date a study on the association between pet ownership and indicators of mental health in these occupations is missing. The present cross-sectional survey (N = 580) investigated pet ownership, attachment to pets, health-benefitting factors (i.e., sense of coherence, trait-resilience, locus of control) and psychopathological symptoms (i.e., general mental health problems, posttraumatic stress, burnout) in medical staff, police officers, and firefighters. Dog owners and non-dog owners showed comparable levels of psychopathological distress and health-benefitting factors. Compared to cat owners, dog owners demonstrated stronger emotional attachment to their pet. Moreover, a stronger attachment was also linked to higher levels of psychopathological symptoms and lower levels of health-benefitting factors. However, the relationship between attachment to pets and health-benefitting factors could be explained by their overlap with psychopathological symptom levels. Overall, our findings are not in line with the notion that pet ownership generally has a health-benefitting effect. Future studies need to investigate circumstances that modulate positive effects of pet ownership.

Attachment Patterns in Subjects Diagnosed With a Substance Use Disorder: A Comparison of Patients in Outpatient Treatment and Patients in Therapeutic Communities

The purpose of the present study is to analyze the quality of attachment in substance abuse patients in outpatient treatment vs. patients in therapeutic communities in order to identify the role of attachment insecurity in choosing a care system. The sample consisted of 127 subjects (107 males and 20 females); 97 were outpatients (83 males) and 30 therapeutic community patients (24 males). Attachment with respect to current, significant relationships was assessed using the Relationship Questionnaire. In the outpatient subgroup, the prevailing attachment style was preoccupied; for the therapeutic community patients, the prevailing attachment style was dismissive. The dimensions of care (how the caregiver is perceived as loving and caring) and overprotection (how the caregiver is perceived as intrusive and interfering)-evaluated by means of the Parent Bonding Instrument-were higher in the outpatient subgroup. Scores were higher with respect to maternal subscales regardless of treatment modality. No differences emerged with respect to self-perceived symptoms (SCL-90-R) between the subgroups; however, fearful-avoidant and dismissive-avoidant individuals reported higher self-perceived symptom regardless of treatment modality. Understanding the distribution of different attachment patterns with respect to the treatment modality may improve efficacious interventions, attuning them to the individual and his or her developmental environment.

[Addiction as an attachment disorder]

BACKGROUND

There is no commonly accepted model for describing the development and treatment of substance use disorders (SUD); however, over several decades the attachment theory has represented an important basis for the clinical handling of SUD. This study gives a systematic review of empirical studies regarding the relationship between SUD and disorders of attachment behavior.

OBJECTIVE

Is there a positive relationship between disorders of attachment behavior and the presence of SUD?

METHOD

Various databases (PsychInfo, Web of Science, PubMed) were systematically searched in order to pinpoint relevant studies in books and articles published in English or German. Based on the results 22 publications were selected. After a stricter limitation to original research, 12 articles could finally be accepted as eligible.

RESULTS

A significant relationship was found between SUD and insecure attachment in 10 out of the 12 studies.

CONCLUSION

Based on the results of the research studies reviewed the hypothesis to characterize SUD as a possible expression of an attachment disorder was confirmed. This corroborates the importance of considering attachment parameters in dealing with prevention and treatment of SUD. Further research might focus on non-substance-related addictive disorders and therapy outcome studies.

Trajectories of Substance Use among Child Welfare-Involved Youth: Longitudinal Associations with Child Maltreatment History and Emotional/Behavior Problems

BACKGROUND

Maltreated children experience a variety of adverse outcomes including substance use problems. Although previous research indicated that there may be distinct trajectories of substance use among these youth, studies have examined them as if they were a single homogeneous group.

OBJECTIVES

The goals of this study were to explore substance use trajectories among child welfare-involved youth and to identify characteristics that distinguish substance use trajectories.

METHODS

Data from the National Survey of Child and Adolescent Well-Being (NSCAW II) were used. Multilevel latent growth mixture modeling (MLGMM) was performed using a subsample of 625 youth from ages 11-17 years investigated for maltreatment in 2008-2009. Measures included self-reported use of substance use during the previous 30 days, demographic characteristics, maltreatment history, placement in out-of-home care, and behavioral health problems.

