attachment and psychosis 2016 babcp keynote

Attachment and Caregiving in psychosis: current status and future directionsAndrew Gumley Twitter @andygumleyPsychosis Research Group, Mental Health and WellbeingInstitute of Health and Wellbeing

44th BABCP Annual Conference – Waterfront Centre Belfast

• Zena Wight• Kate Davidson• Tony Morrison• Max Birchwood• Matthias Schwannauer• Angus Macbeth• Susanne Harder• Suzy Clark• Andrew Moskowitz

• Jacqui Feeney• Hamish McLeod• Joanna McNaughton• Hannah Taylor• Carol George• Jessica Brennan• Giovanni Liotti• Paul Lysaker

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

Something’s not quite right

I could end up back in hospital

I’ll let everyone

down

Relationships

What might happen

Feelings: Fear, anxiety, shameBehaviours: Avoidance, hypervigilance, over positive

Behaviours: Increased monitoring, risk orientedFeelings: Concern, suspiciousness

Service recipient

Service provider

CRIMSON Trial

• CRIMSON Trial• Included and randomised 569

participants• Joint Crisis Care Plans

specifying is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency

• Primary outcome coercion into care: (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0.90 [95% CI 0.58–1.39, p=0.63])

Process evaluation of CRIMSON

• Farrelly et al. (2015) Qualitative Health Research:

• Service users experiences of the therapeutic relationship

Not being known or respected as an individual

Distrusting clinicians“Playing the game”

• Clinicians experiences of the therapeutic relationship

Ritualised interactions

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

Body text

“Behavioural and emotional disturbance is viewed as a developmental construction, reflecting a succession

of adaptations that evolve over time in accord with the same principles that govern normal

development”

Sroufe (1997)

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

• There were 22 papers describing 21 studies that were included in this review.

• There were 1453 participants in the included studies with mean age of the participants was 35.0 years (range of 12– 71 years).

• Outcomes included: • Engagement with mental health

services, hospitalisation, interpersonal problems, recovery / coping style, parental bonding, trauma and symptoms

• Psychosis Attachment Measure (PAM; 54.6%; n = 793). • Adult Attachment Interview (AAI; 19.3%; n = 280). • Attachment Style Questionnaire (ASQ;11.6%; n = 169). • Relationship Questionnaire (RQ; 9.0%; n = 131). • Service Attachment Questionnaire (SAQ; 5.4%; n = 78). • Revised Adult Attachment Scale (RAAS; 3.4%; n = 50). • Adult Attachment Questionnaire (AAQ; 2.1%; n = 30).

• May 2016 Update• 47 papers describing 43

separate studies• Comprising 3,169

participants• 2221 (71%) male with a

mean age 34.7-years

Mary Dozier

Mary Dozier Max Birchwood

Mary Dozier Max Birchwood

Katherine Berry

Mary Dozier Max Birchwood

Katherine Berry

Andrew Gumley

• We applied apriori 3 conceptual models of attachment to the 43 studies.

• Cognitive model – primarily including studies exploring attachment appraisals informed by Internal Working Models (as proposed by Bartholomew) and associations with symptoms (e.g. voices and paranoia), behavioural and emotional responses (21 primary studies).

• Systemic model – primarily studies exploring attachment and associations with working alliance and other interpersonal relationships (13 primary studies).

• Affect regulation model – studies exploring attachment and earlier life experiences, affect regulation and developmental outcomes including mentalisation and their influence on outcomes and recovery (13 primary studies)

• Cognitive model• Attachment avoidance linked to positive symptoms Ponizovsky 2007,

Berry 2008 paranoia Berry 2008 critical rejecting voices Berry 2012 voice distress Robson 2014 aggression Bo 2013 lack of recovery at 12-months Berry 2015 and hopelessness Ringer 2014

• Insecurity of attachment linked to poorer quality of life Couture 2007 greater social anxiety Gajwani 2013 Michial 2014 greater paranoia Wickham

2015 greater emotional regulation difficulties Owens 2012 and emotional distress Ponizovsky 2014

• Less evidence regarding attachment anxiety except in relation to voice distress Berry 2012 and beliefs about voices as being omnipotent and malevolent Robson 2014

• Systemic model• Greater attachment insecurity (particularly avoidance) linked to

poorer therapeutic allianceBerry 2008, Kvrgic 2011, 2013 and lower levels of service engagementTait 2004

• Some evidence that this unfolds through particular attachment strategies linked to disclosure, less help seeking, less use of treatmentDozier 1990, 1994, 1995

• However this could also be linked to clinicians responses including their own attachment insecurity or service responses including hospitalisation and detainment in hospital Blackburn 2010, Ponizovsky 2007

• Evidence that the depth and therapeutic commitment ward climates can change self reported attachment Campbell 2014

