Behaviour Research and Therapy

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1 Behaviour Research and Therapy 46 (2008) Contents lists available at ScienceDirect Behaviour Research and Therapy journal homepage: Attachment theory: A framework for understanding symptoms and interpersonal relationships in psychosis Katherine Berry *, Christine Barrowclough, Alison Wearden School of Psychological Sciences, University of Manchester, 2nd Floor, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK article info abstract Article history: Received 25 March 2008 Received in revised form 26 August 2008 Accepted 29 August 2008 Keywords: Psychosis Schizophrenia Attachment Symptoms Interpersonal We investigated associations between adult attachment, symptoms and interpersonal functioning, including therapeutic relationships in 96 patients with psychosis. Using a prospective design, we also assessed changes in attachment in both psychiatrically unstable and stable groups. We measured attachment using the Psychosis Attachment Measure (PAM) and interpersonal problems and therapeutic relationships were assessed from both psychiatric staff and patient perspectives. Avoidant attachment was associated with positive symptoms, negative symptoms and paranoia. Attachment ratings were relatively stable over time, although changes in attachment anxiety were positively correlated with changes in symptoms. Predicted associations between high levels of attachment anxiety and avoidance and interpersonal problems were supported, and attachment avoidance was associated with difficulties in therapeutic relationships. Findings suggest that adult attachment style is a meaningful individual difference variable in people with psychosis and may be an important predictor of symptoms, interpersonal problems and difficulties in therapeutic relationships over and above severity of illness. Ó 2008 Elsevier Ltd. All rights reserved. Introduction Attachment theory is a lifespan developmental theory that proposes that there is a universal need to form close affectional bonds and that attachment behaviour functions as a homeostatic mechanism for modulating distress in adulthood as well as in childhood (Bowlby, 1980). The theory postulates that earlier interpersonal experiences influence future interpersonal functioning and methods of regulating distress via working models, or representations about the self and others in relationships. If caregivers are responsive and sensitive to distress the individual develops a secure attachment style, which is associated with a positive self-image, a capacity to manage distress, comfort with autonomy and in forming relationships with others. Conversely, if caregivers are insensitive or unresponsive to distress, the individual either escalates levels of distress to get their attachment needs met (insecure anxious or ambivalent attachment) or deactivates their attachment system which is associated with low levels of affect and an avoidance of close relationships (insecure avoidant attachment) (Shaver & Mikulincer, 2002). Although there are different ways of conceptualising adult attachment, Brennan, Clarke, and Shaver s (1998) factor analysis of * Corresponding author. Present address: Clinical Psychology Unit, Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2TP, UK. Tel.: þ44 (0) ; fax: þ44 (0) address: katherinelberry@yahoo.co.uk (K. Berry). more than 320 self-report measures administered to a large sample of respondents revealed two dimensions of attachment. Attachment anxiety is associated with a negative self-image and an overly demanding interpersonal style, coupled with a fear of rejection and high levels of negative affect. Attachment avoidance is associated with a negative image of others, defensive minimisation of affect, interpersonal hostility and social withdrawal (Bartholomew & Horowitz, 1991; Mikulincer, Shaver, & Pereg, 2003). Empirical research has also shown associations between insecure adult attachments and a wide range of psychiatric disorders (Dozier, Stovall, & Albus, 1999) and there is evidence from longitudinal research to suggest that insecure attachment styles predict the onset of psychiatric symptoms in high-risk samples (Bifulco et al., 2006). Psychosis is a significant mental health problem and is characterised by high levels of interpersonal difficulties (Penn et al., 2004). The attachment system is likely to be particularly important in psychosis, as it is triggered by and determines individuals approaches to seeking help during periods of psychological stress, and psychotic experiences are often highly distressing (Bendall, McGorry, & Krstev, 2006). There is increasing recognition of the role of interpersonal factors in predicting the course of psychosis as well as influencing vulnerability (Read, van Os, Morrison, & Ross, 2005). Cognitive models propose that for some individuals difficulties in earlier relationships with significant others and interpersonal traumas lead to the formation of negative beliefs about the self and others, such as I m vulnerable and other people are /$ see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi: /j.brat

2 1276 K. Berry et al. / Behaviour Research and Therapy 46 (2008) untrustworthy which then facilitate the development and maintenance of symptoms (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). In support of these models, there is a high incidence of negative interpersonal events and traumas in people with psychosis and some evidence from longitudinal studies to suggest adverse environmental experiences can predate the onset of psychosis (Read et al., 2005). There is also empirical evidence of associations between negative beliefs about the self and others and psychotic symptoms (Smith et al., 2006). Furthermore, insecure adult attachments, which are associated with negative beliefs about the self and others as well as maladaptive methods of regulating distress, may increase vulnerability to symptoms or have an adverse effect on the course of psychosis once symptoms are present (Berry, Barrowclough, & Wearden, 2007). The majority of the work investigating attachment in samples with a diagnosis of psychosis has been carried out by one group of authors who have assessed attachment representations using the Adult Attachment Interview (AAI; Main & Goldwyn, 1984) in groups of patients with schizophrenia and other forms of severe mental health problems, including schizoaffective disorder, bipolar disorder and major depression (Dozier et al., 1999). These authors have found that individuals with a diagnosis of schizophrenia have higher levels of insecure attachment, in particular avoidant attachment, compared to those with affective diagnoses (Dozier, 1990; Dozier, Stevenson, Lee, & Valliant, 1991). The AAI assesses attachment states of