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

The Effects of Repeated Attachment Security Priming on Social Anxiety and Attention Bias: A Randomized Controlled Trial

BACKGROUND

Although the clinical utility of attachment security priming has been suggested in recent years, the effect of attachment security priming on social anxiety and its core symptoms (i.e., attention bias) remains unspecified. Therefore, the present study explored the potential effectiveness of repeated attachment security priming in alleviating social anxiety and attention bias among Chinese college students.

METHODS

Fifty-six college students with high social anxiety were randomly assigned to the attachment security priming group (n = 30) or control group (n = 26). The priming group completed seven attachment security priming sessions over 2 weeks (every 2 days), and the control group was assigned to a waitlist for 2 weeks.

RESULTS

The results revealed that individuals in the priming group reported less social anxiety after 2 weeks of security attachment priming, and those in the control group did not change significantly. The results also showed that there was no significant change in the attention bias of individuals with social anxiety before and after the intervention.

CONCLUSIONS

Our findings indicate that attachment security priming is a promising alternative intervention option for social anxiety. The potential clinical implications of security attachment priming are discussed.

The Effects of Emotion Regulation on Physical and Psychological Wellbeing in University Students: The Role of Depersonalization and Attachment Style

Our ability to regulate our emotions plays a key protective role against psychological distress and somatic symptoms, with most of the literature focusing on the role of cognitive reappraisal in interventions such as cognitive behavioral therapy (CBT). This study seeks to examine the relationship between emotion dysregulation and psychological and physical distress in university students through the role of depersonalization (DP) and insecure attachment. This study will try to explain the deployment of DP as a defense mechanism to insecure attachment fears and overwhelming stress, developing a maladaptive emotion responding strategy, which affects wellbeing later in life. A cross-sectional design was used on a sample (N = 313) of university students over the age of 18 which consisted of an online survey of 7 questionnaires. Hierarchical multiple regression and mediation analysis were conducted on the results. The results showed that emotion dysregulation and DP predicted each variable of psychological distress and somatic symptoms. Both insecure attachment styles were found to predict psychological distress and somatization, mediated through higher levels of DP, whereby DP may be deployed as a defense mechanism to insecure attachment fears and overwhelming stress, which affects our wellbeing. Clinical implications of these findings highlight the importance of screening for DP in young adults and university students.

Identifying victimisation profiles in people with psychosis and a history of childhood trauma: a latent class analysis

Background

People with psychosis experience higher rates of childhood victimisation compared to the general population, which may impact on mental health and recovery. This study aimed to identify childhood victimisation profiles in a clinical sample to inform recommendations for routine care.

Methods

Participants were 146 adults (ages 19-65 years; M = 42.2) with schizophrenia-spectrum diagnoses reporting trauma. Childhood trauma was assessed using two retrospective measures, and a latent class analysis (LCA) was performed on four trauma types (sexual abuse, emotional abuse, physical abuse and neglect). Multinomial logistic regression investigated demographic differences between the classes.

Results

Four distinct childhood trauma classes were identified: Emotional abuse/neglect (n = 29); physical abuse (n = 14); sexual abuse (n = 19); and poly-victimisation (n = 84). There were no differences between the classes in terms of age, ethnicity, relationship status, education or current employment (relative risk (RR) = 0.85-1.27, p > 0.05). Participants in the poly-victimisation class were significantly more likely to be female (RR = 0.22-0.28, p < 0.04).

Discussion

Adults with psychosis, particularly females, are likely to report poly-victimisation in childhood. This highlights the need to comprehensively but concisely assess experiences of abuse and neglect in clinical care, in line with trauma-informed approaches.

A "transmission gap" between research and practice? A Q-methodology study of perceptions of the application of attachment theory among clinicians working with children and among attachment researchers

Clinical practitioners are frequently encouraged, through literature, training, and policy, to learn, understand, refer to and use their knowledge of attachment theory and research when working to meet the needs of children and families. However, there has been very little empirical study of how practitioners understand and perceive the relevance of attachment concepts and methods. Q-methodology was used to examine the perceptions of attachment knowledge and its applications for practice among 30 UK clinicians working with children and an international group of 31 attachment researchers. Factor analysis revealed three perspectives, described as: i) pragmatic, developmental, and uncertain, ii) academic, and iii) autodidactic and therapeutic. Participants agreed on core tenants of theory, their aspirations for clinical practice and the inaccessibility of current assessment measures for practitioners. Yet they diverged on their understandings of attachment insecurity, disorganisation, and the implications of both for various aspects of child development.

Fluctuations in proximity seeking and paranoia

OBJECTIVES

This study aimed to investigate associations between proximity seeking, stress and paranoia in the context of daily life, and whether these relationships are moderated by trait attachment styles.

METHODS

Sixty non-clinical participants completed 3423 assessments of state stress, proximity seeking and paranoia over a 6-day period using an experience sampling method. Multilevel linear regression was performed to evaluate relationships between variables.

