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

[From relationship to therapeutic alliance with adolescents and young adults at risk of psychotic transition: The perspective of mental health professionals. An exploratory study]

Introduction : Psychotic disorders usually begin during adolescence or early adulthood. The first psychotic symptoms are said to be attenuated in their prodromal phase. It is essential to identify them and initiate follow-up as early as possible to limit the severity of symptoms or even prevent a psychotic transition. However, there is still some uncertainty about the progression of symptoms. The aim of this exploratory study was to show the difficulties that surround the construction of a therapeutic alliance in this context.Methodology : The method adopted was a field survey.Results : Uncertainty about the development of disorders and their worsening and the fact that they are assessed by evaluating the patient's functional weaknesses led professionals to develop a relationship based on knowledge that is acquired empirically and that is in line with a phenomenological approach. Thus, professionals mobilized dynamic and interactive communication techniques to try to forge a therapeutic alliance.Conclusion : It has been shown that professionals seek to build a therapeutic alliance with young people presenting an uncertain evolution toward psychosis using a phenomenological, personalized, and pragmatic logic.

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.

Attachment theory in adult psychiatry. Part 1: Conceptualisations, measurement and clinical research findings

Since its original conception by Bowlby to explain an important evolutionary function of the child–caregiver relationship, attachment theory has been supported by much empirical research in a variety of settings. However, although attachment theory began as a clinical enterprise, its wider application to the everyday clinical understanding of adult mental health problems has lagged behind the available research. The theory can afford valuable insight not only into the developmental nature of common psychiatric disorders, but also into the development of the therapeutic relationship. This article gives an overview of (a) the current conceptualisations of attachment and the measurement of attachment for clinical research purposes and (b) the application of attachment theory to different psychopathologies. The importance of attachment to the therapeutic relationship will be discussed in a future article.

Rethinking placebo in psychiatry: how and why placebo effects occur

This article outlines proximate (physical and mental) and ultimate mechanisms of placebo effects. Interpersonal processes contributing to placebo effects are reviewed and illustrated through research into the process of psychotherapy. Evolutionary theories of how and why the capacity for placebo effects might have evolved are described. The components of treatment and placebo effects are defined. It is concluded that maximising therapeutic placebo effects is effective and a valid clinical goal.

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.

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.

Reflections on the education and training of mental health staff who work with women who have been sexually abused in childhood

Strategies to reduce sexual assault on women patients in mental health inpatient acute wards have included effective policies, a consistent approach to recording and monitoring data relating to incidences of sexual assault, increased staff levels and improvements in the ward layout. A series of workshops were devised to enable mental health staff to work with greater awareness and sensitivity to keep women patients safer on inpatient wards. What emerged in particular during the training was the ways in which staff felt at loss as to how to build therapeutic relationships with women patients, particularly those with histories of sexual abuse. These patients may repeat early ways of relating which may at times be a challenge for the staff caring for them. This paper suggests that psychoanalytic insights offer an understanding of these ways of relating. This can be combined with frequent and supportive supervision to enable staff to safely articulate their often troubling responses to caring for women patients, this creating a caring and supportive environment for staff.

Working with women prisoners who seriously harm themselves: ratings of staff expressed emotion (EE)

BACKGROUND

Prison staff are repeatedly exposed to prisoners' suicidal behaviours; this may impair their capacity to care. Expressed emotion (EE), as a descriptor of the 'emotional climate' between people, has been associated with challenging behaviour in closed environments, but not previously applied to working alliances in a prison.

AIMS

To investigate the feasibility of rating EE between staff and suicidal women in prison; to test the hypothesis that most such staff-inmate alliances would be rated high EE.

METHODS

All regular staff on two small UK prison units with high suicidal behaviour rates were invited to participate. An audiotaped five-minute speech sample (FMSS) about work with one nominated suicidal prisoner was embedded in a longer research interview, then rated by two trained raters, independent of the interview process and the prison.

RESULTS

Seven prison officers and 8 clinically qualified staff completed interviews; 3 refused, but 17 others were not interviewed, reasons including not having worked long enough with any one such prisoner. Participants and non-participants had similar relevant backgrounds. Contrary to our hypothesis, EE ratings were generally 'low'. As predicted, critical comments were directed at high frequency oppositional behaviour.

CONCLUSIONS

EE assessments with prison staff are feasible, but our sample was small and turnover of prisoners high, so the study needs replication. Attributions about problem behaviour to illness, and/or traumatic life experience, tend to confirm generally supportive working relationships in this sample.

Factors correlated with client attachment to mental health services

This study aimed to explore clients' attachments to psychiatric rehabilitation services and associations with adult attachment style and severity of symptoms. Potential correlates of attachments to services were investigated using a cross-sectional design. A total of 78 participants from inpatient rehabilitation units completed measures of attachment to mental health services, adult attachment style, depression, and psychosis. Clients with a more insecure attachment style and greater severity of depression indicated lower levels of attachment to services, although no effects were found for severity of psychotic symptoms. Patients with insecure adult attachment styles and higher levels of depression may experience particular difficulties in developing secure attachments to services.