Is adult attachment associated with engagement with services? A systematic literature review

Strengthening Relationships Within Intensive Psychiatric Care: Staff Perceptions of an Attachment Training Intervention

INTRODUCTION

Intensive psychiatric care units can be challenging environments in which to build strong staff-patient relationships. Attachment theory may provide a useful model for strengthening relationships in this setting.

AIM

The aim of this study was to explore staff perceptions of the utility of attachment theory for understanding patient behaviour in the intensive psychiatric care setting.

METHODS

Semi-structured interviews were conducted with 11 multi-disciplinary staff members. Interviews focused on the staff member's experience of learning about attachment theory and applying this perspective to their work on the ward. Transcripts were analysed using reflexive thematic analysis.

RESULTS

The analysis led to the development of three themes: engaging the reflective self, new perspective on others and cohesive ward culture.

CONCLUSION

Staff reported that learning about attachment theory supported them to better understand patient distress and associated behaviours. Notably, staff also used attachment theory to reflect on both their own internal states and the internal states of their colleagues. These reflections were suggested to bolster staff wellbeing and improve the ward milieu.

IMPLICATIONS FOR PRACTICE

Integrating attachment theory into team formulation, ward rounds and reflective practice groups could have a benefit for clinical practice, staff wellbeing and team cohesion in this setting.

Understanding How, Why and for Whom Link Work Interventions Promote Access in Community Healthcare Settings in the United Kingdom: A Realist Review

INTRODUCTION

Inequity in access to healthcare in the United Kingdom can have a profound impact on people's ability to manage their health problems. Link work interventions attempt to overcome the socioeconomic and structural barriers that perpetuate health inequalities. Link workers are typically staff members without professional clinical qualifications who support patients to bridge the gap between services. However, little is currently known about how and why link work interventions might be effective. This realist review attempts to understand the contexts and resultant mechanisms by which link work interventions affect access to community healthcare services.

METHODS

The authors completed a systematic search of empirical literature in Embase, CINAHL, Medline, PsychInfo and SocIndex, as well as grey literature and CLUSTER searches. Context, mechanism and outcome (CMO) configurations were generated iteratively in consultation with an expert panel and grouped into theory areas.

RESULTS

Thirty-one eligible manuscripts were identified, resulting in nine CMO configurations within three theory areas. These pertained to adequate time in time-pressured systems; the importance of link workers being embedded across multiple systems; and emotional and practical support for link workers.

CONCLUSION

Although link work interventions are increasingly utilised across community healthcare settings, the contexts in which they operate vary considerably, triggering a range of mechanisms. The findings suggest that careful matching of resources to patient need and complexity is important. It affords link workers the time to develop relationships with patients, embed themselves in local communities and referring teams, and develop knowledge of local challenges.

PATIENT OR PUBLIC CONTRIBUTION

The team included people with lived experience of mental health conditions and a carer who were involved at all stages of the review.

Trauma and social pathways to psychosis: Examining the role of attachment, social rank and dissociation in a clinical sample

OBJECTIVES

The trauma and social pathways model of psychosis proposes interactions between trauma, attachment, social rank and dissociation in pathways to psychosis, though this model has yet to be empirically investigated. The primary aim of this study was to examine the overall predictive value of the trauma and social pathways model using regression analysis. A secondary aim was to delineate hypothesized pathways between trauma and positive symptoms of psychosis using serial mediation analysis.

METHOD

This was a cross-sectional study of people attending mental health services for a psychosis-related diagnosis (N = 71). Measures of trauma, positive symptoms of psychosis, attachment, social comparison and dissociation were completed.

RESULTS

A model of recurrent trauma, insecure attachment, social rank and dissociation predicted 23.2% of the variance in positive symptoms of psychosis. Recurrent trauma, attachment and dissociation contributed significantly to the model, while social rank did not. Further, serial mediation analysis indicated that the sequence of disorganized attachment and dissociation fully mediated the relationship between recurrent trauma and positive symptoms.

CONCLUSIONS

Results provide preliminary support for the trauma and social pathways model of psychosis, specifically as it relates to recurrent trauma, insecure attachment and dissociation. Results did not support the social rank component of this model, however. These findings provide clear targets for the development of next-wave psychological interventions that focus on trauma-related variables in psychosis. Future studies should replicate these findings with a larger clinical sample, and consider a measure of shame to further elucidate social processes in pathways to psychosis.

Early intervention in psychosis services: A systematic review and narrative synthesis of barriers and facilitators to seeking access

BACKGROUND

The duration of untreated psychosis (DUP) continues to be a global priority. Early intervention services were established to reduce treatment delays but have had limited impact. This systematic review examines barriers and facilitators to seeking access to these services, to identify targets for service level change.

METHODS

We conducted a systematic review of relevant databases (PsychINFO, MEDLINE, CINAHL, and PsychARTICLES) using pre-defined search terms for psychosis, early intervention, and barriers and facilitators. Given the majority of qualitative studies, a thematic synthesis rather than meta-analysis was indicated.

RESULTS

The search yielded 10 studies. Mental health stigma and discrimination predict DUP, compounded by structural barriers which limit the impact of early intervention services on timely access to recommended treatments. Synthesis of the qualitative studies generated three themes: knowledge, relationships, and stigma. Lack of knowledge, absence of supportive relationships (social and professional), and self-stigma constitute significant barriers to seeking access to early intervention services.

CONCLUSIONS

This is the first review of the barriers and facilitators to seeking access to early intervention services. The findings highlight public health and secondary care service targets to expedite access to recommended treatments and thereby reduce the DUP.