RESULTS

The post-hoc analysis showed antecedent events subjectively appraised as very unpleasant or very pleasant predicted greater levels of momentary proximity seeking at the subsequent timepoint. Greater stress predicted greater subsequent shifts or variability in proximity seeking. Changes in proximity seeking were not associated with momentary paranoia. However, for individuals with an avoidant attachment style, greater shifts in proximity seeking resulted in greater subsequent reports of paranoia.

CONCLUSIONS

These findings suggest that, in daily life, the attachment system may become active in response to stress. For those with an avoidant attachment style, an active attachment system may exacerbate paranoid thoughts possibly due to the activation of attachment-related beliefs that one should be fearful of unavailable others and instead rely on one's autonomy to regulate affect. These findings highlight the need to consider attachment in the assessment and formulation of paranoia.

Digital smartphone intervention to recognise and manage early warning signs in schizophrenia to prevent relapse: the EMPOWER feasibility cluster RCT

BACKGROUND

Relapse is a major determinant of outcome for people with a diagnosis of schizophrenia. Early warning signs frequently precede relapse. A recent Cochrane Review found low-quality evidence to suggest a positive effect of early warning signs interventions on hospitalisation and relapse.

OBJECTIVE

How feasible is a study to investigate the clinical effectiveness and cost-effectiveness of a digital intervention to recognise and promptly manage early warning signs of relapse in schizophrenia with the aim of preventing relapse?

DESIGN

A multicentre, two-arm, parallel-group cluster randomised controlled trial involving eight community mental health services, with 12-month follow-up.

SETTINGS

Glasgow, UK, and Melbourne, Australia.

PARTICIPANTS

Service users were aged > 16 years and had a schizophrenia spectrum disorder with evidence of a relapse within the previous 2 years. Carers were eligible for inclusion if they were nominated by an eligible service user.

INTERVENTIONS

The Early signs Monitoring to Prevent relapse in psychosis and prOmote Wellbeing, Engagement, and Recovery (EMPOWER) intervention was designed to enable participants to monitor changes in their well-being daily using a mobile phone, blended with peer support. Clinical triage of changes in well-being that were suggestive of early signs of relapse was enabled through an algorithm that triggered a check-in prompt that informed a relapse prevention pathway, if warranted.

MAIN OUTCOME MEASURES

The main outcomes were feasibility of the trial and feasibility, acceptability and usability of the intervention, as well as safety and performance. Candidate co-primary outcomes were relapse and fear of relapse.

RESULTS

We recruited 86 service users, of whom 73 were randomised (42 to EMPOWER and 31 to treatment as usual). Primary outcome data were collected for 84% of participants at 12 months. Feasibility data for people using the smartphone application (app) suggested that the app was easy to use and had a positive impact on motivations and intentions in relation to mental health. Actual app usage was high, with 91% of users who completed the baseline period meeting our a priori criterion of acceptable engagement (> 33%). The median time to discontinuation of > 33% app usage was 32 weeks (95% confidence interval 14 weeks to ∞). There were 8 out of 33 (24%) relapses in the EMPOWER arm and 13 out of 28 (46%) in the treatment-as-usual arm. Fewer participants in the EMPOWER arm had a relapse (relative risk 0.50, 95% confidence interval 0.26 to 0.98), and time to first relapse (hazard ratio 0.32, 95% confidence interval 0.14 to 0.74) was longer in the EMPOWER arm than in the treatment-as-usual group. At 12 months, EMPOWER participants were less fearful of having a relapse than those in the treatment-as-usual arm (mean difference -4.29, 95% confidence interval -7.29 to -1.28). EMPOWER was more costly and more effective, resulting in an incremental cost-effectiveness ratio of £3041. This incremental cost-effectiveness ratio would be considered cost-effective when using the National Institute for Health and Care Excellence threshold of £20,000 per quality-adjusted life-year gained.

LIMITATIONS

This was a feasibility study and the outcomes detected cannot be taken as evidence of efficacy or effectiveness.

CONCLUSIONS

A trial of digital technology to monitor early warning signs that blended with peer support and clinical triage to detect and prevent relapse is feasible.

FUTURE WORK

A main trial with a sample size of 500 (assuming 90% power and 20% dropout) would detect a clinically meaningful reduction in relapse (relative risk 0.7) and improvement in other variables (effect sizes 0.3-0.4).

TRIAL REGISTRATION

This trial is registered as ISRCTN99559262.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 27. See the NIHR Journals Library website for further project information. Funding in Australia was provided by the National Health and Medical Research Council (APP1095879).

How does attachment style affect psychosis? A systematic review of causal mechanisms and guide to future inquiry

PURPOSE

The link between attachment and psychosis is now well established, but less is known about the causal mechanisms underlying this relationship. This systematic review synthesises the studies that examine mediating mechanisms in the attachment and psychosis relationship, in both clinical and non-clinical samples.