RESULTS

MLGMM identified two distinct substance use trajectory classes including High Stable Substance Use and Rapid Progression Use. Findings suggest that the experience of physical abuse is the key factor that distinguishes the two groups. When the effects of class-specific covariates were examined, results suggest that involvement in substance use behavior and its escalation vary between groups and are affected by youth's different previous experiences. Conclusions/Importance: The results have important implications for understanding individual differences in substance use behavior over time and how these differences were shaped by youth's experiences of family adversity. Study findings may be helpful for developing and enhancing the effectiveness of interventions targeted at decreasing substance use behaviors in child welfare-involved youth.

Attachment figures in a middle childhood Romanian sample: Does parental migration for employment matter?

This study assessed how children's choices of attachment figures are related to the quality of the parent-child relationship and parental economic migration in a Romanian sample. Two hundred and twenty-two children (n girls =130) 10-13 years of age completed the Attachment Figure Interview and a parental migration interview, and reported their attachment security with mother and father. Approximately 35.6% (n = 79) of children had mothers with a migration history and 48.7% (n = 104) of children had fathers with a migration history. Mothers, and to some extent fathers, serve as primary attachment figures. Grandparents, peers, siblings and relatives serve as secondary attachment figures in some situations. Further, children are less likely to choose mothers as primary attachment figures and show lower attachment security when their mothers rather than their fathers have a history of migration. Overall, this study provides empirical grounds to conceptualize parental migration as an attachment disruption.

The Relationship between Adult Attachment and Mental Health Care Utilization: A Systematic Review

OBJECTIVE

Several studies have shown a relationship between individual attachment and various aspects of treatment utilization in individuals with medical problems as well as mental health disorders. This review systematically evaluates existing literature targeting the relationship between attachment and all aspects of treatment utilization, such as engagement, participation, and completion, in adults with mental health problems.

METHOD

A computerized search of PsycINFO, Medline, Embase, PubMed, and Healthstar and a manual search were employed. Of 5733 titles, 105 abstracts were selected. Of these, 18 studies met full inclusion criteria. The quality of studies was evaluated and scored according to 9 characteristics.

RESULTS

Most studies supported an association between attachment and treatment engagement and participation. In general, attachment anxiety was associated with higher engagement and participation in services while attachment avoidance was associated with less. Data regarding attachment dimensions and treatment completion were less conclusive.

CONCLUSIONS

The review suggests a clear relationship between attachment and stages of treatment engagement and participation in a variety of psychiatric populations and treatments. The 2 attachment dimensions appear to have opposite effects, with possible risks for either treatment over- or underutilization. Clinical implications are discussed.

Security of mind: 20 years of attachment theory and its relevance to psychiatry

In this editorial, I suggest that no psychiatrist should be without a working knowledge of attachment theory, and it is a capability that all trainees should cover in the proposed new curriculum. I have focused on three domains of research to argue that attachment theory is relevant to practicing psychiatrists.Declaration of interestNone.

Attachment theory in psychiatric rehabilitation: informing clinical practice

This article highlights the relevance of attachment theory for psychiatric rehabilitation services and discusses practice implications derived from the theory. Attachment theory can guide the development of interpersonal relationships during recovery and this aspect of rehabilitation is emphasised here. Attachment theory can also be used to help staff predict and understand problematic behaviours such as violence and aggression, and different styles of recovery. The theory can help promote positive staff–service-user relationships by highlighting the qualities of effective caregivers and the way in which people with different attachment styles might benefit from different approaches. We conclude by suggesting ways of teaching rehabilitation staff to become more effective attachment figures.

Attachment theory in adult psychiatry. Part 2: Importance to the therapeutic relationship

This article focuses on how the general adult psychiatrist, in thinking about everyday clinical problems, may usefully apply attachment theory to gain insight. Fictional case vignettes are used to illustrate the importance of attachment in shaping and understanding the clinician–patient relationship. Ways in which service configurations may be informed by attachment theory are also examined.