Exploring Patients' Feeling of Being Coerced During Psychiatric Hospital Admission: A Qualitative Study

Various coercive measures can be used to legally compel a person suffering from psychiatric disorder to undergo treatment. However, evidence suggests that patients' feeling of being coerced is not determined solely by their being submitted to formal coercion. This study aimed to explore voluntary and involuntary patients' experience of coercion during psychiatric hospitalisation and to identify which factors, from their perspective, most affected it. We chose a qualitative design inspired by a hermeneutic-phenomenological approach. Participants were purposively selected from six psychiatric hospitals in Switzerland. Maximum variation sampling was used to ensure the inclusion of patients with different levels of perceived coercion and different admission statuses. In-depth, semi-structured interviews were co-conducted by a research psychologist and a service-user researcher. The transcribed data underwent thematic analysis. All twelve interviewed patients described the hospitalisation as an experience of loss of control over their life due to either external or internal pressures. During the process, perceptions of these pressures varied and sometimes overlapped, leading some patients to describe their admission as a form of simultaneous protection and violation. The balance between these two contradictory feelings was affected by a variety of contextual and relational factors, as well as by the meaningfulness of the experience and the patient's subsequent satisfaction with it. Increasing policy-makers' and clinicians' awareness about the main factors influencing patients' experience of loss of control is of paramount importance in order to develop skills and strategies able to address them, reinforcing patients' empowerment, reducing their feeling of coercion and improving their well-being.

The association between attachment style and social functioning in patients with non-affective psychotic disorders, unaffected siblings and healthy controls

OBJECTIVE

In patients with psychotic disorders, insecure attachment styles and impaired social functioning are highly prevalent. Our aim was to explore the multi-cross-sectional and longitudinal associations between attachment style and social functioning.

METHODS

This study was performed in a subsample of 119 patients with non-affective psychotic disorders, 128 unaffected siblings and 66 healthy controls within the Genetic Risk and Outcome of Psychosis (GROUP) Study. Attachment style (using the Psychosis Attachment Measure) and three social functioning domains, namely withdrawal, interpersonal behaviour and pro-social activities as measured with the Social Functioning Scale (SFS) were assessed on two moments in time. Generalized linear mixed models and linear regression models were used. Bonferroni correction for multiple testing was applied.

RESULTS

In the patient group, a significant negative association was found between avoidant attachment and pro-social functioning. In the sibling and control group, we found significant negative associations between avoidant attachment and the social functioning domains withdrawal and interpersonal behaviour. We also found a significant negative association between anxious attachment and the social functioning domain withdrawal in siblings. Higher levels of insecure anxious attachment at baseline predicted a reduction of the social functioning domain interpersonal behaviour in siblings over a period of three years on a trend level.

CONCLUSIONS

Findings indicate that levels of insecure attachment are elevated in patients with psychotic disorders and have a negative association with social functioning in both patients, siblings and controls. These findings warrant specific attention for attachment style in the treatment of patients with psychotic disorders and individuals with an increased vulnerability for developing psychosis.

Associations between attachment, therapeutic alliance, and engagement in black people with psychosis living in the UK

BACKGROUND

Compared to other ethnic groups in the UK, Black people have the highest rates of psychosis. This may partly be explained by both assessment bias and structural racism. Mental health services often find it difficult to develop therapeutic relationships with Black people with psychosis. Attachment theory posits that the quality of previous caregiving experiences influence current interpersonal functioning and emotional regulation. In this study, we applied the theory to improve the understanding of therapeutic relationships with people with psychosis.

AIMS

This is the first study to examine associations between attachment difficulties, therapeutic alliance, and service engagement in a Black sample with psychosis.

METHOD

Fifty-one participants completed self-report measures of attachment and alliance. Staff completed measures of alliance and service engagement.

RESULTS

Higher attachment avoidance was related to poorer alliance ratings. These significant findings were not upheld in a regression model controlling for total symptom scores and perceived ethnic/racial discrimination in services. Attachment anxiety was generally not associated with alliance ratings. Neither attachment anxiety nor attachment avoidance was significantly associated with service engagement.

CONCLUSIONS

Staff should be supported to better understand the needs of service users with avoidant attachment behaviours and to develop mutually-agreed treatment goals and therapeutic bonds.

The centrality of secure attachment within an interacting network of symptoms, cognition, and attachment dimensions in persons with schizophrenia-spectrum disorders: A preliminary study

BACKGROUND

Research in the field of psychosis broadly suggests that symptoms, neurocognitive deficits, social cognition, cognitive biases, and attachment experiences influence each other. However, little is known if any of these constructions play a more central role than others as they interact.

METHOD

To clarify this issue, we conducted a "network" analysis to explore the interplay among a set of variables related to attachment, cognition domains, and psychotic symptoms in a small sample of outpatients with stabilised schizophrenia-spectrum disorders (n = 25). Eighteen participants (72%) were first-episode patients. We assessed psychotic symptoms, attachment dimensions, neurocognitive performance, "theory of mind", emotion recognition, and "jumping to conclusions" bias using standardised instruments.

RESULTS

The study provides preliminary evidence about a network structure in which the secure attachment (SA) is the most central "node" within the interacting network considering all centrality measures, followed by general psychopathology. SA was closely connected to self-sufficiency (avoidant attachment) and child traumatism, as well as with neurocognition. Emotion recognition impairment was the most robust connection to positive symptoms and mediated the influence of SA on psychotic symptoms.

CONCLUSIONS

Beyond the importance of symptoms, our results, although preliminary, suggest the need to assess attachment experiences and cognition domains to improve specific interventions that can promote recovery in outpatients with psychosis.