METHOD

We conducted a database search (PsychINFO, MEDLINE, Web of Science) to identify all eligible studies irrespective of publication status, the language of article or article date. We assessed methodological quality and completed a narrative synthesis given the heterogeneity of studies to date.

RESULTS

We identified 17 papers, comprising 3,672 participants. The relationship between attachment and psychosis is mediated by four variables or groups of variables. There is good evidence for the causal role of affective factors (affective dysregulation and affective disturbances) and cognitive factors (e.g., self-beliefs and self-esteem and beliefs about symptoms). Affective factors differed by attachment style. Tentative evidence was found for the role of duration of untreated psychosis and baseline negative symptoms.

CONCLUSIONS

Cognitive and affective factors mediate the relationship between attachment style and psychosis. Whilst cognitive factors are routinely targeted in recommended psychological interventions for psychosis, affective factors and attachment style are less commonly considered. Psychological therapies may be improved by calibrating cognitive and affective interventions by attachment style, which should be subjected to experimental and then field studies to assess the impact on clinical and recovery outcomes.

PRACTITIONER POINTS

The relationship between attachment and psychosis is now well established, and studies have started to examine mediating mechanisms. Affective and cognitive factors mediate the attachment-psychosis relationship. Affective factors differ by attachment style. There is limited evidence for the duration of untreated psychosis and negative psychotic symptoms as mediating mechanisms, and research replication is needed. Cognitive factors are routinely targeted in recommended psychological therapies for psychosis, but affective factors and attachment style are less commonly considered. Research should be conducted into the effectiveness of psychological therapies which calibrate cognitive and affective interventions, according to attachment style.

Associations between attachment, therapeutic alliance, and engagement in black people with psychosis living in the UK

BACKGROUND

Compared to other ethnic groups in the UK, Black people have the highest rates of psychosis. This may partly be explained by both assessment bias and structural racism. Mental health services often find it difficult to develop therapeutic relationships with Black people with psychosis. Attachment theory posits that the quality of previous caregiving experiences influence current interpersonal functioning and emotional regulation. In this study, we applied the theory to improve the understanding of therapeutic relationships with people with psychosis.

AIMS

This is the first study to examine associations between attachment difficulties, therapeutic alliance, and service engagement in a Black sample with psychosis.

METHOD

Fifty-one participants completed self-report measures of attachment and alliance. Staff completed measures of alliance and service engagement.

RESULTS

Higher attachment avoidance was related to poorer alliance ratings. These significant findings were not upheld in a regression model controlling for total symptom scores and perceived ethnic/racial discrimination in services. Attachment anxiety was generally not associated with alliance ratings. Neither attachment anxiety nor attachment avoidance was significantly associated with service engagement.

CONCLUSIONS

Staff should be supported to better understand the needs of service users with avoidant attachment behaviours and to develop mutually-agreed treatment goals and therapeutic bonds.

Attachment-based CBT models for psychosis: a PPI-informed approach for acute care settings

People with psychosis often have prolonged in-patient1 admissions at high personal and economic costs. This is due in part to cognitive, affective and behavioural processes that delay recovery and discharge. For many, these processes are affected by enduring insecure attachment styles. People with insecure attachment struggle to manage strong feelings when unwell, and ward staff may struggle to know how best to offer support. Here, we outline the model of interpersonal process in cognitive therapy, and how this may be adapted to capture beliefs and behaviours associated with insecure attachment. Psychological interventions in acute care often fail due to implementation issues. For this reason, and in line with current guidance on developing complex interventions, we report on a series of Patient and Public Involvement (PPI) consultations with people with lived experience of psychosis, family members and ward staff on the potential utility of these attachment-based CBT models. The PPI meetings highlighted three themes: (1) the need to improve staff–patient interactions on wards; (2) continuity in staff–patient relationships is key to recovery; and (3) advantages and barriers to an attachment-based CBT approach. We conclude by describing how the models can be implemented in routine clinical practice, and generalised across services where interpersonal cognitive and behavioural processes may contribute to delays in people’s recovery.

Key learning aims

(1)

Young adults' dynamic relationships with their families in early psychosis: Identifying relational strengths and supporting relational agency

OBJECTIVES

Most existing research on the family context of psychosis focuses on the 'burden' of caring for people experiencing psychosis. This research is the first to ask young people experiencing early psychosis to 'map' and describe their experiences and understandings of their family relationships, and how they have related to their psychosis and recovery.

DESIGN

The research took an inductive, multimodal hermeneutic-phenomenological approach (Boden, Larkin & Iyer, 2019, Qual. Res. Psychology, 16, 218-236; Boden & Larkin, 2020, A handbook of visual methods in psychology, 358-375).