Caregiver-mediated therapy for an adult with visual and intellectual impairment suffering from separation anxiety

BACKGROUND

Separation anxiety among intellectually disabled (ID) persons with comorbid visual impairment could be rooted in a weak sense of person permanence. Technology-assisted Therapy for Separation Anxiety (TTSA) was used to address this problem.

AIMS

The primary aim was to determine whether technology alone or including caregivers was the best option, and whether TTSA decreased separation anxiety and challenging behaviour. Also, how the caregivers and the client experienced TTSA.

METHODS AND PROCEDURES

A pre-experimental, quantitative approach (AB1C1B2C2D) was used for this single-subject study. The frequency of the client's text messages was recorded daily. The variables were monitored with standardised instruments and caregivers rated the intensity and frequency of the client's anxious and challenging behaviour. The social validity was evaluated by means of questionnaires.

OUTCOMES AND RESULTS

There was a significant decrease in the anxious and angry messages sent, and in anxious and challenging behaviour, in the phase in which the caregivers were included, compared with the phase in which technology alone was used. The client and the caregivers were positive about TTSA.

CONCLUSION AND IMPLICATION

Technology and the caregivers reactions reduces the anxiety and challenging behaviour. It might also aid the acquisition of the concept of person permanence.

Using attachment theory to inform the design and delivery of mental health services: a systematic review of the literature

PURPOSE

The aim of this review was to propose and describe the design and delivery of an attachment-informed general mental health service.

METHOD

We systematically searched the PsycINFO, MEDLINE, Web of Knowledge, COPAC, CINAHL, and Science Direct databases from 1960 to 2013. We also searched reference lists of relevant papers and directly contacted authors in the field. Literature describing attachment theory and its applicability in designing and delivering general mental health services was synthesized using thematic analysis. Papers published in English, books or chapters in edited books that described applying attachment theory in designing and delivering mental health services for adults and adolescents were included in the review. Of the 1,105 articles identified, 14 met inclusion criteria for the review. Eight key themes, and four subthemes, were extracted and organized to reflect the experience of a service user moving through the mental health system.

RESULTS

Key themes extracted were as follows: service policy and evaluation; referrals; assessment and formulation; intervention; support for staff; support for carers; moving on; and potential service benefits. Papers reviewed suggested that service users with severe mental health problems have attachment needs that should be met in general mental health services.

CONCLUSIONS

Attachment theory provides a useful framework to inform the design and delivery of general mental health services. The resource implications for services are discussed, as are limitations of the review and recommendations for future research.

PRACTITIONER POINTS

Attachment theory should be used to inform the design and delivery of general mental health services. Mental health services should evaluate the extent to which they meet service users' attachment needs. Attachment-informed mental health services should assess outcomes, including cost-effectiveness over time. Papers included in this review focus on long-stay residential care or secure services and there is a limited experimental evidence base to show that providing an attachment-informed service improves patient outcomes.

Anorexia and attachment: dysregulated defense and pathological mourning

The role of defensive exclusion (Deactivation and Segregated Systems) in the development of early relationships and related to subsequent manifestations of symptoms of eating disorders was assessed using the Adult Attachment Projective Picture System (AAP). Fifty-one DSM-IV diagnosed women with anorexia participated in the study. Anorexic patients were primarily classified as dismissing or unresolved. Quantitative and qualitative analyses of defensive exclusion were carried out. Results showed potential benefits of using the AAP defense exclusion coding system, in addition to the main attachment classifications, in order to better understand the developmental issues involved in anorexia. Discussion concerned the processes, such as pathological mourning, that may underlie the associations between dismissing and unresolved attachment and anorexia. Implications for developmental research and clinical nosology are discussed.

Service attachment: the relative contributions of ward climate perceptions and attachment anxiety and avoidance in male inpatients with psychosis

BACKGROUND

It has been suggested that mental health services can help meet the attachment needs of inpatients and improve patient outcomes through the provision of a 'secure base'; however, what defines the latter is unclear. Perception of ward climate might be a useful indicator.

