The Effectiveness of Attachment Security Priming in Improving Positive Affect and Reducing Negative Affect: A Systematic Review

Secure attachment imagery facilitates help-seeking and help-acceptance in psychosis

OBJECTIVES

People with psychosis delay accessing recommended treatments, resulting in poor healthcare outcomes and increased risk of relapse. Means of improving help-seeking and help-acceptance could reduce duration of untreated psychosis (DUP). This study examined the role of attachment style in help-seeking and help-acceptance in psychosis.

DESIGN

We used an experimental design to test the effect of attachment imagery priming on help-seeking and help-acceptance intentions, in a sample with self-reported psychosis. The independent variables were attachment imagery condition (secure vs. avoidant) and time (pre- vs. post-prime). The dependent variables were state paranoia, help-seeking intentions and help-acceptance intentions.

METHODS

We used an online research platform to recruit people with psychosis (n = 61). Participants were randomly allocated to the secure or avoidant attachment priming condition. All completed measures of state paranoia, help-seeking, and help-acceptance, before and after priming.

RESULTS

In comparison with the avoidant condition, secure attachment imagery resulted in reduced paranoia and increased help-seeking and acceptance intentions, all with large effect sizes.

CONCLUSIONS

This is the first study to use an experimental design to assess the role of attachment style in help-seeking and help-acceptance in a clinical sample. Attachment style is causally linked to behavioural intentions that contribute to DUP. Clinicians should assess attachment and help-seeking and acceptance, highlight these in formulation, and prioritise in treatment planning. Interventions that enhance help-seeking and acceptance could improve access to recommended treatments and reduce DUP.

A feasibility and pilot additive randomised control trial of attachment security priming during behavioural activation

BACKGROUND

There is some initial evidence that attachment security priming may be useful for promoting engagement in therapy and improving clinical outcomes.

AIMS

This study sought to assess whether outcomes for behavioural activation delivered in routine care could be enhanced via the addition of attachment security priming.

METHOD

This was a pragmatic two-arm feasibility and pilot additive randomised control trial. Participants were recruited with depression deemed suitable for a behavioural activation intervention at Step 2 of a Talking Therapies for Anxiety and Depression service. Ten psychological wellbeing practitioners were trained in implementing attachment security priming. Study participants were randomised to either behavioural activation (BA) or BA plus an attachment prime. The diagrammatic prime was integrated into the depression workbook. Feasibility outcomes were training satisfaction, recruitment, willingness to participate and study attrition rates. Pilot outcomes were comparisons of clinical outcomes, attendance, drop-out and stepping-up rates.

RESULTS

All practitioners recruited to the study, and training satisfaction was high. Of the 39 patients that were assessed for eligibility, 24 were randomised (61.53%) and there were no study drop-outs. No significant differences were found between the arms with regards to drop-out, attendance, stepping-up or clinical outcomes.

CONCLUSIONS

Further controlled research regarding the utility of attachment security priming is warranted in larger studies that utilise manipulation checks and monitor intervention adherence.

Does disorganised attachment lead to auditory hallucinations via dissociation? An experimental study with an analogue sample

OBJECTIVES

Auditory hallucinations (such as hearing voices) are common in clinical and non-clinical populations. Many people who hear voices also report early adversity and have an insecure attachment style. Current cognitive models suggest that dissociation mediates an association between disorganised attachment and auditory hallucinations, but this has not been tested experimentally.

DESIGN

We recruited a non-clinical analogue sample highly predisposed to auditory hallucinations and utilised an experimental design to examine the impact of disorganised attachment imagery on hallucinatory experiences, and whether dissociation mediates an expected association.

METHODS

Participants completed self-report measures of state auditory hallucinations and dissociation before and after random allocation to secure or disorganised attachment conditions.

RESULTS

Attachment imagery did not affect auditory hallucinations. Both secure and disorganised attachment conditions increased state dissociation. Secure attachment imagery reduced paranoia, but state dissociation did not mediate this effect. An exploratory analysis found that trait dissociation fully accounted for the association between trait-disorganised attachment and hallucinatory experience while controlling for paranoia.

