Attachment Issues in
Clinical Practice: Issues for
Research
Dr Ken Ma
Consultant Child and Adolescent Psychiatrist
Coventry CAMHS
Coventry and Warwickshire Partnership Trust
Outline of Presentation
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Brief overview of attachment theory
Assessment of attachment
Why attachment may be important as a clinical
research variable
Why attachment may be important as a
sociological/ political research variable
Attachment in clinical research - some findings
John Bowlby (1907-1990)
What is Attachment Theory? (1)
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Conceived by Bowlby to explain an important
evolutionary function of the child-caregiver relationship.
Gene survival promoted by selection of attachment
behaviours leading to increased child-caregiver
proximity.
When a child is attached to someone, he or she is:
…strongly disposed to seek proximity to and contact
with a specific figure and to do so in certain situations,
notably when he is frightened, tired or ill.
Bowlby, Attachment and Loss, Vol.1 Attachment, 1969, p.371
What is Attachment Theory? (2)
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The attachment figure thus acts as a ‘secure base’ for
the child, especially in times of stress.
The child can thus successfully explore outside world
 implications for social, emotional and cognitive
development.
Attachment in Adulthood
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Now generally agreed the attachment system is operative
throughout lifespan.
Attachment behaviours change.
Physical proximity important in childhood.
As child grows, availability/ trustworthiness of
attachment figures becomes internalised psychologically
 cognitive-emotional representations.
Internal working models (IWMs) of self and attachment
figures develop.
Different ways of measuring attachment in childhood and
adulthood.
Measuring Attachment in Infancy the Strange Situation Procedure
Ainsworth et al. (1978)
Mary Ainsworth
(1913-1993)
The Strange Situation
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Laboratory session lasting 20 minutes with 12mth-old infant, caregiver and experimenter.
Responses of infant to separation from
caregiver (moderate stress) and reunion with
caregiver are assessed.
Four broad categories are observed.
Role of temperament/ genetic influences?
SS Classification
Infant attachment Observations of Putative
category
infant in SS
caregiver style
Protests when caregiver
Secure.
Secure (B)
disappears. Protest continues
Consistent.
on return, but soon pacified
Responsive.
(Organised)
and resumes exploratory play.
Avoidant (A)
(Organised)
Ambivalent (C)
(Organised)
Little protest on separation.
On caregiver’s return, hovers
warily by, inhibited play.
Disorganised (D)
Freezes on separation, seems
Unresolved loss and trauma in
unable to sustain any organised caregiver.
pattern of behaviour on return.
“Frightened and frightening”.
Behaviours may appear
bizarre, stereotyped, ‘autistic’.
Protests, and hard to pacify on
caregiver’s return. Clings,
buries head in lap, pushes
away toys offered.
Broadly rejecting.
Inconsistent.
Measuring Attachment in Adulthood
The Parenting Tradition vs. the Romantic
Attachment Tradition
(after Bartholomew & Shaver, 1998)
Parenting Tradition
Romantic Attachment
Tradition
Orientation
Psychodynamic focus on clinical Social/ personality psychology.
problems.
Preferred
method of
assessment
Interviews and behavioural
measures in small groups of
participants.
Simpler (incl. self-rated)
questionnaires in larger
populations.
Also interview measures.
Focus
Caregiver-child relationships.
State of mind with respect to
attachment.
Close social/ romantic
relationships (friendships,
dating relationships, marriage).
Age groups
Across the lifespan.
Initially in young adults, now
extending at least into
adolescence.
Examples of
measures
The SS
Adult Attachment Interview
(AAI)
Kobak’s Q-Sort
ASQ (Hazan & Shaver, 1988)
RSQ (Griffin & Bartholomew, 1994)
ECR-R (Fraley, Waller & Brennan,
2000)
IPPA (Armsden & Greenberg, 1987)
The Adult Attachment Interview
(Main & Goldwyn, 1998)
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Semi-structured interview about early attachment history.
Measures adolescent’s / adult’s state of mind with respect to
attachment, e.g. current representations of childhood
relationships with caregivers.
Questions designed to ‘surprise the unconscious’.
Focus on both content and discourse style.
Both categorical and continuous data.
Four categories similar to those in SS.
Very detailed (!) coding manual.
High correspondence between adult’s AAI category and
infant’s subsequent category  validity.
Categories on the AAI (1)
AAI category
Corresponding SS
category
Typical discourse style
Secure
autonomous (F)
Secure (B)
Narrative coherence. Valuing of
attachment but objectivity evident.
Able to give examples to support
statements.
Dismissing (Ds)
Avoidant (A)
Brief discourse, can be idealising.
Few supporting examples.
Preoccupied (E)
Ambivalent (C)
Incoherent, vague and rambling.
Preoccupied with past experiences.
Speaker can appear angry, passive or
fearful.
Unresolveddisorganised (U)
Disorganised (D)
Striking lapses in monitoring of
reasoning during discussion of loss
or abuse.
Categories on the AAI (2)
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Participants with the U classification are also
assigned one of the other categories that best
captures underlying attachment strategies, i.e.
U/F, U/Ds and U/E.
The Relationship Scales Questionnaire
(RSQ) –
An Example of a Romantic Attachment
Tradition questionnaire
Kim Bartholomew
http://www.sfu.ca/psyc/faculty/bartholomew/
The RSQ
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30 descriptive items. Self-rated/ other-rated.
Interviewees score each item on scale of 1-5 to show
level of agreement.
Examples:
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I find it difficult to depend on other people.