METHOD

Ten young adults (18-23), under the care of early intervention in psychosis services in the UK, participated in an innovative relational mapping interview (Boden, Larkin & Iyer, 2018), which invited participants to draw a subjective 'map' of their important relationships. This visual methodology enables subtle, complex, ambivalent, and ambiguous aspects of the participants' experiences to be explored.

RESULTS

Findings explore the participants' accounts of how they love, protect, and care for their families; how they wrestle with family ties as they mature; and their feelings about talking about their mental health with loved ones, which was typically very difficult.

CONCLUSIONS

This paper advances understanding of recovery in psychosis through consideration of the importance of reciprocity, and the identification and nurturance of relational strengths. The capacity of a young person to withdraw or hold back when trying to protect others is understood as an example of relational agency. The possibility for extending strengths-based approaches and family work within the context of early intervention in psychosis services is discussed.

PRACTITIONER POINTS

Young adults experiencing early psychosis may benefit from support to identify their relational strengths and the opportunities they have for reciprocity within their family structures, where appropriate. Relational motivations may be important for a range of behaviours, including social withdrawal and non-communication. Services may benefit from exploring the young person's relational context and subjective meaning-making in regard to these actions. Young adults experiencing early psychosis may benefit from opportunities to make sense of their family dynamics and how this impacts on their recovery. Attachment-based and relationally oriented interventions that increase trust and openness, and reduce feelings of burdensomeness are likely to support family functioning as well as individual recovery.

Is there an association between caregiver antipathy and psychosis? A systematic review

PURPOSE

Existing reviews of trauma and psychosis have identified associations between childhood emotional abuse (CEA) and psychosis. However, conceptual issues relating to assessment of CEA limit the conclusions that can be drawn from the literature. The aim of this review was to identify and evaluate studies reporting an association between childhood experiences of caregiver antipathy (i.e. criticism, hostility, coldness, or rejection from a parental figure experienced prior to age 17 years) and psychosis symptoms/diagnosis.

METHODS

Five databases were systematically searched for articles published until May 2020. Studies were evaluated against inclusion/exclusion criteria, and a narrative synthesis of findings was completed. Study quality was assessed by two independent raters.

RESULTS

Fourteen studies comprised of 1,848 participants met inclusion criteria. Twelve of these studies found significant associations between caregiver antipathy and psychosis, and two did not. There was evidence that adults with schizophrenia-spectrum diagnoses report more severe caregiver antipathy in childhood than non-clinical controls and that caregiver antipathy severity is positively correlated with psychosis symptom severity. Most studies received weak or moderate quality ratings and all used cross-sectional or case-control designs which showed associations, rather than causal relationships, between childhood caregiver antipathy and later psychosis.

CONCLUSIONS

Future research would benefit from more rigorous and valid assessment of CEA, use of multivariate methods to account for possible patterns of co-occurrence, and longitudinal study designs to make more robust causal claims. The findings may have important implications for the delivery of psychological care for people with psychosis who report adverse caregiving experiences.

PRACTITIONER POINTS

People with schizophrenia-spectrum diagnoses may report more severe caregiver antipathy in childhood than non-clinical controls. Caregiver antipathy severity appears to be positively correlated with psychosis symptom severity in clinical and non-clinical populations. Clinicians should consider the possible impact of caregiver antipathy on psychosis symptoms, their content and distress maintenance. Clinicians should also recognise the potential impact of adverse caregiving experiences on therapeutic relationships, patterns of help-seeking and service engagement. Best practice in clinical services would be to adopt individual, formulation-based approaches within trauma-informed models of care.

The transition process between child and adolescent mental services and adult mental health services for patients with anorexia nervosa: a qualitative study of the parents' experiences

BACKGROUND

Patients with Anorexia Nervosa (AN) often experience the transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) as challenging. This period tends to have a negative influence on the continuity of care for the adolescents and represents a demanding and difficult period for the parents. To our knowledge, no previous study has explored the parents' experience with the transition from CAMHS to AMHS. Therefore, this qualitative study examines how parents experience the transition process from CAMHS to AMHS.

METHODS

In collaboration with a service user with carer experience, qualitative interviews were conducted with 10 parents who had experienced the transition from CAMHS to AMHS, some from outpatient care and others from both in- and outpatient mental care units in Norway. All had some experience with specialized eating disorder units. The interviews were analyzed with a Systematic Text Condensation (STC) approach. Service users' perspectives were involved in all steps of the research process.

RESULTS

Six categories represent the parents' experiences of the transition: (1) the discharge when the child turns 18 years old is sudden; (2) the lack of continuity is often followed by deterioration and relapses in the patient; (3) the lack of involvement and information causes distress; (4) knowledge - an important factor for developing a trusting relationship between parents` and clinicians`; (5) parents have overwhelming multifaceted responsibilities; and (6) parents need professional support.