CONCLUSIONS

Secure attachment imagery reduces paranoia but not auditory hallucinations and the impact on paranoia is not mediated by dissociation. Secure attachment imagery may be useful in reducing fears and distress associated with voices, rather than the frequency or severity of hallucinations. Disorganised attachment may increase hallucinatory experiences for people vulnerable to dissociation. Trait dissociation should be assessed in clinical settings and addressed where indicated as a means of targeting vulnerability to distressing voices.

Meta-analytic evidence that attachment insecurity is associated with less frequent experiences of discrete positive emotions

OBJECTIVE

Individual differences in attachment insecurity can have important implications for experiences of positive emotions. However, existing research on the link between attachment insecurity and positive emotional experiences has typically used a composite measure of positive emotions, overlooking the potential importance of differentiating discrete emotions.

METHOD

We conducted a meta-analysis of 10 cross-sectional samples (N = 3215), examining how attachment insecurity is associated with self-reported frequency of experiencing positive emotions, with a distinction made between more social (i.e., love and gratitude) and less social (i.e., peace and awe or curiosity) positive emotions.

RESULTS

High (vs. low) levels of both attachment anxiety and avoidance were associated with less frequent experience of positive emotions regardless of their social relevance. When analyzing each emotion separately, we found that attachment anxiety showed negative relations to all emotions except gratitude. Attachment avoidance was negatively associated with all emotions, and the link was even stronger with love (vs. peace, awe, or curiosity). Additional analyses of daily diary data revealed that attachment anxiety and avoidance were also negatively associated with daily experiences of positive emotions, regardless of social relevance.

CONCLUSION

Our results underscore the need to further investigate the mechanisms underlying insecure individuals' blunted positive emotional experiences.

Do emotion regulation strategies mediate the attachment-paranoia association? An experimental study of repeated attachment imagery priming and stress buffering

OBJECTIVES

Paranoia describes unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but limited research examines mechanisms of change and no studies examine how secure imagery may be implemented most effectively in clinical practice. In this study, we tested: (a) the causal impact of secure, anxious, and avoidant attachment imagery on paranoia and anxiety, (b) whether emotion regulation strategies mediate these relationships, and (c) whether secure imagery buffers against social stress.

DESIGN

We utilized a longitudinal, experimental design.

METHOD

A general population sample with high non-clinical paranoia (N = 265) completed measures of paranoia, anxiety, and emotion regulation strategies. Participants were randomly allocated to secure, anxious, or avoidant conditions and repeated an imagery prime for four days prior to a social stress task.

RESULTS

Relative to anxious and avoidant imagery, secure imagery decreased state paranoia and anxiety. These associations were not mediated by state emotion regulation strategies, and secure imagery did not buffer against stress. Exploratory analyses on trait variables revealed that: (a) hyperactivating strategies mediated the association between attachment anxiety and paranoia, and (b) suppression mediated the association between attachment avoidance and paranoia.

CONCLUSIONS

Secure attachment imagery reduces state paranoia and anxiety and could be incorporated into psychotherapies to attenuate clinical paranoia. Measurement of state emotion regulation was problematic. Attachment imagery does not buffer stress; further research is required to test whether secure imagery facilitates recovery from stress. Attachment style is likely to account for trait paranoia via attachment-congruent emotion regulation strategies. Research is now needed to determine if these strategies can be targeted to alleviate paranoia in clinical populations.

Attachment Security Priming: A Meta-Analysis

Attachment security priming has important theoretical and practical implications. We review security priming theory and research and the recent concerns raised regarding priming. We then report the results of a meta-analysis of 120 studies (N = 18,949) across 97 published and unpublished articles (initial pool was 1,642 articles) investigating the affective, cognitive, and behavioral effects of security priming. A large overall positive effect size (d = .51, p < .001) was found across all affective, cognitive, and behavioral domains. The largest effect was found for affect-related outcomes (d =.62, p < .001), followed by behavioral (d = .44, p < .001), and cognitive (d = .45, p < .001). Trait attachment anxiety and avoidance moderated the effects of subliminal security priming for behavioral outcomes-security priming effects were larger among people higher on attachment anxiety and avoidance. Assessment of publication bias revealed mixed evidence for the possible presence of asymmetry.

