A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research

Clinical Psychology Review 27 (2007) 458 – 475

A review of the role of adult attachment style in psychosis: Unexplored issues and questions for further research Katherine Berry ⁎, Christine Barrowclough, Alison Wearden School of Psychological Sciences, University of Manchester, Rutherford House, Manchester Science Park, Lloyd Street North, Manchester, M15 6SZ, UK Received 26 June 2006; accepted 29 September 2006

Abstract Attachment styles reflect individual differences in beliefs about self and others, interpersonal functioning and affect regulation. We review and critically appraise studies suggesting higher levels of insecure attachment, and dismissing attachment in particular, in samples with psychosis compared to controls. We also review the role of social cognition, interpersonal factors, and affect regulation in the development and maintenance of psychosis, and specific symptoms associated with the diagnosis. We review studies showing that insecure attachment is associated with poorer interpersonal relationships and less integrative recovery styles and highlight how recent theories and empirical findings in the psychosis literature can be understood within the framework of attachment theory. In doing so, we argue that investigations of the nature of attachment styles in psychosis and how they relate to the cognitive, interpersonal and affective factors that have been implicated in psychosis will help develop theoretical knowledge in relation to the condition. We conclude by outlining the clinical implications of applying attachment theory to the understanding of psychosis and summarising the conceptual and methodological limitations of the theory which should be addressed, including the need for studies with longitudinal designs, larger, more representative samples, and more valid measures of assessing attachment styles in psychosis. © 2006 Elsevier Ltd. All rights reserved. Keywords: Attachment styles; Attachment theory; Measurement; Psychosis; Schizophrenia; Review

Contents 1. 2.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . Models and measures of attachment . . . . . . . . . . . . . 2.1. Definition of attachment . . . . . . . . . . . . . . . . 2.2. Working models of the self and others . . . . . . . . 2.3. Classification of attachment security. . . . . . . . . . 2.4. Conceptualisations of adult attachment and approaches 2.5. Narrative approach . . . . . . . . . . . . . . . . . . . 2.6. Self-report tradition . . . . . . . . . . . . . . . . . . 2.7. Are attachment styles stable across the lifespan? . . .

⁎ Corresponding author. Tel.: +44 161 2758498; fax: +44 161 2758487. E-mail address: [email protected] (K. Berry). 0272-7358/$ - see front matter © 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.cpr.2006.09.006

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3. 4. 5. 6.

Attachment theory and psychosocial models of psychosis . . . . . . . . . . . . . . . . . Overview of studies investigating attachment in psychosis . . . . . . . . . . . . . . . . The nature of attachment representation in psychosis . . . . . . . . . . . . . . . . . . . How can attachment theory contribute to current psychological theories of psychosis? . . 6.1. Attachment style and social cognitive models of psychosis. . . . . . . . . . . . . 6.2. Attachment style and expressed emotion in psychosis . . . . . . . . . . . . . . . 6.3. Attachment style and therapeutic alliance in psychosis . . . . . . . . . . . . . . . 6.4. Attachment style and interpersonal functioning in psychosis . . . . . . . . . . . . 6.5. Attachment style and coping style in psychosis. . . . . . . . . . . . . . . . . . . 6.6. Attachment style and recovery in psychosis . . . . . . . . . . . . . . . . . . . . 6.7. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. How can attachment theory inform the understanding of specific symptoms in psychosis? 8. Clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. Conceptual issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. Methodological limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction Attachment theory conceptualises ‘the propensity of human beings to make strong affectional bonds to particular others … and the many forms of emotional distress and personality disturbance…… to which unwilling separation and loss give rise’ (Bowlby, 1977, p. 201). Although attachment theory has had a significant impact on theories and research concerning the nature of human relationships (Cassidy, 1999), there is limited research investigating its relevance to psychosis (Dozier, Stovall, & Albus, 1999). This is surprising as interpersonal difficulties are one of the hallmarks of the diagnosis and are associated with a significant degree of psychological distress (Penn et al., 2004). The primary aims of this review are to assess the contribution that attachment theory can make to the understanding and treatment of psychosis, and identify questions for further research. In order to provide a context for the main body of the review, we will begin by summarising the key concepts of Bowlby's theory and different models and measures of adult attachment. Next, we will describe current theories of the role of psychosocial factors in psychosis (see reviews by Bentall, Corcoran, Howard, Blackwood, & Kinderman, 2001; Garety & Freeman, 1999; Penn, Corrigan, Bentall, Racenstein, & Newman, 1997), assess the extent to which attachment theory can enhance theoretical developments, summarise the existing literature investigating attachment styles and psychosocial factors in psychosis, and recommend future research. We will conclude by discussing the clinical implications of attachment theory, as well as highlighting the conceptual and methodological limitations that will need to be addressed in applying the theory to the study of psychosis. The review incorporates studies involving samples with psychosis or other forms of severe and enduring mental health problems that were found from a search of the PsycInfo database for the years 1985 to 2004, entering the term ‘attachment’. Articles that were cited in these studies in relation to the topics of attachment and psychosis were then followed up from reference lists, and expert sources in attachment theory and interpersonal theories of psychosis were consulted. We also included selected studies identified by the search terms ‘parental bonding’ and ‘schizophrenia’, in order to highlight the main findings of investigations of retrospective memories of parental bonding in this group. Our review extends previous reviews of the relevance of attachment theory to adult mental health (Dozier et al., 1999; Goodwin, 2003; Platts, Tyson, & Mason 2002) by focusing specifically on the understanding of psychosis and psychotic symptoms. 2. Models and measures of attachment 2.1. Definition of attachment Attachment is defined as a type of affectional bond, which the individual forms with a specific person, who is approached in times of distress. The bond is conceptualised as persistent and emotionally significant, is associated with