CONCLUSION

Improving the transition by including parents and adolescents and preparing them for the transition period could ease parental caregiving distress and improve adolescents' compliance with treatment. Clinicians should increase their focus on the important role of parents in the transition process. The system should implement routines and guidelines to offer caregivers support and guidance during the transition process.

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.

Service users' and carers' experiences of engaging with early intervention services: A meta-synthesis review

AIM

The provision and implementation of early intervention for psychosis services (early intervention services [EIS]) has received increasing attention over recent years. Maximizing engagement with EIS is of clinical and economic importance, and exploring the experiences of those who access EIS is vital. Although research has been conducted exploring the experiences of engaging with EIS from both a service user and carer/family member point of view, these data have not been systematically collated to generate new understanding. The primary aim of this study is to review, critically appraise and synthesize qualitative findings relating to the experiences of service users and/or carers and family members engaging with EIS.

METHODS

Four databases were systematically searched. Studies were analysed using an inductive thematic analysis approach, within a critical realist epistemological framework. Studies were critically appraised using the critical appraisal skills programme tool.

RESULTS

Fourteen papers were identified for inclusion. Three main themes were identified: the importance of a personal relationship with an EIS staff member, the impact of this relationship and consideration of life after EIS. The importance of a strong relationship with EIS staff was the most prominent theme throughout the papers reviewed.

CONCLUSIONS

The quality of the therapeutic relationship with at least one EIS staff member was the single most important factor in determining whether the experience of accessing EIS was a positive or negative one. The majority of the studies reviewed were conducted in the United Kingdom or Australia. Therefore, more research across countries is needed to understand transferability of findings.

Attachment in Patients with Bipolar and Unipolar Depression: A Comparison with Clinical and Non-clinical Controls

Background

A link between depression and insecure attachment has long been postulated. Although many studies examined the relationship between depressive symptoms and attachment, relatively few studies were performed on patients diagnosed with depression. Also, research on patients with bipolar disorder is scarce.

Objective

We aimed at testing the association between attachment insecurity and unipolar and bipolar depression.

Methods

We studied 21 patients with bipolar disorder, current episode depressed, and three age- and sex-matched groups, each consisting of 21 individuals: patients with major depressive disorder, recurrent episode; patients with epilepsy; non-clinical participants. The Experience in Close Relationships questionnaire was used to assess adult attachment style.

Results

Patients with both bipolar and unipolar depression displayed significantly higher scores on attachment-related avoidance as compared with patients with epilepsy and non-clinical participants. Also, patients with bipolar depression scored significantly higher on attachment-related anxiety than all other groups. In both psychiatric groups, attachment dimensions were not significantly correlated with global clinical severity or severity of depression.

Conclusion

Despite some study limitations, our results are consistent with some previous studies and provide support to Bowlby's seminal hypothesis that attachment insecurity may predispose to depression. Attachment theory may provide a valuable theoretical framework for future research and for guiding treatment.

Peer Attachment and Academic Procrastination in Chinese College Students: A Moderated Mediation Model of Future Time Perspective and Grit

Although prior research has considerably documented the prevalence and correlates of academic procrastination in college students, relatively little is known about the role of longer volitional processes of goal striving, such as grit, on academic procrastination; moreover, the knowledge about direct and interactive effects of social context and personal characteristic on facilitating grit, which in turn mitigate academic procrastination, are still underexplored. Given these gaps in the existing literature, the current study, more exploratory in nature, investigates a moderated mediation model of future time perspective and grit in the association between peer attachment and academic procrastination in Chinese college students. A total of 1,098 undergraduate students (43.2% girls) aged from 18 to 25 were involved in the current study, and participants were asked to fill in a battery of self-report questionnaires. Results indicated that (a) peer attachment was negatively and significantly associated with academic procrastination; (b) grit partially mediated the association between peer attachment and academic procrastination; more precisely, peer attachment was positively associated with grit, which in turn was negatively linked to academic procrastination; and (c) future time perspective moderated the association between peer attachment and grit; more specifically, for students with low levels of future time perspective, the association between peer attachment and grit turned out to be significantly negative. These findings suggest that interventions targeting the enhancement of peer attachment and grit may prevent or reduce academic procrastination, and college students who regard future orientation as pessimistic should be paid specific attention by university-based counseling services.

