This section will focus on the implications of the theory for clinical psychology practice, by considering the implications of attachment on mental health. Literature examining links between mental health and attachment style at different stages of the lifecycle will be reviewed, following which ideas for attachment based clinical work will be discussed.
Empirical evidence from infancy through to adolescence
There is evidence to suggest that insecure attachment styles can have a negative effect on mental health and how we relate to others across the lifespan. In a prospective longitudinal study, Carlson (1998) measured attachment styles during infancy, behaviour during schooling years, and mental health during adolescence. The author found that attachment disorganisation was related to physical abuse, psychological unavailability and neglect of the caregiver. Disorganised infants, compared to infants with other attachment styles, displayed significantly more socio-emotional difficulties through to adolescence. They had behaviour problems in preschool, dissociative experience during primary school, and had diagnostic ratings of psychopathology by 19.
In a further longitudinal study, Allen, Hauser & Borman-Spurrell (1996), compared a group of adolescents with no diagnosed mental health difficulty, with a group who were given a psychiatric diagnosis and admitted into an inpatient unit at age 14. Assessment measures were taken at age 14 and 25. The authors found that only seven per cent of the previously hospitalised sample were securely attached, compared with nearly half of the comparison sample. The high prevalence of insecure attachment style was due to a high frequency of unresolved attachments, which is the adult equivalent of disorgnaised. This style reflects a lack of resolution following an abusive or frightening care giver.
Further studies have replicated the finding that adolescents who have been hospitalised for mental health difficulties ‘overwhelmingly’ have insecure attachment styles (Rosenstein, Harvery 1996).
In sum, this study lends support to the prediction that the quality of caregiver-infant early interactions, and attachment style, contribute to later mental health difficulties.
Empirical evidence from adulthood
Further evidence that early difficulties with attachment may result in later mental health problems and difficulties relating to others, comes from studies examining attachment in people who have been given a diagnosis of a personality disorder (PD). Many theorists have speculated that PD’s are disorders of attachment and understand this difficulty as placed on a spectrum as opposed a clear presence or absence of a ‘disorder’ (Shorey & Snyder, 2006). Borderline personality disorder (BPD) describes a chronic difficulty in relating to other people, intense and overwhelming emotions, disturbance in self-image, and frantic efforts to avoid real or imagined abandonment. In a review of studies, Agrawal, Gunderson, Holmes & Lyons-Ruth, 2004, found that secure attachments were inversely related to BDP, and the attachment styles found to be most frequent in people with a diagnosis of BPD were unresolved, preoccupied, and fearful. All studies concluded that diagnosis of BDP were correlated with insecure styles of attachment.
The diagnosis is congruous with the features of these insecure attachment styles as well as Lineham’s conception of BDP. Inconsistent or unpredictable parenting, leads to hyperactivation of attachment behaviours and difficulties self soothing (intense and overwhelming emotions), and individuals are either preoccupied with their attachment figures whereabouts (abandonment fears) or they are vacillate between wanting to be close to others and wanting to protect themselves. They are thought to have internalised a sense of themselves being not acceptable, or unlovable in the eyes of their caregiver (disturbance in self image). Furthermore, people with these attachment styles show a strong desire for close relationships but apprehension regarding rejection and dependency. This supports the central role of interpersonal difficulties seen in BDP, ‘ambivalent and erratic feelings in close relationships’. Finally, the unresolved attachment style is also congruent with numerous studies showing that a diagnosis of BPD is frequently associated with past abuse (i.e. Jonson, Cohen, Brown Smailes & Bernsein 1999).
In sum, studies have linked insecure attachment styles to people with a diagnosis of BDP, which is marked by with emotion dysregulation and interpersonal difficulties. This lends support to the notion that insecure attachment styles may lead to the development of mental health and interpersonal difficulties, though, of course, these are studies do not demonstrate causality.