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a desire for close proximity to the attachment figure and results in distress following involuntary separation (Bowlby, 1973, 1980, 1982). The attachment relationship is hypothesised to provide a ‘secure base’, which enables the individual to engage in exploration, and develop and gain independence (Ainsworth, Blehar, Waters, & Wall, 1978). Attachment behaviours are triggered by environmental threats, distress, illness, or fatigue; and are defined as any form of behaviour that results in the individual regaining or retaining contact with his or her attachment figure (Bowlby, 1973, 1982). Attachment bonds are first formed with primary caregivers during childhood, but are of importance throughout the life cycle (Bowlby, 1979). 2.2. Working models of the self and others Bowlby (1982) proposed that as a result of their interactions with caregivers during infancy and childhood, individuals develop mental representations of the self in relation to significant others and expectations about how others behave in social relationships. These working models are hypothesised to guide attention, interpretation, memory and predictions about future interpersonal interactions (Cassidy, 1999). They are hypothesised to involve cognitive elements, which reflect beliefs about whether the individual him or herself is worthy of attention and whether other people are reliable; and also represent emotions associated with interpersonal experiences, such as happiness, fear and anger (Pietromonaco & Feldman Barrett, 2000). 2.3. Classification of attachment security Empirical support for Bowlby's theory comes from laboratory-based observations (a procedure known as the ‘Strange Situation’) of the infant's response to two brief separations from his or her caregiver (Ainsworth et al., 1978). Responses, which are hypothesised to relate to different working models and methods of regulating distress, are traditionally classified as: secure; insecure avoidant; or insecure ambivalent (Ainsworth et al., 1978). An infant classified as secure is able to use the caregiver as a secure base for exploration, is distressed by the separation, but is easily comforted upon reunion (Weinfield, Sroufe, Egeland, & Carlson, 1999). The caregiver's sensitivity to distress appears to be a significant factor in determining the type of attachment that the infant develops (Weinfield et al., 1999). In the case of avoidant attachment, the child's emotions are consistently ineffective in eliciting contingent responses in caregivers, so the child learns to inhibit negative affect. In the case of ambivalent attachment, caregivers' responses are inconsistent, so the child learns to exaggerate negative affect in order to elicit a response (Crowell & Treboux, 1995). 2.4. Conceptualisations of adult attachment and approaches to assessment There are two major paradigms in adult attachment research. Both argue that working models developed as a result of earlier interpersonal experiences influence psychosocial functioning in adulthood. However, they differ in their hypotheses about the content and structure of the models and are associated with different methods of assessment (Simpson & Rholes, 1998). 2.5. Narrative approach Main and colleagues argue that individual differences in attachment relate to the organisation of representations of earlier attachment figures and developed the Adult Attachment Interview (AAI), which measures ‘attachment states of mind’ on the basis of the coherence of the individual's narrative in describing parental–child relationships (Main, Kaplan, & Cassidy, 1985). Individuals are classified as secure-autonomous, dismissing (a type of avoidant attachment), or preoccupied. There is also an unresolved category, which is associated with reports of loss events or abuse, and confusion and disorganisation in discussing the topic (Crowell, Fraley, & Shaver, 1999). One approach to analysing AAI interview transcripts in research investigating attachment representations in psychosis has been Kobak's (in press) Q-sort method. The method can be used to rate individuals on two independent dimensions (secure versus anxious and dismissing versus preoccupied), or classify them into secure, dismissing and preoccupied attachment categories (Hesse, 1999).