Responding to Distress Choosing Between Care and Food: Attachment Orientation and Emotion Regulation

According to attachment theory, care-seeking is the primary coping strategy in threatening situations. However, anxious and avoidant individuals often use secondary regulation strategies. The purpose of this study was to test whether, in a potentially threatening situation, the participants' attachment orientation affects whether they prefer to resort to care or food to regulate their negative emotions. Ninety-two participants took part in an experimental situation in which they had to choose between pictures of care or food, following the presentation of threatening images randomly alternating with neutral ones. Results showed that care pictures were chosen to a greater extent in the threatening condition compared to the food pictures and the neutral condition, without distinction of attachment orientation. In addition, in threatening condition, anxious individuals chose to care less than non-anxious individuals. Finally, avoidant participants chose care pictures to a lesser extent than individuals low on avoidance in the neutral condition, but not in the threatening condition. In conclusion, attachment anxiety was associated with more difficulty in the choice of representation of care in a threatening condition, while avoidant individuals show their defensive strategies in the neutral condition rather than in the threatening condition.

Attachment security schemas to attenuate the appeal of benevolent sexism: The effect of the need to belong and relationship security

Previous research has repeatedly shown a positive association between the need for relationship security and the appeal of benevolent sexism. Possibly, no studies to date had investigated the role of the need to belong with respect to a preference for the ideal partner to endorse benevolently sexist attitudes. Attachment security is considered to attenuate the need for relationship security and to divert the focus from the need to belong. Study 1 therefore investigated potential associations among attachment anxiety, the need to belong, and the appeal of benevolent sexism. It also examined whether the association between the need to belong and a preference for the ideal partner to hold benevolently sexist attitudes is moderated by attachment anxiety. In Study 2, we used a causal design to confirm the findings from Study 1 through the activation of attachment security schema. A moderated regression analysis showed significant interactive effects between the need to belong and attachment anxiety-that is, a positive association between the need to belong and the appeal of benevolent sexism was found only among people high in attachment anxiety. Secure-base scripts attenuated the need to belong as well as the appeal of benevolent sexism. The present findings suggest the importance of attachment schemas in influencing preference for specific partner attitudes through the need to belong and relationship security.

How does insecure attachment lead to paranoia? A systematic critical review of cognitive, affective, and behavioural mechanisms

Background

The relationship between attachment and paranoia is now well established. There is good theoretical reason and evidence to indicate that attachment style affects cognitive, affective, and behavioural processes which, in turn, contribute to the maintenance of paranoia, but this research has not been integrated. We critically and systematically review research that examines relevant cognitive, affective, and behavioural processes, which may explain how attachment insecurity leads to paranoia and constitute key targets in psychotherapeutic interventions for people with psychosis.

Method

We conducted three systematic searches across six databases (PsycINFO, CINAHL, Medline, Web of Science, Embase, and Google Scholar), from inception to September 2021, to investigate key cognitive, affective, and behavioural processes in the attachment–paranoia association.

Results

We identified a total of 1930 papers and critically reviewed 16. The literature suggests that negative self‐ and other‐beliefs, inability to defuse from unhelpful cognitions, and use of maladaptive emotion regulation strategies mediate the association between attachment insecurity and paranoia in people with psychosis/psychotic experience. Attachment‐secure people with psychosis are more likely to seek help and engage with services than attachment‐insecure people.

Conclusions

Attachment styles impact help‐seeking behaviours in people with psychosis and are likely to influence paranoia via self‐ and other‐beliefs, cognition fusion, and emotion regulation – these candidate mechanisms may be targeted in psychological therapy to improve clinical outcomes for people with psychosis, characterized by paranoia.

Practitioner points

Insecure attachment is likely to lead to paranoia via negative beliefs about self and others, cognitive fusion, and use of maladaptive emotion regulation strategies. These mechanisms can be targeted in psychotherapeutic interventions for psychosis, such as cognitive behaviour therapy, to improve clinical and recovery outcomes.