mind on the basis of the nature and form of the individual s discourse when describing parenting experiences during the interview. Questionnaire measures, on the other hand, assess adult attachment styles on the basis of self-reported feelings, thoughts and behaviours in close relationships in adulthood (Crowell, Fraley, & Shaver, 1999). The AAI therefore provides a measure of the person s current organisation of attachment memories elicited through narrative histories of childhood attachment relationships, whereas self-report measures provide more convenient surface indicators of attachment-related dynamics in adulthood. Both have unique value in the investigation of the function and operation of the attachment system (Roisman et al., 2007; Shaver & Mikulincer, 2002). Using a simple three-item, self-report instrument, Ponizovsky, Nechamkin, and Rosca (2007) found that avoidant attachment was associated with severity of both positive and negative symptoms, but the authors did not report associations between attachment and specific types of symptoms. Avoidant attachment may be a particularly important predictor of the positive symptom of paranoia, which is characterised by interpersonal distrust and social withdrawal (Freeman, Garety, Kuipers, Fowler, & Bebbington, 2002). If attachment theory is to advance our knowledge of psychosis, it is also important to demonstrate, ideally using prospective designs spanning acute phases and remission, that measures of attachment styles in this group are not confounded by the presence of psychotic symptoms. It is possible that psychotic episodes lead to temporary increases in characteristics associated with both anxious and avoidant attachment, such as negative beliefs about the self and others and social withdrawal (Davila, Burge, & Hammen, 1997). Prospective studies comparing acute and stable populations would allow us to determine whether changes in attachment styles are influenced by changes in symptoms. Previous research with nonclinical samples has found changes in attachment styles over periods of time as short as six months (Fraley & Brumbaugh, 2005). As well as informing our understanding of the symptoms of psychosis, attachment styles may provide useful ways of understanding interpersonal difficulties, particularly difficulties with psychiatric staff. Due to diminished social networks, psychiatric staff often play a number of different roles in the lives of people with psychosis, and some authors have even conceptualised staff as attachment figures with the potential to modify attachment working models (Adshead,1998). The extreme and inflexible nature of anxious and avoidant response styles is problematic and is associated with both self- and informant-reports of interpersonal difficulties in nonclinical samples (Bartholomew & Horowitz, 1991). More specifically, we might expect that attachment anxiety would be associated with an overly demanding interpersonal style, whereas attachment avoidance would be associated with interpersonal hostility, and furthermore that these attachment-related interpersonal problems might impact on staff and patient relationships. Tait, Birchwood, and Trower (2004) found associations between insecurity in self-reported adult attachment relationships and poorer engagement with services in a sample of people with psychosis. Dozier and colleagues found that avoidant attachment on the AAI was associated with clinician ratings of rejection of treatment (Dozier, 1990) and difficulties in engaging in therapeutic tasks as rated by independent observers (Dozier, Lomax, Tyrrell, & Lee, 2001). In non-psychosis samples, there is growing evidence of associations between attachment and the concept of working alliance which is defined in terms of collaborative endorsement of tasks, mutual agreement of goals and degree of emotional bond (Bordin, 1979). This concept is relevant across a range of different clinical models (Howgego, Yellowlees, Owen, Meldrum, & Frances, 2003) and is a key determinant of outcome in psychosis (Neale & Rosenheck, 1995). However, it is important to assess alliance from both patient and staff perspectives, as the two are not necessarily related (Couture et al., 2006). The present study aims to extend attachment and psychosis research in a number of important ways. Using a prospective design, we will assess associations between avoidant attachment and symptoms, including paranoia. The study will also assess associations between anxious and avoidant attachment and interpersonal difficulties; and avoidant attachment and therapeutic relationships, measured from both patient and staff perspectives. Firstly, we predict attachment avoidance will be associated with both positive and negative symptoms and that there will be a specific association between avoidance and paranoia. Secondly, assuming psychotic symptoms have a minimal influence on attachment styles, we predict that mean changes in attachment scores over time will be similar in both psychiatrically stable and unstable groups and changes in attachment scores will be unrelated to changes in symptoms. Thirdly, we predict associations between attachment and interpersonal problems, with specific associations between attachment anxiety and overly demanding behaviour and attachment avoidance and interpersonal hostility. Fourthly, we predict associations between attachment avoidance and both staff and patient perceptions of poorer therapeutic alliance. Finally, associations between attachment and interpersonal difficulties, and between attachment and therapeutic relationships will be maintained when the potential confound of illness severity is controlled. Method Participants and procedure Ninety-six patients from psychiatric services across Greater Manchester were recruited to the study. Inclusion criteria were: documented diagnosis of schizophrenia, schizoaffective or nonaffective psychosis; able to give informed consent; English speaking; and no history of organic factors implicated in the aetiology of psychotic symptoms. Psychiatric teams were informed about the study and staff were asked to provide potential participants with a study information sheet. With patient permission, the researcher then visited participants to answer any questions about the research and obtain informed consent. Sixteen (16.67%)