AIM

The aim of this study was to examine whether inpatient perceptions of the ward climate, which is partly under the control of the service, or inpatients' own personal levels of attachment anxiety and avoidance are more associated with their attachment to their service.

METHOD

Seventy-six men diagnosed with a psychotic illness, who were residents in one of four regional medium-security units in England, completed questionnaire measures of service attachment, personal attachment style and ward climate.

RESULTS

Ward climate was more strongly associated with service attachment than personal levels of attachment anxiety and avoidance. The most important aspect of ward climate for service attachment was the depth and influence of staff support for the inpatients.

CONCLUSIONS

Although patient characteristics are important influences on development of service attachment, ward climate is also important. The latter may be easily and reliably monitored with a brief questionnaire. Strategies to enhance and maintain its positive components are likely to be important for progress with forensic hospital inpatients who have a psychotic illness.

Psychological consultation in older adult inpatient settings: a qualitative investigation of the impact on staff's daily practice and the mechanisms of change

OBJECTIVES

Psychological consultation is becoming increasingly common within older adult mental health and dementia services. However, there is very little research that examines the impact or effectiveness of this method of working. This study explored how psychological consultation impacted on the daily practice of staff working on mental health and dementia inpatient units. It also examined the mechanisms that enabled this process.

METHOD

Given the lack of current literature in this area, an exploratory qualitative design was employed. Ten staff who had received psychological consultation were individually interviewed. Staff comprised qualified and unqualified staff from a range of professions, and worked on older adult mental health or dementia units. Interviews were subject to thematic analysis.

RESULTS

Five themes were identified from the analysis: (1) 'It makes you understand the reasons why people are like they are'; (2) 'It depends on the patient or service user'; (3) the importance of visibility and accessibility; (4) impact of psychology consultation on the effectiveness of the team; and (5) impact of psychology consultation on feelings invoked in the workplace.

CONCLUSIONS

The findings suggest that psychological consultation impacted on staffs' daily practice in a variety of ways. Psychological consultation also appeared to increase team efficiency. Less positive findings were identified within the dementia setting. Specific recommendations are drawn from the conclusions to further guide clinical psychologists working within teams. Direction for future research in the area of psychological consultation is also suggested.

Teacher-child relationships from an attachment perspective

This special issue aims to prompt reflection on the mutual contribution of attachment theory, on the one hand, and teacher-child relationship research, on the other, by bringing together conceptual and empirical contributions taking an attachment perspective on teacher-child relationships. In this introductory article, we contend that the teacher can be regarded as an ad hoc attachment figure with a safe haven and secure base function, although for most children the relationship with the teacher is probably not an attachment bond. Furthermore, we explain how attachment theory and research: (1) shape the way in which "high quality" teacher-child relationships are conceptualized and operationalized; (2) highlight the importance of teacher sensitivity to children's needs, as a central proximal determinant of relationship quality; (3) guide research hypotheses regarding the consequences of teacher-child relationship quality and the intervening mechanisms; and (4) inspire the development of interventions to improve teacher-child relationships.

A meta-analysis of attachment to parents and delinquency

To investigate the link between attachment to parents and delinquency, and the potential moderating effects of age and sex, 74 published and unpublished manuscripts (N = 55,537 participants) were subjected to a multilevel meta-analysis. A mean small to moderate effect size was found (r = 0.18). Poor attachment to parents was significantly linked to delinquency in boys and girls. Stronger effect sizes were found for attachment to mothers than attachment to fathers. In addition, stronger effect sizes were found if the child and the parent had the same sex compared to cross-sex pairs of children and parents. Age of the participants moderated the link between attachment and delinquency: larger effect sizes were found in younger than in older participants. It can be concluded that attachment is associated with juvenile delinquency. Attachment could therefore be a target for intervention to reduce or prevent future delinquent behavior in juveniles.