People with psychosis who are attachment‐secure are more likely to seek help and engage with services than those who are attachment‐insecure (particularly avoidant). Attachment style can be assessed to predict service engagement and help‐seeking behaviours in people with psychosis.

Attachment styles are important predictors of key cognitive, affective, and behavioural processes in people with psychosis. These processes can be assessed and incorporated into individualised formulations, and then targeted in therapy to effect psychotherapeutic change.

Adult attachment anxiety is associated with night eating syndrome in UK and US-based samples: Two cross-sectional studies

Previous research has shown that "attachment anxiety" is a robust predictor of disinhibited eating behaviours and that this relationship is underpinned by difficulties in managing emotion. Night eating syndrome (NES), a proposed eating disorder characterized by evening hyperphagia, nocturnal awakenings to eat, and morning anorexia, is also associated with eating to manage emotion. Across two studies (N = 276 &N = 486), we considered a relationship between attachment anxiety and NES. In Study 1, we hypothesised (pre-registered) that attachment anxiety would predict NES score and that this relationship would be mediated by disinhibited eating. Participants were asked to complete questionnaire measures of attachment orientation, disinhibited eating (emotional and uncontrolled eating) and NES. Our parallel mediation model confirmed a direct relationship between attachment anxiety and NES (p < .001) and showed an indirect path via both emotional (95% CI: 0.15-0.63) and uncontrolled eating (95% CI: 0.001-0.36). In Study 2, we showed that fear of negative evaluation of eating significantly mediated a reversed relationship between attachment anxiety and NES (95% CI: 0.02-0.04). Finally, across both studies we used a novel tool to assess "eating to cope". We showed a relationship with emotional eating but failed to show a robust relationship with NES. Attachment orientation may represent a potential intervention target for night eating syndrome. Future research should consider a longitudinal approach to strengthen our understanding of directionality amongst these factors.

The Role of Implicit Memory in the Development and Recovery from Trauma-Related Disorders

Post-traumatic Stress Disorder is a chronic condition that occurs following a traumatic experience. Information processing models of PTSD focus on integrating situationally triggered sensory-emotional memories with consciously accessible autobiographical memories. Review of the nature of implicit memory supports the view that sensory-emotional memories are implicit in nature. Dissociation was also found to be associated with the development and severity of PTSD, as well as deficits in autobiographical memory. Moreover, disorganized attachment (DA) was associated with greater degrees of dissociation and PTSD, and like the defining neural activation in PTSD, was found to be associated with basal ganglia activity. In addition, subcortical neuroception of safety promotes a neurophysiological substrate supportive of social engagement and inhibition of fear-based responses. Furthermore, activation of representations of co-created imagined scenes of safety and secure attachment are associated with increases in this neurophysiological substrate. Repeated priming of secure attachment imagery was associated with modification of internal working models of DA along with reductions in dissociation and recovery from complex PTSD. In conclusion, it is posited that adequate recovery from extensive trauma experiences requires more than conscious elaboration of traumatic autobiographical memories and that the application of implicit nonconscious memory modification strategies will facilitate more optimal recovery.

How does attachment imagery for paranoia work? Cognitive fusion and beliefs about self and others mediate the impact on paranoia and anxiety

OBJECTIVES

Paranoia describes unfounded and distressing interpersonal threat beliefs. Secure attachment imagery has been shown to attenuate paranoia and anxiety in non-clinical and clinical groups, but little is known about the differential effects of anxious and avoidant imagery or mechanisms of change. In this study, we tested the impact of secure, anxious, and avoidant attachment imagery on paranoia, anxiety, and help-seeking intentions. We also examined hypothesized mechanisms of change, specifically whether cognitive fusion and negative self- and other-beliefs mediate these relationships.

DESIGN

This study utilized an experimental, cross-sectional design.

METHODS

A large (N = 303), international general population sample with high levels of non-clinical paranoia completed a series of measures before and after engaging in secure, anxious, or avoidant imagery.

RESULTS

Relative to anxious and avoidant attachment imagery, secure attachment imagery reduced paranoia and anxiety and increased help-seeking intentions. Cognitive fusion and negative self- and other-beliefs mediated the impact of attachment imagery on paranoia and anxiety, but not help-seeking.