3 K. Berry et al. / Behaviour Research and Therapy 46 (2008) patients approached did not want to participate. Informant measures were completed by a mental health worker who had known the patient for at least three months. No mental health workers who were approached about the study refused to participate, but one worker was not available for interview due to longterm leave. Medical records were reviewed to obtain information about demographic and illness-related variables, including diagnosis, age of onset and number of in-patient admissions. Subgroups of patients from this larger sample participated in the follow-up part of the study investigating the influence of symptoms on attachment style. The first subgroup had 33 psychiatrically stable patients who completed symptom and attachment measures at sixmonth follow-up. This group comprised all patients who were recruited to the larger sample over a six-month period who did not relapse between the time one assessment and the six-month followup. The group did not differ from the remaining sample in terms of baseline demographic or illness-related variables. The second subgroup had 21 patients who completed the symptom and attachment measures during an acute phase of illness and again following the remission of symptoms. This group comprised all patients who were recruited from inpatient psychiatric services. Additional inclusion criteria for the acute sample were the presence of hallucinations or delusions at the time of recruitment which remitted within a period of six months. See the appendix for recruitment flowchart. Measures Psychosis Attachment Measure (PAM) The attachment measure has 16 items, with eight items assessing the construct of avoidance and eight items assessing the construct of anxiety. Items were derived from existing self-report attachment measures (Brennan et al., 1998), but there were no items referring specifically to romantic relationships. Our measure has advantages over existing attachment measures, as items are rated on simple and anchored, four-point Likert scales, and unlike the majority of other self-report attachment questionnaires it can be used by people who do not currently have or have not recently had a romantic partner. The fact that it assesses attachment in terms of the two dimensions of attachment anxiety and avoidance also facilitates comparisons with previous and future studies. Total scores were calculated for each dimension by averaging individual item scores, with higher scores reflecting higher levels of anxiety and avoidance. The PAM has been shown to have good psychometric properties in two independent non-clinical samples (Berry, Band, Corcoran, Barrowclough, & Wearden, 2007; Berry, Wearden, Barrowclough, & Liversidge, 2006). These studies provided evidence to support the measure s construct validity, with positive associations between insecure attachment and measures of self-esteem, interpersonal problems and negative experiences in earlier interpersonal relationships. Evidence for the measure s concurrent validity was obtained in the present sample, with significant associations between attachment anxiety and avoidance dimensions and theoretically similar dimensions of model of self and model of others on the Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991; anxiety and model of self: r ¼.59, p <.001; avoidance and model of other: r ¼.54; p <.001). Positive and Negative Syndrome Scale (PANSS) The PANSS (Kay, Fiszbein, & Opler, 1987) is a 30-item, semistructured interview with positive, negative and general psychopathology subscales. A total symptom score can also be derived by summing subscale scores and this was used as a measure of severity of psychiatric symptoms. One of the positive subscale items refers specifically to paranoid ideation and was used as a measure of paranoia. All subscale alphas were above.70 in the present sample and high levels of inter-rater reliability were obtained with an experienced PANSS rater throughout the study (all Intraclass Correlation Coefficients, ICCs >.80). Inventory of Interpersonal Problems-32 (IIP-32) The 32-item IIP (Barkham, Hardy, & Startup, 1996) is a selfreport questionnaire that assesses a range of interpersonal problems, including aggression, poor sociability and excessive dependence on others. The alpha in the present study was.85. Social Behaviour Scale (SBS) Two items from the informant-rated SBS (Wykes & Sturt, 1986) measuring attention seeking and hostility were used to provide more specific measures of overly demanding and hostile interpersonal styles. Working Alliance Inventory (WAI) The 12-item WAI (Tracey & Kokotovic, 1989) assesses agreement on therapeutic goals, agreement on therapeutic tasks and emotional bond, and has both patient and staff versions. A global rating of alliance is derived by summing scores for individual items, with high scores indicating a good therapeutic alliance. Alphas in the present study were.96 for the patient version and.90 for the informant version. Data analysis Prior to carrying out analyses, data sets were screened for normality and outliers. Given that the PAM is a relatively new measure, its psychometric properties were examined in this clinical sample. A principal components analysis with varimax rotation was carried out to determine the measure s underling factor structure. There were at least five participants per item to justify this analysis and the Kaiser Meyer Olkin (KMO) measure of sampling adequacy was above the criterion of.80. Inspection of the residuals suggested that the solution provided an acceptable fit of the data (Field, 2000). When items loaded onto more than one factor above.4, items were incorporated into subscales with the highest loadings. Internal consistencies were assessed using Cronbach s alphas and test retest estimates and interrater reliability were assessed using ICCs. Associations between continuous variables were examined using Pearson s correlations, or in the case of the illness-related variable of number of hospital admissions and change scores for hallucinations, which remained skewed following transformations, Spearman Rank correlations. Associations between the PAM and categorical measures were assessed using independent group t-tests and one-way analyses of variance (ANOVA). A hierarchical regression analysis was used to control for the influence of severity of illness on associations between paranoia and avoidant attachment. There was no evidence of multicollinearity in this model andanalysesofresidualssuggestedthemodelprovidedagoodfitof the data. All other potential confounds were controlled using partial correlations in the case of continuous variables or Analyses of Covariance (ANCOVAs) in the case of categorical variables. Where there were missing data, all available data were analysed, and the sample size for each analysis reported in the tables. Results Patient and informant sample characteristics The mean age for patients was 44 years (SD ¼ 12.8) and 68% (n ¼ 66) were male. 1 The group comprised the following ethnicities: 1 Males had significantly higher attachment avoidance scores than females [t(94) 2.15, p ¼.034]. All analyses depicted in Tables 2 and 3 were therefore repeated controlling for gender and significance levels were unaffected.