Randomized controlled trial of the Circle of Security-Intensive intervention for mothers with postpartum depression: maternal unresolved attachment moderates changes in sensitivity

Postpartum depression is related to inadequately sensitive caregiving, putting infants at risk for insecure attachment. Therefore, promoting sensitive maternal caregiving and secure child attachment is particularly important in postpartum depressed mothers and their infants. In this randomized-controlled-trial, we evaluated the efficacy of the Circle of Security-Intensive (COS-I)-intervention in supporting maternal sensitivity and mother-infant-attachment compared to treatment-as-usual (TAU) with unresolved-maternal attachment as a moderator of treatment effect. Eligible mothers with infants (N=72) 4-9 months-old were randomly assigned to treatment (n=36 dyads). Infant attachment was rated at follow-up (child age 16-18 months) (Strange-Situation-procedure). Maternal sensitivity was measured at baseline and follow-up (Mini-Maternal-Behavior-Q-sort). Maternal-unresolved-attachment was assessed at baseline (Adult-Attachment-Interview). We found no significant differences between treatments in infant attachment nor changes in mothers' sensitivity. However, in COS-I, unresolved-mothers exhibited significantly more change in sensitivity than non-unresolved-mothers, whereas in TAU, the opposite was true. These findings may help to optimize clinical use of COS-I.

Review: Transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS): a meta-synthesis of parental and professional perspectives

BACKGROUND

Transition between Child and Adolescent Mental Health Services (CAMHS) and Adult Mental Health Services (AMHS) can be stressful for the young person and family alike. Previous reviews have focused on specific aspects of transition or perspectives of young people, or have not used systematic approaches to data identification and analysis. The objective of this review was to develop the understanding of the transition between CAMHS and AMHS by systematically identifying and synthesising evidence regarding professionals' and parents/carers' perspectives.

METHOD

A systematic search in July 2018 was conducted on Medline, PsycINFO and CINAHL. Google Scholar and references of selected articles were also searched. Papers were included if they presented empirical qualitative research in peer-reviewed journals with a primary focus on experiences of parents/carers and/or mental health professionals in relation to adolescents making the CAMHS-AMHS transition. Data were extracted from each full-text paper. The quality of included studies was appraised using an expanded Critical Appraisal Skills Programme (2018) tool, and studies' results were synthesised using meta-ethnography.

RESULTS

Fourteen studies of variable quality were identified. Four main third-order constructs were developed through synthesis: (a) Service cultures; (b) Service resources and gaps; (c) Working relationships between the services; and (d) Leaving secure relationships for new ones.

CONCLUSIONS

Professionals and parents experience adolescents' transition from nurturing and comprehensive CAMHS to more individualistic AMHS as having many barriers. There is desire for better preparation for transition between services and relationships, more joint working and better CAMHS-AMHS communication. AMHS service gaps exist, for example for those with neurodevelopmental conditions.

How do inpatient psychiatric nurses make sense of and respond to behaviours in dementia? An Interpretative Phenomenological Analysis

Objectives: Existing literature demonstrates that nurses' understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia. Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA. Results: Four interrelated themes were identified: 'Effort to sense make', 'Pressures of the organisation', 'Balancing personal and professional selves: The underlying emotional connection'; and '"Looking back on it…"'. Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.

Sensitive Periods of Moving on Mental Health and Academic Performance Among University Students

Moving within and across nations becomes a non-reversible increasing trend globally. The current research investigated the unique effect of residential mobility at different developmental stages (i.e., early childhood, late childhood, and adolescence) on university students' mental health and academic performance. In addition, we investigated the role of two different types of coping resources, i.e., resilience and family income, in moderating the negative effect of residential mobility. The data from 3753 first-year university students revealed that: (1) residential mobility in late childhood and adolescence (but not in early childhood) predicted poorer mental health among university students; (2) high resilience and higher family income alleviated the association of residential mobility in adolescence and mental health status; and (3) residential mobility in adolescence (but not in early childhood and late childhood) was associated with poorer academic performance but this pattern was not moderated by resilience or family income. The theoretical implications and practical implications of these findings were discussed.

A systematic review of qualitative studies of adults' experiences of being assessed for psychological therapies

Objective

To synthesize the qualitative literature on adults’ experiences of psychological therapy assessments. The review was led by people with experience of undergoing assessments, with high levels of client involvement throughout.

Search strategy

A comprehensive search of electronic databases was undertaken, with additional search strategies employed to locate further literature.

Inclusion criteria

Studies were included that qualitatively explored the experiences of people aged 16+ who had been assessed for psychological therapy services. Assessments could be structured or unstructured. Qualitative was defined as any analysed account of people's experiences, including qualitative survey data.

Data extraction and synthesis

Literature quality was appraised using the Critical Appraisal Skills Program checklist, modified to include client involvement and intersectionalities. Following data extraction, thematic synthesis was used to synthesize findings across studies.

Results

Of 12 743 titles were screened, with 13 studies relevant to the review. Themes and subthemes were identified at three stages of the assessment process: the journey to the assessment, at the assessment, and after the assessment. Findings highlighted the emotional impact of assessments, collaboration, intersectionalities, rights, pathologization, socioeconomic restrictions, and information and support needs. Implications and limitations were indicated.

Discussion and conclusions

Findings were situated within the trauma‐informed (TIA) literature. Trauma‐informed assessment principles, including collaborative assessments, may be fruitful means of improving people's experiences. Whilst the benefits of collaboration appear self‐evident, explicitly collaborative approaches were not the norm, nor were studies conducted independently. Further service user research is needed. A greater understanding of the experience of minority groups is also needed.