CONCLUSIONS

In line with attachment and cognitive theory, secure attachment imagery is effective in reducing paranoia and anxiety and works by reducing cognitive fusion and negative self- and other-beliefs. These novel findings suggest that the secure imagery task could be incorporated into cognitive and behavioural therapies to reduce distressing interpersonal threat beliefs and associated negative affect, and increase help-seeking intentions.

PRACTITIONER POINTS

When working with people experiencing paranoia, secure attachment imagery may be effective in reducing state paranoia and anxiety and improving help-seeking intentions. Attachment imagery works by influencing beliefs about self and others, and the degree to which people are fused with their beliefs. In clinical practice, the rationale for the imagery task fits well with psychological models of paranoia and the secure imagery task can be introduced as a way to cope when struggling with distressing beliefs about self and others, and feeling overwhelmed by these fears.

Attachment anxiety and resilience: The mediating role of coping

In recent research, attachment has been addressed as a core factor that potentially contributes to resilience. However, there is still much to investigate regarding the mechanisms of this relationship. Emotion-focused coping and problem-focused coping strategies may be promising pathways via which attachment associates with resilience. The present study evaluated the role of attachment insecurity (i.e., attachment anxiety and avoidance) in resilience among a Turkish sample during the COVID-19 pandemic. We hypothesized that individuals with high levels of attachment anxiety would experience lower resilience via emotion-focused coping strategies. On the other hand, we did not have a specific hypothesis for attachment avoidance due to contrasting research findings of previous studies. Participants reported their attachment orientation, resilience, and coping strategies. Attachment anxiety was directly and, through both coping strategies, indirectly linked to resilience however attachment avoidance was only indirectly related to resilience through problem-focused coping. The findings indicate that low levels of attachment anxiety and the ability to use problem-focused coping strategies may be associated with greater resilience. The fostering of attachment security may thus reduce the use of emotion-focused strategies and may promote resilience among individuals with high levels of attachment anxiety. Moreover, our study is one of the first to investigate attachment orientations in relevance with coping and resilience during the ongoing pandemic This research has implications regarding the potentials of introducing psycho-educational trainings for better coping strategies in crisis like COVID-19 pandemic.

The Impact of Repeated Attachment Priming on Paranoia, Mood and Help-Seeking Intentions in an Analogue Sample

Attachment security priming effects therapeutic change in people with depression and anxiety. Preliminary studies indicate that visualising secure attachment memories also reduces paranoia in non-clinical and clinical groups, probably due to a decrease in cognitive fusion. Benefits to clinical populations depend on the sustainability of these effects and the impact on help-seeking behaviours. The combination of paranoia and an insecure-avoidant attachment style is likely to be a particular barrier to help seeking. We used a longitudinal experimental design to test the impact of repeated attachment priming on paranoia, mood and help-seeking intentions and whether cognitive fusion mediates these effects. Seventy-nine people with high levels of non-clinical paranoia, aged 18-50 years (M = 20.53, SD = 4.57), were randomly assigned to a secure or insecure-avoidant priming condition. Participants rehearsed the visualisation prime on four consecutive days and were assessed on standardised measures of paranoia, positive and negative affect, help-seeking intentions and cognitive fusion. A series of mixed-model analyses of variance showed that security priming decreases paranoia, negative affect and cognitive fusion and increases positive affect and help seeking, compared to insecure-avoidant priming. Examining the impact of primed attachment (rather than measured attachment style) allows us to draw conclusions about the causal processes involved; mediation analyses showed indirect effects of the primes on paranoia and negative affect through cognitive fusion. With a growing understanding of (1) the impact of security priming on paranoia, affect and help-seeking behaviours, (2) causal mechanisms and (3) sustainability of effects, security priming may be developed into a viable intervention for clinical populations.