• Affect regulation model• Attachment insecurity particularly anxiety linked to previous

childhood traumas Berry 2015, van Dam 2014 and trauma arising from psychosis and hospitalisation Berry 2015

• Avoidance linked to lower mentalisation Macbeth 2010 which in turn is linked to more poorer premorbid adjustment, negative symptoms and less helpseeking Macbeth 2014

• Prospectively insecurity of attachment mediated relationship between DUP and outcome of negative symptoms in first episode psychosis Gumley 2014

• Attachment insecurity particularly avoidance linked to lower mentalisation and predicts recovery of positive and negative symptoms McLeod 2014

*(F = 9.99, p = 0.003)Recovery of positive symptoms over 12-months

*(F = 4.22, p = 0.047)Recovery of general symptoms over 12-months

*(F = 5.83, p = 0.021)

Recovery of negative symptoms over 12-months

• Early keyworker perceptions of problematic engagement provide a window into factors linked to early arrested recovery.

• Are more likely to be subject to coercive admission within 6-months of service entry

• Are more likely to be admitted to hospital between 6 and 12-months.

• Less likely to have a psychological intervention• Have poorer pre-morbid functioning

–Adolescent sociability and withdrawal–Adolescent Peer relationships

• Early arrested recovery was reflected in persistent and stable negative symptoms.

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

• Why Attachment Theory applied to psychosis?• The developmental roots of resilience and adaptation• Where are we now?• An Integrated Attachment Model of Psychosis• Where do we go now?

Public & Maternal Mental

Health

Understanding emotion

psychosis links

• Literature relies on self-reported attachment or Adult Attachment Interview (AAI)

• Both have their own challenges and limitations.• Self reports do not necessarily capture when attachment

system is “online”• AAI is complex to administer, code and score• Experience sampling methodologies may provide a useful

alternative to explore attachment – emotion – psychosis links over time allowing for close fine-grained analysis of attachment system signals

Cognitive Therapy

• From attachment perspective Cognitive Therapy well placed as an intervention in psychosis

• Emphasis on collaboration, shared goals, clarity of model of Thoughts, Actions and Feelings and transparency of links between problems, goals and therapeutic activities.

• However attachment avoidance may be linked to earlier attachment disorganisation arising from trauma and loss and thus conceal more intense dysregulated emotions.

• This can be a challenge to collaborative alliance and also the wider system.

• Role for case formulation in supporting staff and teams to respond optimally.

Caregiving environment

• “Warmth. This 6-point rating was based on the amount of warmth demonstrated by the respondent when talking about the particular person in the home. In general, stereotyped endearments were ignored, but positive comments, especially if made spontaneously, were regarded as important. Sympathy and concern, interest in the other as a person, and expressed enjoyment in mutual activities were all relevant. Particular attention was paid to warmth expressed in tone of voice.” (p. 245)

• “Warmth was not used in the overall index…. Marked warmth free from these unfavourable factors [criticism and emotional over involvement] was associated with a low rate of relapse. Only one patient relapsed out of these 11 families characterized warmth in the absence of high p<.01).” (p. 246)

• Bowlby proposed that the behavior of the attachment figure is organized by a caregiving behavioural system (Bowlby, 1969/1982, 1988).

• Caregiving behavior is organized within a behavioural system that is independent from, but linked developmentally and behaviorally to attachment (George & Solomon, 1996; Solomon & George, 1996).

• Function of the caregiving system to move flexibly between safe haven and secure base

• May provide a helpful framework for mental health services

• Safe Haven – need for safe haven enabling the expression of distress and the seeking of comfort and soothing.–Developing understanding of threats to help-seeking in

the context of increased stress, formulating help-seeking in terms of threats, blocks, competences and role of therapeutic alliance

• Secure Base – creating the context to enable freedom, exploration and autonomy.–Fostering approaches to enhance empowerment, choice,

connectedness, involvement, meaning making and positive risk taking

Health policy implications

• Attachment theory provides a strengths based framework to understand resilience and adaptation over time.

• Places connectedness to oneself and others at the heart of recovery and empowerment

• Symptom focus is often default focus in services driven by risk pressures on services.

• Challenge to services and policy to have greater focus on relationships for example investment in peer support and peer leadership in mental health services

• Concluding remarks• Attachment theory has come a long way in a relatively short

period of time.• Many of the studies are cross sectional but emerging

prospective studies are demonstrating importance of attachment to recovery.

• Need for intervention based studies focusing on enhancing the quality of collaborative relationships for people with psychosis, empowering decision making and self management to reduce coercion into treatment.

• Need for cluster randomised controlled trials that place the caregiving environment at the centre of intervention efforts.

Thank you

@andygumley

andrew.gumley@glasgow.ac.uk