Attachment-based therapy for elder suffering PTSD symptoms: A narrative of modeling efficacy for improved outcomes

PURPOSE

This paper will acquaint the psychiatric nurse with attachment theory-based therapy through a narrative of post traumatic stress disorder (PTSD) treatment of a Vietnam veteran with a history of compound trauma in childhood.

DESIGN AND METHODS

Application of attachment-based therapy is discussed within the context of its guiding principles and tenets.

FINDINGS

Attachment-based therapy is effective in reducing PTSD symptoms in a Vietnam veteran through forming secure base scripts from which the patient better evaluated and managed stressors, resulting in improved life functioning.

PRACTICE IMPLICATIONS

Attachment theory provides valuable tools with which to treat PTSD sufferers by utilizing nurses' expert skills in establishing rapport and relationship building to form the basis of effectual therapy.

Defining professionalism for mental health services: a rapid systematic review

Background: Efforts have been made to define professionalism across the professions, yet little attention has been paid to the concept in mental health services, where patients' needs differ to that in other healthcare specialties. Aims: To derive a definition of professionalism for mental health services using the existing literature. Method: A rapid, systematic review was conducted to identify empirical and non-empirical records that described professionalism in a mental health service context from 2006 to 2017. Studies were synthesised narratively using thematic analysis. Results: Seventy records were included in the review. Professionalism was described on two levels; at a societal level, a dynamic social contract between professions and society, and; at an individual level, having intrapersonal, interpersonal, and working professionalism. Utilising emerging themes, an operationalised definition of professionalism, suitable for a mental health service context was derived. Conclusions: Within mental health services, emphasis is placed on the interpersonal aspects of practice such as communication skills, maintaining boundaries and humanity. Themes relating to the vulnerability of patients and the challenge of supporting autonomy and choice whilst maintaining safety and acting in a client's best interest are also evident. 'Practical wisdom' and a flexible approach to working are needed to manage these challenging situations.

Attachment Security Priming as a Potential Intervention for Depressive Symptoms

Numerous studies have demonstrated that people high on attachment insecurity are more likely to report depressive symptoms as compared to those low on insecurity (secures). These findings suggest that enhancing one's sense of attachment security could help relieve depressive symptoms. One promising technique for increasing attachment security that has received relatively little attention as a therapeutic intervention is attachment security priming. Compared with other interventions, security priming is easier and takes less time to administer. The current studies examined if priming techniques used to increase attachment security could reduce depressive symptoms in an adolescent and emerging adults samples. In Study 1, depressive symptoms were assessed before exposure to either attachment security or neutral primes and then re-assessed one week later. Results revealed that participants who were exposed to the security primes reported a greater decrease in depressive symptoms than the control group. In Study 2, adolescents who were repeatedly exposed over two weeks to security primes showed lower depression symptoms than participants exposed to neutral primes. Overall, our findings provide initial support to the idea that attachment security priming can be a useful method to help decrease depressive symptoms.

Preliminary Validation of a Short-Form Version of the Attachment Style Questionnaire for Use in Clinical Rehabilitation Counseling Research and Practice

The purpose of this study was to develop and validate a short-form version of the Attachment Style Questionnaire (ASQ) in people with disabilities. The construction sample consisted of 108 participants recruited from spinal cord injury (SCI) advocacy organizations. The cross-validation sample comprised 140 individuals with traumatic injuries recruited from a rehabilitation hospital. Measures administered were the ASQ, Trait Hope Scale, Sense of Coherence Scale, and Satisfaction With Life Scale. Results showed that the three subscales of secure, anxious, and avoidant attachment from the short-form ASQ had high correlations with the three subscales from the long-form ASQ. The reliability of the subscales for the short-form ASQ was adequate and similar to the long-form ASQ. Both the short- and long-form ASQ subscales were found to correlate with hope, sense of coherence, and subjective well-being in the expected theoretical directions. Confirmatory factor analysis also supported the three-factor measurement structure of the short-form ASQ. This study provides evidence to support the psychometric properties of the abbreviated ASQ in people with disabilities. The short-form version of the ASQ is a brief, reliable, and psychometrically sound measure of attachment that can be used in clinical rehabilitation counseling research and practice.

A qualitative investigation in the role of the baby in recovery from postpartum psychosis

Psychosis after childbirth is a rare but severe type of mental health difficulty experienced by perinatal women. Research has explored mothers' experiences of onset and recovery from psychosis after childbirth. This study explored the role of the baby in 12 mothers' experiences of recovery. A thematic analysis of the data identified three core themes that described the role of the baby in the mothers' recovery from psychosis after childbirth. Findings revealed that the baby was central to recovery, experienced by mothers as both helpful and unhelpful. The baby interacted with the mother, increasing self-efficacy, and reducing emotional distress. Findings also showed that the baby could act as a barrier to recovery by increasing the women's emotional distress and hindering access to help and self-care. The findings of the study add to the existing evidence based on recovery from psychosis after childbirth. The research and clinical implications of these findings are discussed with reference to the existing literature.