4 1278 K. Berry et al. / Behaviour Research and Therapy 46 (2008) % (n ¼ 88) White British; 3.1% (n ¼ 3) Black British; 3.1% (n ¼ 3) Asian; and 2.1% (n ¼ 2) Mixed Race. Seventy-six percent (n ¼ 73) were single,12.5% (n ¼ 12) were divorced, 6.3% (n ¼ 6) were married and 5.2% (n ¼ 5) were widowed. Approximately half of the sample had not completed secondary education (42.7%, n ¼ 41) and none were in full time employment. The majority had a diagnosis of schizophrenia (80.2%, n ¼ 77), 15.6% (n ¼ 15) had a diagnosis of schizoaffective disorder and 4.2% (n ¼ 4) were experiencing a psychotic episode. The median age of onset was 24 years (range ¼ 15 57) and the median number of in-patient admissions was 5 (range ¼ 0 20). Seventy-five mental health workers participated in the study, with five staff completing the informant measures for more than one patient. 2 The majority were female (66.7%, n ¼ 50), 49.3% (n ¼ 37) were support workers, 44% (n ¼ 33) were nurses, 5.3% (n ¼ 4) were social workers and 1.3% (n ¼ 1) were occupational therapists. The mean number of years of experience in mental health was 10 (SD ¼ 7.8) and the median number of months staff had known patients was 12 (range ¼ 3 180). Psychometric properties of the PAM Self-report version A two-factor solution provided the most theoretically comprehensible fit of the data, with one of the factors representing anxiety and the other avoidance (see Table 1). The anxiety factor accounted for 25.37% of the variance and the avoidance factor accounted for 20.74% of the variance. Subscale alphas suggested good levels of internal reliability (attachment anxiety ¼.82; attachment avoidance ¼.76). Item-total correlations for subscales ranged from.46 to.75, suggesting that all of the items were contributing to overall reliability. Attachment and avoidance subscales were not significantly correlated, indicating that they were assessing unique constructs (r ¼.096, p ¼.355). The reproducibility of the factor structure was assessed further in a second clinical sample of 101 patients with psychosis and substance misuse participating in a Medical Research Council funded trial of Motivational Interventions for Drug and Alcohol Misuse in Schizophrenia (MIDAS; A twofactor solution with varimax rotation again provided the most comprehensive fit of the data with item loadings consistent with those reported in the main sample and the anxiety factor accounting for 20.78% of the variance and the avoidance factor accounting for 18.06% of the variance. The 33 patients participating in the six-month follow-up study also completed the attachment measure at one-month follow-up. ICCs indicated that measure was stable over time (attachment anxiety ¼.71; attachment avoidance ¼.56), with comparable test retest estimates to existing measures (Fraley & Brumbaugh, 2005). There were no significant differences in time one scores and onemonth follow-up scores for either anxiety [t(32).62, p ¼.542] or avoidance [t(32) 1.19, p ¼.243]. Informant-report version There is also an informant version of the PAM with parallel items to the self-report measure, rephrased to reflect observable behaviours. Staff in the present study completed the measure in addition to other informant measures and a principal components analysis with varimax rotation was carried out using this data. The 2 Analyses were also carried out excluding data for staff who completed more than one measure. When staff had completed measures for two or three patients, scores for only one patient were entered into the analysis and data for any other patients were excluded. As findings and significance levels were unaffected when scores were excluded, the non-independence of the data was not deemed to be a confounding factor. Table 1 Factor loadings for the PAM Items Anxiety Avoidance I prefer not to let other people know my true.70 thoughts and feelings. I find it easy to depend on other people for support with.70 problems or difficult situations. a I tend to get upset, anxious or angry if other people are.56 not there when I need them. I usually discuss my problems and concerns.62 with other people. a I worry that key people in my life won t be.71 around in the future. I ask other people to reassure me that they care about me If other people disapprove of something.70 I do, I get very upset. I find it difficult to accept help from other people.57 when I have problems or difficulties. It helps to turn to other people when I m stressed. a.61 I worry that if other people get to know me better,.63 they won t like me. When I m feeling stressed, I prefer being on.45 my own to being in the company of other people. I worry a lot about my relationships with other people..77 I try to cope with stressful situations on my own I worry that if I displease other people, they won t.68 want to know me anymore. I worry about having to cope with problems and.77 difficult situations on my own. I feel uncomfortable when other people want to get to know me better a Reverse items. factor structure and items loadings were consistent with the selfreport measure, with the informant-report anxiety factor accounting for 24.24% of the variance and the informant-report avoidance factor accounting for 22.89% of the variance. The measure also had good levels of internal consistency (informantreported anxiety alpha ¼.83; informant-reported avoidance alpha ¼.81) and one-month test retest reliability (informantreported anxiety ICC ¼.85; informant-reported avoidance ICC ¼.81). Inter-rater reliability was assessed by asking a second mental health professional involved in the patient s care to complete the measure. This sample comprised 26 of the 33 patients who participated in the follow-up study who had two mental health professionals involved in their care. Good reliability was obtained for both attachment anxiety (ICC ¼.71) and avoidance (ICC ¼.74). Are adult attachment styles associated with specific symptom profiles? We examined associations between attachment dimensions