I’m not sure that I can always depend on others to be there
when I need them.
I worry that others don’t value me as much as I value them.
I often worry that romantic partners won’t want to stay with
me.
Bartholomew’s four-category model
- as assessed using RQ/RSQ
Positive IWM of
Others (low
avoidance)
Negative IWM of
Others (high
avoidance)
Positive IWM of
Self (low
dependence)
Negative IWM of
Self (high
dependence)
Secure
Preoccupied
Comfortable with
Preoccupied with
relationships, high
emotional reactivity
intimacy and autonomy
Dismissing
Dismissive of
attachment; counterdependent
Fearful
Afraid of intimacy and
rejection; believes self to
be worthy of rejection;
high emotional reactivity
AAI versus Self-Report Measures
AAI
Self-report measures
Advantages
Regarded as ‘gold
standard’ by many.
Able to tap into
unconscious.
Construct validity
unquestioned.
Quick, easy to
administer.
Can be used in largescale research.
Disadvantages
Long.
Impractical to use in
clinical settings/ largescale research.
Extensive and expensive
training required.
Construct validity
questioned by those on
the ‘other side’
 really measuring
attachment?
Attachment in Clinical Research
- The ‘Why Measure It?’ Question
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Better understanding of aetiology of psychopathology
 Attachment insecurity may be a (significant) risk factor for
psychopathology, in both childhood and adulthood.
 Attachment security may be a resilience factor in adversity.
Attachment system likely to be activated in times of stress, e,g.
psychiatric/ physical disorder
 Attachment pattern may predict pattern of help-seeking,
healthcare utilisation and compliance.
 It may also influence the therapeutic alliance or patientclinician relationship in ways that will help/ hinder
treatment (process research).
Attachment pattern of clinician may similarly be important.
However, attachment is not the be-all and end-all!
Attachment in Sociological/ Political
Research
- Systemic Influences on the Healthcare
System
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Wider systemic issues.
Healthcare utilisation and expenditure - e.g.
‘heartsink patients’.
Attachment may predict political leaning (e.g.
Ds and neo-fascism).
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Attachment security of policy makers?
Attachment in Clinical Research
- Some Findings
Attachment and Psychopathology Some General Points
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Majority of studies thus far cross-sectional.
Poor diagnostic clarity.
Different measures used make studies difficult to compare
 one explanation for contradictory results.
Questions of causality on the whole not answered as yet.
Relative balance of genetic and social/ environmental
factors
Postulated association between ‘maximising’ attachment
strategies and “internalising” psychopathology, and
between ‘minimising’ attachment strategies and
“externalising” psychopathology.
Depression
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Association with preoccupied/ unresolved
strategies (Fonagy et al., 1996 - n=82 pts, 85
controls; Cole-Detke & Kobak, 1996)
Association with preoccupied/ fearful
attachment (Carnelly et al., 1994; Haaga et al.,
2002; Reis & Grenyer, 2004) all using selfreport measures.
Anxiety
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Association with anxious-ambivalent
attachment longitudinally (Warren et al., 1997)
and with preoccupied/ unresolved attachment
cross-sectionally (Fonagy et al., 1996)
Twaite & Rodriguez (2004) - attachment
partially mediated link between childhood
abuse and PTSD following 9/11 (self-report
measure).
Borderline Personality Disorder
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High proportion with a U/E classification Fonagy et al., 1996; Barone, 2003.
Patterns of Help-Seeking
Ciechanowski et al. (2002)
 N =701 adult female primary care HMO pts.
 RSQ.
 Preoccupied and fearful patients reported more
physical symptoms, but no differences
between groups in medical co morbidity.
 Patients with preoccupied attachment had the
highest primary care costs and utilisation.
 Those with fearful attachment had the lowest.
Compliance with Treatment
Ciechanowski et al. 2000
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276 tertiary care type I diabetes patients.
RSQ.
Dismissing attachment associated with significantly
higher HbA1c.
Dozier et al., 1990
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Those patients with insecure attachment less
compliant with psychotropic medication.
Healthcare Staff as Attachment Figures
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Can staff act as attachment figures for vulnerable
clients whose attachment system is activated?
If so, what are the implications?
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Compliance with management.
Formation of therapeutic alliance - especially with
patients with dismissing attachment strategies.
How to assess attachment to staff/ services?
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Goodwin’s Service Attachment Questionnaire
(Goodwin et al., 2003).
What about the attachment
strategies of healthcare staff?
Attachment Strategies of Healthcare Staff
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Healthcare is a stressful preoccupation!
Dozier et al. (1994)
 18 psychiatric case managers - those with
preoccupied attachment may intervene more
actively with clients  ?dominance of counter
transference issues.
What are the implications?
 Relevance for supervision?
 Influence on outcome of treatment?
 Implications for managers
Conclusions and Implications
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Which measure is used depends on what one is
trying to measure.
There are a number of areas where the
consideration of attachment might provide
fresh, valuable insight.
Please consider self-report measures!
THANK YOU!
Cassidy, J. & Shaver, P. (eds) (1999) Handbook of Attachment:
Theory, Research and Clinical Implications. New York:
Guilford.
Ma, K. (2007) Attachment theory in adult psychiatry. Part 2:
Importance to the therapeutic relationship. Advances in
Psychiatric Treatment, 13, 10-16.
Ma, K. (2006) Attachment theory in adult psychiatry. Part 1:
Conceptualisations, measurement and clinical research
findings. Advances in Psychiatric Treatment, 12, 440-9.