Empirical evidence from older adulthood
Researchers have identified a need for more studies into attachment theory using an older adult population (cite), and studies investigating the impact on attachment styles and mental health are no exception. In a longitudinal study, Zhang & Labouvie-Vief (2010), looked at attachment style and indicators of mental health and wellbeing over time. The sample included a wide age range, including older adults. The authors predicted that as attachment theory delineates that a fundamental role of the attachment system is to regulate emotions, they would expect to find different ways of coping with distressing emotions to be related to attachment style. This is indeed what they found. At any age, when an individual was feeling more secure, they were using more adaptive coping mechanisms and were less depressed, but when individuals were insecure, they scored higher on measures of defensive’ maladaptive coping and depression measures.
In sum, this study demonstrated that across a broad range of ages, including older adults, when individuals feel more secure they use more adaptive ways of regulating their emotions, and when they feel insecure they tend to use less adaptive methods and feel more depressed.
Clinical implications of mental health research
Attachment styles are thought to affect how we regulate emotions, our mental health, and how we relate to other people, across the lifespan. Studies have shown that a very high number of service users, both inpatients and outpatients, have insecure attachment styles (van Ijzenboorn & Bakermans-Kranenburg, 1996), and many have abusive and traumatic histories (cite report).
It seems probable that this has a big impact on therapeutic work. Individuals who have an insecure attachment style due to a difficult upbringing may have internalised a sense of other people being untrustworthy. Such individuals may find it extremely difficult to form new relationships. Clinical staff may face a challenge when working with such individuals, to form and maintain an alliance, which is widely recognised as the cornerstone of therapeutic change.
The BPS recommends that CP’s use attachment theory to inform formulations. This might be helpful for team formulations which include staff members, to increase understanding and compassion. Attachment theory could shed light on behaviours that staff might find confusing, frustrating, or even frightening. For example, clients who have a dismissing style, may not engage with the therapeutic relationship, and be deemed treatment resistant by staff. From an attachment theory perspective, individuals who have grown up with hostile parents, and used emotional suppression and compulsive self reliance as an adaptive strategy, understandably find it difficult to form new relationships. Alternatively, clients who are preoccupied may seek proximity to clinicians in a way that is deemed emotionally draining (Bucci, Roberts, Danquah & Berry 2014). Attachment theory would understand these individuals as having unpredictable caregivers, and so using ‘hyperactivation’ strategies when feeling threatened, as they fear abandonment, and want to maintain proximity to someone they view as a ‘safe base’.
Individuals who have been given a diagnosis of borderline personality disorder can elicit strong emotions from staff teams, and often ‘split’ them, with some staff feeling very positive about the service user, and others feeling extremely negative. Attachment theory could again be helpful to inform a shared understanding. Children who have grown up with abusive or frightening caregivers may have used ‘splitting’ defences to maintain an attachment bond. Rather than perceive that their parent does not care about them, or actively wishes them harm, they internalise this negativity, and attribute their rejection as due bad behaviour on their part. In this way they can maintain a view of their parent as caring. However, when this strategy is repeated, it leads to black and white thinking, and people are perceived as all good, or all bad, creating intense and chaotic interpersonal relationships. This understanding, when created and shared within a team, can help staff increase empathy towards service users that may be challenging interpersonally. CP’s could also run reflective groups, and staff training, to help staff normalise and process strong feelings. These are recommended aspects of attachment informed services (Bucci, Roberts, danquah & Berry 2014). CP’s are well placed to help set up and implement such services, which would be applicable across the lifespan.
Conclusion
Bowlby thought that early interactions with primary caregivers provide a template for relationships and wellbeing later in life. This template, or IWM, remains stable throughout the lifespan, and new experiences are assimilated into it. This is the case unless a significant attachment experience occurs, such as a new relationship, either a positive one, or an abusive one, which can change the template. In this way development is viewed as a product of both our attachment history and our present circumstances. Attachment style, which is an external measure of this template, is thought to continue to affect how we relate to others, and regulate our emotions, throughout the lifespan, and even during illnesses such as dementia. Insecure attachments are related to mental health difficulties. Using attachment theory to create attachment informed services could help staff deal compassionately with ‘behaviour that challenges’.