and symptom subscales. As predicted, attachment avoidance was positively correlated with paranoia, positive and negative symptom subscale scores. Associations between attachment anxiety and symptoms did not reach significance (see Table 2 for correlations). In order to test whether patients who were more paranoid had higher levels of avoidant attachment simply because they were more symptomatic, a hierarchical regression analysis was carried out. With paranoia as the dependent variable, and with severity of illness, as measured by PANSS total scores (excluding scores for paranoia item), already in the model, adding avoidant attachment resulted in a significant increase in predictive power [R 2 change ¼.04, F change (1, 89) 6.57, p ¼.012]. Both avoidance (b ¼.20, p ¼.044) and total symptom scores (b ¼.24, p ¼.019) were significant predictors in the final model, suggesting that paranoia is associated with avoidant attachment independently of severity of illness.

5 K. Berry et al. / Behaviour Research and Therapy 46 (2008) Table 2 Associations between attachment and symptoms Symptom measures Attachment anxiety Attachment avoidance PANSS total scores (n ¼ 96) PANSS positive scores <.001 PANSS negative scores PANSS general psychopathology scores Paranoia (PANSS item) <.001 PANSS ¼ Positive and Negative Syndrome Scale. How stable are attachment styles and do changes in attachment scores relate to changes in symptoms? Prior to carrying out analyses of changes in attachment, we verified that there were no statistically significant changes in total PANSS scores over the six-month study period for the psychiatrically stable sample [t(32) 1.40, p ¼.171; M change score ¼ 1.91; 95% confidence interval ¼.47.87]. Case notes were also reviewed to verify that there were no changes in psychiatric treatment for this group. As expected, there was a statistically significant change in total PANSS scores for the psychiatrically unstable patients from acute phases of illness to remission [t(20) 7.50, p <.001; M change score ¼ 24.20; 95% confidence interval ¼ ]. In the psychiatrically stable sample, attachment scores at time one were significantly positively correlated with attachment scores at six months (attachment anxiety: r ¼.52, p ¼.002; attachment avoidance: r ¼.51, p ¼.003). Attachment scores at acute phases and remission were also significantly positively correlated (attachment anxiety: r ¼.61, p ¼.003; attachment avoidance: r ¼.47, p ¼.033). Attachment change scores were calculated for the stable patient group and the acute patient group by subtracting time two scores from time one scores. Across both groups, there were no statistically significant differences between attachment change scores for attachment anxiety [t(53.67), p ¼.506] or attachment avoidance [t(53).01, p ¼.992]. We also examined correlations between attachment change and symptom change scores. Combining data for both samples, there were positive associations between changes in attachment scores and changes in symptoms as measured by PANSS total change scores, although these only reached significance for attachment anxiety (attachment anxiety: r ¼.30, p ¼.027; attachment avoidance: r ¼.10, p ¼.457). Similar analyses correlated changes in attachment scores with changes in PANSS positive and negative subscale scores and changes in the delusions and hallucinations positive symptom items. The only significant correlation was between change scores for the hallucinations item and change in attachment anxiety (Spearman s r ¼.30, p ¼.026). Are attachment anxiety and attachment avoidance associated with interpersonal problems? We firstly examined associations between attachment dimensions and overall severity of interpersonal problems. As predicted, the majority of the analyses revealed significant positive correlations between attachment styles and interpersonal problems (see Table 3 for correlations). Further analyses were carried out to test specific associations between attachment anxiety and an overly demanding interpersonal style and attachment avoidance and interpersonal hostility. The attachment anxiety scores of the 21 patients who were rated as attention seeking on the SBS were compared with the 58 patients who were not rated as having a problem in this area. The attachment avoidance scores of the 28 patients who were rated as Table 3 Correlations between adult attachment, interpersonal problems and therapeutic relationships Interpersonal measures IIP full-scale (n ¼ 81) Patient WAI (n ¼ 81) Staff WAI (n ¼ 80) Attachment anxiety hostile on the SBS were compared with the 51 patients who were not rated as having a problem in this area. Group comparisons for attention seeking revealed predicted group differences for attachment anxiety [t(77) 2.82, p ¼.006], with higher levels of attachment anxiety in the attention seeking compared to the non-attention seeking group [attachment anxiety attention seeking group M ¼ 1.33, SD ¼.85; attachment anxiety non-attention seeking group M ¼.84, SD ¼.65]. Group comparisons for hostility revealed predicted group differences for attachment avoidance [t(77) 2.77, p ¼.007], with higher levels of avoidance in the hostile compared to the non-hostile group [self-reported attachment avoidance hostile group M ¼ 1.87, SD ¼.72; self-reported attachment avoidance nonhostile group M ¼ 1.47, SD ¼.55]. Is attachment avoidance associated with difficulties in therapeutic relationships? We assessed associations between attachment avoidance and poorer therapeutic alliance from both patient and staff perspectives. As predicted, there were significant negative correlations between attachment avoidance and both patient- and staff-rated therapeutic alliance. There were no significant associations between attachment anxiety and therapeutic alliance (see Table 3 for correlations). Is adult attachment associated with interpersonal problems and difficulties in therapeutic relationships independently of severity of illness? In order to assess whether