KEY PRACTITIONER MESSAGE

The baby has an important role in recovery from psychosis after childbirth. The baby can be perceived by mothers to both hinder and help their recovery. Interacting with the baby can be helpful for the mothers' recovery by improving their self-efficacy and reducing emotional distress. Specialist interventions offered by a mother and baby unit can provide practical support that facilitates mother-baby interactions, which helps move women forward in the recovery process.

Cognitive Attachment Model of Voices: Evidence Base and Future Implications

There is a robust association between hearing voices and exposure to traumatic events. Identifying mediating mechanisms for this relationship is key to theories of voice hearing and the development of therapies for distressing voices. This paper outlines the Cognitive Attachment model of Voices (CAV), a theoretical model to understand the relationship between earlier interpersonal trauma and distressing voice hearing. The model builds on attachment theory and well-established cognitive models of voices and argues that attachment and dissociative processes are key psychological mechanisms that explain how trauma influences voice hearing. Following the presentation of the model, the paper will review the current state of evidence regarding the proposed mechanisms of vulnerability to voice hearing and maintenance of voice-related distress. This review will include evidence from studies supporting associations between dissociation and voices, followed by details of our own research supporting the role of dissociation in mediating the relationship between trauma and voices and evidence supporting the role of adult attachment in influencing beliefs and relationships that voice hearers can develop with voices. The paper concludes by outlining the key questions that future research needs to address to fully test the model and the clinical implications that arise from the work.

Case formulation in clinical practice: Associations with psychological mindedness, attachment and burnout in staff working with people experiencing psychosis

OBJECTIVES

Case formulation can impact on therapeutic relationships, staff understanding and outcomes, which might be particularly important when working with complex mental health problems such as psychosis. However, the evidence base is equivocal and there is insufficient understanding around the staff-related factors that influence effective psychological case formulation. This study investigated the influence of staff characteristics (both professional and personal) on case formulation skill.

DESIGN

This was a cross-sectional study, with all of the measures collected at the same time point.

METHODS

Fifty staff members working on inpatient wards with individuals experiencing psychosis were recruited. Measures included independently rated case formulation skill and psychological mindedness (the ability to draw together aspects of thoughts, feelings and actions), both in relation to hypothetical cases. Self-report questionnaires assessed psychological mindedness, attachment styles, symptoms of burnout and professional qualifications.

RESULTS

The preliminary analyses indicated that case formulation skill was associated with higher psychological mindedness (both self-reported and independently-rated) and lower levels of avoidant attachment styles. Simultaneous entry multiple regression demonstrated that the only independent predictor of case formulation skill was independently rated psychological mindedness.

CONCLUSIONS

These findings highlight the factors that contribute to staff's ability to case formulate and the possibility for services to develop psychological mindedness and case formulation skills through formal training, alongside fostering a psychological minded working environment.

PRACTITIONER POINTS

Case formulation skill is positively associated with the personal ability (or inclination) to draw together aspects of experience in a psychological manner (i.e., psychological mindedness) It might also be important to consider avoidant attachment tendencies in relation to formulation skills The sample was relatively small and drawn from a limited number of services, which might reduce the generalizability of the findings Psychological mindedness might not be captured adequately by self-report tools and services may wish to employ more novel ways of assessing this important skill in staff groups (such as the speech sample used in the current study).

Associations between attachment and psychopathology dimensions in a large sample of patients with psychosis

Attachment theory is a powerful theoretical framework that complements and extents current models psychosis. We tested the hypothesis that attachment anxiety and avoidance are differentially associated with the severity of positive, negative and general psychopathology symptoms in patients with a diagnosis of psychosis. Five hundred patients with DSM-IV or ICD-10 diagnoses of psychotic disorders (schizophrenia, schizoaffective or non-affective psychosis) from independent samples from Netherlands, United Kingdom and Israel completed the Relationship Questionnaire. Psychopathology was assessed with the Positive and Negative Syndromes Scale. We used both categorical and dimensional approach to attachment data, which were analyzed using ANOVA with post-hoc tests, Pearson's correlations and multiple regression analysis. The conservative level of statistical significance was established (p < 0.001) to control for multiple testing. After adjustment for possible confounders, attachment anxiety predicted severity of positive symptoms as well as affective symptoms. Both attachment anxiety and avoidance were associated with severity of hallucinations and persecution Contrary to predictions, attachment avoidance was not associated with overall scores for negative symptoms, although there was some evidence of relatively weaker association between avoidance and social and emotional withdrawal.