The effect of attachment security priming and oxytocin on physiological responses to trauma films and subsequent intrusions

To further understand protective mechanisms to prevent post-traumatic stress disorder or assist recovery from psychological trauma, this study investigated whether pharmacological and psychological activation of a secure attachment representation elicits higher felt-security and a related response pattern of reduced physiological arousal and increased parasympathetic activation; and whether it protects individuals from developing intrusions and experiencing distress in the week following exposure to a trauma film. Using a double-blind, experimental mixed factorial design, 101 volunteers received either oxytocin or placebo and either secure attachment or neutral priming before watching a trauma film. We measured felt security as an indicator of the strength of activation of a secure attachment representation, skin conductance and heart rate as indicators of physiological arousal, and high frequency heart rate variability as an indicator of parasympathetic activation during the priming and the film. Participants then completed a seven-day intrusion diary. Secure attachment priming, but not oxytocin administration or the combination of both, was associated with reduced physiological arousal and increased parasympathetic activity during priming. Although secure attachment priming was not related to the absolute number of intrusions or to less perceived distress or physiological arousal during the trauma film, it was associated with lower intrusion-related distress in the 7-days post-testing. Our findings extend previous research that suggests the importance of interventions that address intrusion-related distress for recovery from trauma, and suggest a promising role for secure attachment priming in trauma-focused psychological therapies. We contribute to the growing literature that finds that higher subjective distress during a trauma is associated with higher intrusion-related distress. We discuss theoretical implications and possible mechanisms through which secure attachment priming may exert potential beneficial effects.

Attachment and attitudes toward children: effects of security priming in parents and non-parents

The present two-study investigation is the first to examine whether experimentally boosting attachment security (security priming) affects attitudes in the parenting domain for both parents and non-parents. Mothers (n = 72) and childless undergraduates (n = 82) were randomly assigned to a neutral or a secure prime condition and then completed measures of implicit attitudes (a child-focused version of the Go/No-Go Association Task) and explicit attitudes (self-reported) toward children. Following the priming manipulation, mothers in the secure prime condition had more positive implicit attitudes toward their child compared to mothers in the neutral prime condition. Security priming also increased mothers' positive explicit attitudes toward their children, but only among mothers who scored high on self-reported attachment-related avoidance. No priming effects emerged among non-parents. These results provide the first evidence for a causal link between parental attachment security and parental attitudes toward children.

Theoretical Boundary Conditions of Partner Buffering in Romantic Relationships

Attachment insecurity is consequential for both personal and relationship wellbeing. Some research has documented that partner buffering can downregulate insecure individuals' immediate feelings of distress, allowing them to feel more secure at least temporarily. The benefits of partner buffering, however, may be limited by several contextual factors. In this article, we identify boundary conditions that may curb or amplify the benefits of partner buffering for both targets (those who receive buffering) and agents (those who enact buffering). We suggest that motivation, ability, and timing may all affect partner buffering outcomes for targets and agents. If partner buffering is delivered in an adaptive way that does not reinforce the target's insecure tendencies, it may help insecure targets learn that they can trust and depend on their partners (agents), which may facilitate greater security in targets. We recommend that future research consider these contextual factors and examine partner buffering as an inherently dyadic relationship process capable of enhancing attachment security.

Cognitive Fusion Mediates the Impact of Attachment Imagery on Paranoia and Anxiety

Background

Paranoia, in both clinical and non-clinical groups, is characterised by unfounded interpersonal threat beliefs. Secure attachment imagery attenuates paranoia, but little is known about the mechanisms of change. Cognitive fusion describes the extent to which we can ‘step back’ from compelling beliefs, to observe these as mental events, and is implicated in psychopathology cross-diagnostically.

Aims

This study extends previous research demonstrating the impact of attachment imagery on paranoia and anxiety to determine whether cognitive fusion mediates these relationships.

Method

We utilised a randomized experimental design and recruited an analogue sample with high levels of non-clinical paranoia to test the impact of imagery and the role of cognitive fusion.

Results

Secure attachment imagery resulted in reduced paranoia and anxiety compared to threat/insecure imagery. Cognitive fusion mediated the relationships between imagery and paranoia, and imagery and anxiety.

Conclusions

Secure attachment imagery is effective in reducing paranoia and anxiety and operates via cognitive fusion. In clinical practice, these interventions should seek to facilitate the ability to ‘step back’ from compelling threat beliefs, in order to be most beneficial.