attachment dimensions were associated with interpersonal problems and difficulties in therapeutic relationships over and above their associations with psychiatric symptoms, we repeated the above analyses controlling for the influence of severity of illness as measured by PANSS total scores. These analyses were repeated using PANSS positive scores, PANSS negative scores and the PANSS paranoia item scores as illness severity covariates and in all cases findings were replicated. All significant associations between attachment and interpersonal problems were maintained when controlling for the influence of illness severity. Attention seeking and hostile group differences in attachment anxiety and avoidance were also still significant when co-varying for influence of illness severity [Group differences in self-reported anxiety for attention seeking versus non-attention seeking groups: F(1, 76) 6.46, p ¼.013; group differences in self-reported avoidance for hostile versus non-hostile groups: F(1, 76) 4.59, p ¼.035]. All significant associations between avoidant attachment and therapeutic relationships were maintained when controlling for the influence of illness severity (see Table 3 for partial correlations). Informant version of the PAM Partial correlation controlling for PANSS Attachment avoidance <.001 < L.44 L < L.33 L Partial correlation controlling for PANSS IIP ¼ Inventory of Interpersonal Problems; WAI ¼ Working Alliance Inventory. All major analyses were repeated using the informant version of the PAM, and as findings were replicated with similar levels of

6 1280 K. Berry et al. / Behaviour Research and Therapy 46 (2008) significance, for clarity and ease of interpretation these analyses are not reported here. Discussion We found predicted associations between avoidant attachment and both positive and negative symptoms and paranoia. There were also no significant differences in the stability of attachment ratings in psychiatrically stable and unstable groups. We found support for predicted associations between attachment anxiety and avoidance and interpersonal problems, with specific associations between anxiety and overly demanding behaviour and avoidance and interpersonal hostility. As predicted, high levels of attachment avoidance were associated with difficulties in therapeutic relationships. Effects were maintained when controlling for the influence of severity of illness. Associations between attachment avoidance and positive symptoms are consistent with previous research investigating associations between self-report measures of attachment and symptoms (Ponizovsky et al., 2007) and higher levels of avoidant attachment on the AAI in samples with schizophrenia (Dozier et al., 1991). Ponizovsky et al. (2007) also found associations between attachment anxiety and positive symptoms. This difference in findings may be attributable to the use of a simple three-item measure of attachment in the Ponizovsky et al. (2007) study, compared to the use of the multiple-item PAM in our study. It also suggests that relationships between attachment anxiety and psychotic symptoms may be less robust than relationships between attachment avoidance and psychotic symptoms. Ponizovsky et al. (2007) did not report associations between attachment and specific symptoms. Our study is the first to demonstrate associations between avoidant attachment and the positive symptom of paranoia in a sample with psychosis. Although the proportion of variance accounted for in paranoia was low (4%) and the clinical significance of this finding is unclear, the fact that associations between avoidant attachment and paranoia were upheld when controlling for total symptom scores, suggests that higher levels of avoidant attachment in paranoid patients was not attributable to illness severity. Associations between avoidant attachment and positive symptoms and paranoia support cognitive models of psychosis, which propose that negative beliefs and social withdrawal play a role in the maintenance of positive symptoms (Garety et al., 2001) and paranoia in particular (Freeman et al., 2002). Findings of associations between avoidant attachment and negative symptoms support cognitive models of schizophrenia which conceptualise social withdrawal and emotional blunting as methods of coping with social stress (Beck, 2004). Evidence of psychological correlates of negative symptoms are important as previous research in this area has tended to focus on positive symptoms, despite the fact that negative symptoms result in significant impairment and are often resistant to treatment (Provencher & Mueser, 1997). Associations between attachment and symptoms support cognitive models of psychosis, but more importantly suggest that attachment theory in its own right may provide a useful framework to understand the development and maintenance of symptoms. Previous studies of attachment in psychosis are limited by crosssectional designs. Our study is the first to show that the degree of change in attachment styles over time is similar in patients who are psychiatrically stable and those with fluctuating symptom profiles. The strength of test retest correlations in both groups was moderate and comparable to those reported in previous studies investigating changes in attachment styles over similar time periods in non-clinical samples, with correlations in previous research averaging around 0.54 (Fraley & Brumbaugh, 2005). Therefore although self-reported attachment styles in samples of people with psychosis do vary over time, they are no less stable than attachment styles in the general population. Although attachment styles at time one and two were significantly correlated in both samples and were comparable to those reported in existing research, a considerable degree of variance remains unaccounted for (Baldwin & Fehr, 1995). There is a growing recognition in the attachment literature that these fluctuations in attachment ratings are not the result of unreliable or