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2.6. Self-report tradition The second paradigm developed from Hazan and Shaver's (1987) conceptualisation of romantic love as an attachment process. These authors translated Ainsworth et al.'s (1978) three categories (secure, avoidant and anxiousambivalent) into prototypical adult attachment styles. Several multi-item continuous self-report measures have been developed to measure attachment styles in romantic and other relationships (Collins & Read, 1990; Simpson & Rholes, 1998). Factor analyses have suggested that two dimensions underlie self-report measures, which can be conceptualised in affective–behavioural terms (anxiety versus avoidance) or cognitive terms (model of self versus model of others) (Crowell et al., 1999). Bartholomew (1990) argued that Main and colleagues' dismissing attachment and Hazan and Shaver's avoidant attachment represented two different types of avoidance, which are respectively motivated by defensive selfsufficiency and avoidance of rejection. As outlined in Fig. 1, Bartholomew's (1990) model incorporates both types of avoidance and describes four attachment prototypes which can also be conceptualised as two dimensions (see Bartholomew, 1990, 1997 for a more comprehensive description of the prototypes and developmental origins). The dimensional approach to conceptualising attachment has psychometric advantages, whereas attachment prototypes add interpretational power to the dimensions as they capture characteristics associated with combinations of dimensions (Griffin & Bartholomew, 1994a). 2.7. Are attachment styles stable across the lifespan? Attachment styles are hypothesised to be stable over time because working models direct attention to information consistent with representations, influence interpretations in a direction consistent with those representations, and lead the individual to behave in a way that elicits responses from others consistent with his or her expectations (Pietromonaco & Feldman Barrett, 2000). However, attachment theory does recognise that working models can be revised as a result of significant interpersonal experiences, particularly when there is a high degree of inconsistency between the models and experiences (Crowell & Treboux, 1995). Retrospective and longitudinal studies within both narrative and self-report research paradigms have provided evidence of relative stability, but not complete consistency in attachment styles, over time scales ranging from several months to 30 years (Hamilton, 2000; Klohnen & Bera, 1998; Scharfe & Bartholomew, 1994). Longitudinal studies indicate that life events, including the loss or formation of key relationships, or interpersonal traumas, such as sexual or physical abuse are key factors in determining the stability of attachment style (Hamilton, 2000; Waters, Merrick, Treboux, Crowell, & Albersheim, 2000). Thus it would seem that adult attachment style and attachments in infancy are not entirely isomorphic, as later life experiences may disconfirm initial mental representations (Kirkpatrick & Hazan, 1994). Adult attachment relationships also incorporate features that are less relevant to childhood attachments to

Fig. 1. Bartholomew's (1990) model.