Attachment type for adolescents in residential treatment centers

The styles of attachment in two groups of adolescents with different characteristics and life experiences are examined. Participants were 81 adolescents residing inside residential treatment centers (M age = 15.5 yr., SD = 1.1; 48% boys, 52% girls) and 81 adolescents living with their own families (M age =15.6 yr., SD = 1.3; 49% boys, 51% girls). The Italian adaptation of the Separation Anxiety Test was used to measure attachment style. Only the data obtained from the "Self" perspective indicated a significant difference between the two groups, showing higher percentages of Secure attachment among adolescents living with their families. When replies were referred to the "Self," the risk of assessing Insecure attachment in the Residential group was about 2 times higher than in the Family group (OR = 2.28).

Wellbeing of adult children and ageing parents: associations with intergenerational support and relationship quality

The current study describes from an attachment-theoretical viewpoint how intergenerational support in adult child-parent relationships is associated with wellbeing in both generations. The attachment perspective and its focus on affective relationship characteristics is considered as an important theoretical framework for the investigation of special relationships across the life span. Data from the Netherlands Kinship Panel Study (N=1,456 dyads) were analysed to investigate if relationship quality moderated the association between providing intergenerational support to parents and wellbeing in adult children, on the one hand, and receiving intergenerational support from children and wellbeing of older parents on the other hand. The perspectives of both relationship partners were taken into account to allow for dependence within dyads. Intergenerational support, in terms of instrumental help provision, was negatively associated with the child's and parent's wellbeing. Being the stronger and wiser partner in adult-child parent relationships, as reflected by giving advice and being the initiator within the relationship, was beneficial for the wellbeing of both generations. Additionally, relationship quality was the strongest predictor of wellbeing in both generations. Parental wellbeing was benefited by filial support in high quality relationships. If an intergenerational relationships was of high quality, the challenges of intergenerational support provision and receipt were easier to deal with for both generations, parents and children.

Attachment figures in middle childhood

Previous research has focused on who the primary attachment figures are for children in middle childhood, but there has been relatively little research on other important people who may fulfill attachment needs. The goal of the study was to identify who children use as non-parental attachment figures and to examine whether children's use varies with certain child characteristics. Children 7—12 years of age completed an open-ended interview to identify attachment figures. This study suggests that children may, at times, direct secure base behavior towards peers, siblings, grandparents, and teachers. The study also shows that the identity and use of attachment figures may vary with certain child characteristics such as age, gender, and sibling status. Older siblings were more likely than younger siblings to be used as attachment figures, and older children were more likely than younger children to turn to peers to fulfill attachment needs.

Inter-generational relationships at different ages: an attachment perspective

This study examines the characteristics of parent-child relationships after childhood from a theoretical attachment perspective. It describes how relationships between adult children and their parents vary by age group of the child on three dimensions that were derived from attachment theory: direction, penetration and quality. Data from 4,589 respondents to the Netherlands Kinship Panel Study were analysed to describe relationships between adult-children and their parents. Analyses of covariance were used to specify differences by age group. The results showed that age had notable effects on relationships between adult children and parents, especially their direction and penetration or centrality. The direction was reversed for parents of children in the two oldest age groups. The level of penetration was lower for the older age groups, and quality was higher in the younger age groups, but the effect size was small. The age effects on the dimensions were qualified by the personal circumstances of the adult children. Having one's own children was associated with different patterns of attachment at different ages. Adult children may be an important source of support for their elderly parents and may even become ‘attachment figures’. Given the current increases in longevity, there could be increasing pressure on adult children to support their parents. Attachment theory is a useful framework for studying the characteristics of inter-generational relationships, also after childhood.

Attachment style, home-leaving age and behavioral problems among residential care children

In a prospective study, the attachment style, home-leaving age, length of time in residential care, and behavioral problems among Israeli residential care children (N = 68), were studied. Data analyses showed that children removed from their homes at a later age suffered from higher levels of anxiety, depression and social problems compared to children taken from their homes at the age of 7 or less. It was also found that a prolonged stay (over 2 years) in residential care was related to higher levels of anxiety and depression. An interaction effect of a child's attachment style and home-leaving age was found in the child's level of aggressive behavior.