imprecise measurement, but reflect meaningful variability in underlying constructs. The present study and previous research suggests that psychiatric symptoms may be one such factor (Davila et al., 1997). We found significant positive correlations between increases in self-reported attachment anxiety and changes in total symptom scores and between increases in self-reported attachment anxiety and changes in hallucinations. However, fluctuations in symptoms cannot provide a complete explanation given that our test retest estimates were similar to those obtained in non-clinical studies and there were no significant association between attachment avoidance and changes in symptoms. Instability in attachment styles could also relate to the fact that individuals have different attachment working models for different relationships that may be more or less influential at different points in time depending on fluctuations in mood states or in the nature of current relationships. Determining the factors which are associated with variations in attachment working models in samples of people with psychosis is important, as it may be possible to help individuals with insecure attachment styles develop more positive relationships with others. Findings supported predicted associations between attachment anxiety and avoidance and interpersonal difficulties. As predicted, there were specific relationships between attachment anxiety and overly demanding behaviour and attachment avoidance and hostility. Attachment theory may therefore provide a useful framework to help understand and formulate patterns of interpersonal difficulties in psychosis. Cognitive behavioural interventions for psychosis would benefit from incorporating this interpersonal focus, as thus far they have been shown to have limited impact on social functioning (Penn et al., 2004). Insights gained from attachment theory also open up the possibility of understanding and reducing negative patient-staff interactions (Adshead, 1998). If clinicians could understand difficult interpersonal behaviours in terms of attachment styles that were functional in the context of past experiences with significant others, they would be less inclined towards negatively appraising such behaviours and consequently less inclined towards critical or hostile attitudes towards the patient (Barrowclough et al., 2001). As predicted, we found significant associations between attachment avoidance and both patient- and clinician-rated therapeutic alliance. Dozier (1990) and Dozier et al. (2001) also found particular difficulties in therapeutic relationships with patients with dismissing-avoidant attachment on the AAI, suggesting that associations between attachment avoidance and poorer therapeutic relationships is a fairly robust findings that can be replicated using different measures of attachment. Dozier and colleagues describe a self-perpetuating pattern, whereby avoidant individuals reject help, which reinforces negative perceptions of others. In the counselling literature, avoidant attachment is similarly a more consistent correlate of alliance than anxiety (Daniel, 2006). Psychiatric staff may find it easier to form therapeutic relationships with and empathise with anxiously attached individuals compared to individuals with avoidant attachment, possibly because the former are more likely to report symptoms and to seek help in the first place (Vogel & Wei, 2005). Nonetheless, anxiety might be associated with difficulties in alliance in the early stages of therapeutic relationships or be associated with more ruptures in alliance (Daniel, 2006). Our findings extend previous research by demonstrating that associations between attachment style and

7 K. Berry et al. / Behaviour Research and Therapy 46 (2008) interpersonal problems and attachment style and therapeutic relationships were maintained when controlling for the influence of symptoms. These findings are consistent with the hypothesis that adult attachment style is an important explanatory variable in understanding interpersonal difficulties in psychosis independently of severity of illness. Given the importance of therapeutic relationships in influencing outcomes (Neale & Rosenheck, 1995), associations between attachment avoidance and difficulties in therapeutic relationships have important clinical implications. Identifying individuals with an avoidant attachment style upon entry to services would help highlight people who might experience difficulties in engaging with services and who are likely to need increased input. The finding that difficulties in the therapeutic relationship are associated with attachment avoidance assessed by a relatively brief self-report measure, means it is possible to screen for attachmentrelated difficulties in therapeutic relationships. It may also be possible to maximise engagement and clinical effectiveness by varying therapeutic approaches in accordance with patients attachment styles. For example, individuals with avoidant attachment may benefit from interventions which encourage them to focus on their emotional reactions, whereas those with anxious attachment would benefit from approaches which minimise the focus on emotional distress (Tyrrell, Dozier, Teague, & Fallot, 1999). Caveats and conclusions The study assesses attachment styles in a large sample of people with psychosis and therefore makes an important contribution to the literature. However, as with earlier research by Dozier and colleagues, the sample was one of convenience and therefore unrepresentative. Participants in this study were older with relatively long histories of psychosis, so it would be particularly helpful to replicate the study in early onset samples. As with all naturalistic research, the direction of associations between variables in this study cannot be ascertained. Associations between attachment, symptoms and therapeutic relationships are most likely dynamic and bi-directional, with symptoms and therapeutic relationships