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caregivers. For example, adult–adult attachment relationships are often reciprocal with both partners playing the roles of ‘attachment figure’ and ‘attached individual’ at different points in time (Goodwin, 2003). 3. Attachment theory and psychosocial models of psychosis Attachment theory provides a framework for conceptualising the role of social cognition, interpersonal experiences and regulation of affect in the development of both interpersonal functioning and psychological distress (Mallinckrodt, 2000). Psychosocial models of psychosis highlight the importance of negative beliefs about the self and the social world in terms of both vulnerability and maintenance (Penn et al., 1997). According to these models, past interpersonal relationships and traumas are hypothesised to increase vulnerability to negative beliefs and symptoms (Garety, Kuipers, Fowler, Freeman, & Bebbington, 2001). The quality of current interpersonal relationships and interpersonal functioning has also been associated with relapse and recovery (Platts et al., 2002). Maladaptive coping in relation to emotional distress is a further factor that is hypothesised to influence the course of psychosis (Nuechterlein & Dawson, 1984); integrative and less avoidant coping has been linked to improved recovery following the onset of symptoms (McGlashan, 1987). Moreover, there is a growing recognition of the ways in which cognitive, interpersonal and affective factors interact in determining vulnerability and outcome in psychosis (Garety et al., 2001). We propose that insights derived from attachment theory can inform current conceptualisations of psychosis by enhancing formulations of the nature and development of social cognition, and by generating more specific hypotheses about the role and predictors of interpersonal relationships in the development and course of psychosis. 4. Overview of studies investigating attachment in psychosis The majority of the existing studies investigating attachment styles in psychosis have been carried out by Dozier and colleagues. This group of authors have investigated attachment states of mind in schizophrenia and other forms of severe mental health problems, including schizoaffective disorder, bipolar disorder and major depression. These studies all used the AAI and Kobak's (in press) Q-sort method of classifying responses to assess degree of attachment security, and the individual's use of dismissing versus preoccupied attachment strategies. There is a larger body of research investigating parental bonding in samples with a diagnosis of schizophrenia, but these studies measure participants' memories of their parents during childhood, and do not assess attachment styles in the context of adult relationships nor specific types of insecurity. Table 1 summarises the published studies investigating adult attachment representations in samples with psychosis, and a selection of studies which represent the main findings of retrospective reports of parental bonding in schizophrenia. 5. The nature of attachment representation in psychosis A pre-requisite condition to establishing the relevance of attachment theory to the study of psychosis, is evidence of high levels of insecure attachment in individuals with the diagnosis. Three of Dozier and colleagues' studies have compared the nature of attachment representations in psychiatric and control samples, or in different diagnostic subgroups. Two studies found significantly higher levels of attachment insecurity in the psychiatric group, and individuals with a diagnosis of schizophrenia had higher levels of insecurity than those with affective diagnoses, including bipolar disorder and major depression (Dozier, 1990; Dozier, Stevenson, Lee, & Velligan, 1991). Dozier et al. (1991) also found higher levels of dismissing-avoidant attachment in their psychiatric sample compared to a nonclinical sample, and higher levels of dismissing-avoidant attachment in individuals with schizophrenia compared to affective disorders. In contrast, the relationship between psychiatric diagnosis and dismissing attachment did not reach significance in Dozier's (1990) study or in a later study by Dozier, Cue and Barnett (1994). These discrepant findings may be partly due to the relatively small sample sizes and in particular to the small number of individuals with schizophrenia in the 1990 and 1994 studies, compared to the 1991 study. Mickelson, Kessler and Shaver (1997) investigated the prevalence of adult attachment styles, using Hazan and Shaver's (1987) measure of adult attachment in romantic relationships, in a large nationally representative sample in the United States which included a subset of approximately 800 individuals with a diagnosis of schizophrenia. In line with Dozier and colleagues' research and thus further supporting the potential relevance of attachment theory to psychosis, these authors found a high level of insecure attachment in the schizophrenia sample. Consistent with Dozier

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Table 1 Studies investigating attachment and parental bonding in patients with a diagnosis of psychosis Study

Participants

Method of assessing attachment Key results

Dozier (1990)

42 patients with serious psychopathological disorders. Using DSM-III-R criteria 12 were diagnosed with schizophrenia, 25 with bipolar disorder, 3 with major depression, and 2 with atypical psychosis.

AAI Q-sort method with ratings on security/anxiety and avoidance/preoccupation dimensions.