exerting an influence on attachment styles. Although a major strength of our study is that we measured changes in attachment using a prospective design, our follow-up period was relatively short and was limited to one time point. Longitudinal studies assessing attachment over multiple episodes of illness may reveal more substantial changes. The onset of the first episode of psychosis may be a particularly significant factor in influencing attachment as this is often associated with major changes in interpersonal relationships and has been conceptualised as a traumatic interpersonal event (Bendall et al., 2006). This study does not compare attachment ratings in patients with psychosis with clinical or non-clinical controls. It is therefore not possible to determine whether the sample have significantly high levels of insecure attachment. However, there is evidence from previous research that insecure attachment is associated with a range of psychiatric conditions and not all individuals with insecure attachment styles develop psychosis (Dozier et al., 1999). If attachment style does play a role in the development of psychosis or other forms of psychiatric distress, it should be considered in the context of a range of risk and resilience factors (Dozier, 1990). This study used a self-report measure approach to assess attachment and consistent with other self-report measures, the PAM generated constructs of anxiety and avoidance. The concepts of anxiety and avoidance place an emphasis on psychopathology as opposed to core aspects of attachment theory which provide a framework to think about resilience and adaptation. Although the use of a questionnaire to measure attachment introduces the possibility of self-reporting biases, including social desirability biases, a major strength of this study is that interpersonal problems and alliance were measured from staff perspectives and findings were replicated using an informant version of the PAM, thus helping to control for self-reporting biases and the potential confound of common method variance. As in the case of other measures of attachment, it is difficult to determine whether individuals were reporting thoughts, feelings and behaviours in attachment relationships or more general social relationships. However, in answering questions, participants were asked to think specifically about close interpersonal relationships and upon completion of the questionnaire, the majority reported answering with reference to relationships with significant others, including family, romantic partners and key workers. Critics of self-report measures of attachment have argued that measures of adult attachment styles are proxy measures of personality traits (Crowell & Treboux, 1995). However, the available evidence suggests that attachment dimensions are not redundant to the five factors of personality and are in fact better predictors of relationship variables (Shaver & Brennan, 1992). There is also an issue of tautology, particularly with reference to associations between attachment avoidance and paranoia, as some of the items on the avoidance subscale are consistent with paranoid ideation. In developing the PAM, we did, however, ensure that all items were derived from existing attachment measures and that the measure had content validity through consultation with clinical psychologists and researchers with a good knowledge of attachment theory. As self-reported attachment styles are not necessarily correlated with unconscious attachment representations and there are distinctions between the correlates of these measures (Roisman et al., 2007), research is needed to explore how both constructs relate to symptoms and interpersonal relationships in psychosis. However, consistent findings of associations between avoidant attachment and symptoms of schizophrenia and avoidant attachment and difficulties in therapeutic relationships in previous research using the AAI and this research using a self-report measure of attachment, highlight the validity of the associations. Although therapeutic alliance measures produce some of the most robust findings in the psychotherapy literature, there is potential for confounding with acquiescence and co-operation. Further work is therefore needed to determine whether therapeutic alliance measures are assessing intended constructs in populations with a diagnosis of psychosis. A final criticism is the possibility of Type I errors resulting from multiple testing. All analyses were, nevertheless, hypothesis driven and findings were supported by previous research. Despites these caveats, our findings do suggest that adult attachment style may be an important predictor of symptoms and interpersonal difficulties in people with psychosis, both of which are associated with poorer outcomes. This is the first study to demonstrate associations between avoidant attachment and paranoia and investigate the stability of attachment styles. Our findings also extend previous research by demonstrating associations between attachment and interpersonal difficulties, demonstrating associations between attachment avoidance and therapeutic alliance, showing that findings are consistent across both staff and patient perspectives and are independent of illness severity. This study is the largest most comprehensive study assessing the concept of attachment in psychosis since Dozier and colleagues work investigating attachment using the AAI. The fact that associations between avoidant attachment, symptoms and therapeutic relationships were replicated not only increases confidence in the validity of associations, but also has important clinical implications as self-report measures are easier to administer than the AAI, so are more amenable to use in clinical practice. Finally, the findings provide further evidence to support the reliability and validity of the PAM and suggest that the measure would be useful in assessing attachment styles in future studies with clinical samples.