Dozier et al. (1991)

40 patients with serious psychopathological disorders. Using DSM-III-R criteria 21 were diagnosed with schizophrenia, 11 with bipolar disorder, and 8 with depression. 40 family members. 27 patients with serious psychopathological disorders. Using DSM-III-R criteria 8 were diagnosed with paranoid schizophrenia, 8 with undifferentiated schizophrenia, 9 with bipolar disorder, 1 with panic disorder, and 1 with conversion reaction. 18 case managers. 76 patients with serious psychopathological disorders. Using DSM-III-R criteria 24 were diagnosed with paranoid. schizophrenia, 23 with undifferentiated schizophrenia, 27 with bipolar disorder, 1 with panic disorder, and 1 with conversion disorder. 8098 participants in a National Co-morbidity Survey, 1.26% of whom had a DSM-III-R diagnosis of schizophrenia. 54 patients with serious psychiatric disorders. Using DSM-IV criteria 31 were diagnosed with schizophrenia, 9 with schizoaffective disorder, 8 with bipolar disorder, and 6 with major depression. 21 clinical case mangers.

Dozier et al. (1994)

Dozier & Lee (1995)

Mickelson et al. (1997) Tyrrell et al. (1999)

Dozier et al. (2001)

34 patients with serious psychopathological disorders. Using DSM-IV criteria, 10 were diagnosed with schizophrenia and 7 with bipolar mood disorders. 17 case managers and 17 significant others, including family members and romantic partners. Parker et al. (1982) 72 patients with a clinical diagnosis of schizophrenia and case-controls.

Baker et al. (1984) 49 patients meeting DSM-III-R criteria for schizophrenia. 21 patients had at least one hospital admission in the last 18 months and a minimum of 3 in their lifetime (relapsers) and 28 who had not been admitted in the past 18 months (non-relapsers). Parker & Mater 72 patients with schizophrenia discharged to (1986) their families.

Greater security was associated with schizophrenia rather than affective disorders. Greater security was associated with more compliance with treatment. Higher levels of avoidance were associated with greater rejection of treatment providers, less selfdisclosure, and poorer use of treatment. AAI Q-sort method with ratings Patients with more extreme repressing or on security/anxiety and preoccupied attachment strategies were repressing/preoccupation more likely to have relatives with higher dimensions. EOI. AAI Q-sort method with ratings on security/insecurity and dismissing/preoccupation dimensions.

Compared with secure case managers, insecure case managers attended more to dependency needs and intervened to a greater depth with preoccupied than they did with dismissing patients.

AAI Q-sort method with ratings on security/insecurity and deactivating/hyperactivating dimensions.

Patients with hyperactivating strategies reported more psychiatric symptoms than those with deactivating strategies, but interviewers conducting the study rated individuals with deactivating strategies as more symptomatic. Schizophrenia was a significant predictor of insecure attachment style.

Hazan and Shaver's (1987) three-category attachment style measure. AAI Q-sort method with ratings on deactivating/ hyperactivating dimensions.

Patients who were more deactivating with respect to attachment had better alliances and functioned better with less deactivating case managers, whereas clients who were less deactivating worked better with more deactivating case managers. AAI Q-sort method with ratings Patients who relied more on dismissing strategies spent less time on task when on security/insecurity and interacting with case managers than clients deactivation/hyperactivation who relied on preoccupied strategies and dimensions. reported more confusion following these interactions. PBI Patients rated both parents as less caring and fathers as more overprotective than controls. Those who rated both parents as low care and overprotective had an earlier age of initial hospitalisation and 9 months following discharge were more likely to be readmitted. PBI and modified version Only present representations of family measuring current perceptions members differentiated relapsers and nonof parental relationships. relapsers.

PBI

PBI predicted whether or not patients relapsed. (continued on next page)

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Table 1 (continued ) Study

Participants

Method of assessing attachment Key results

Warner & 62 patients meeting DSM-III criteria for Atkinson (1988) schizophrenia.

PBI

Lebell et al. (1993) 39 patients meeting DSM-III-R criteria for schizophrenia and family members. Onstad et al. 12 monozygotic and 19 same sex dizygotic twin (1994) pairs discordant for DSM-III-R schizophrenia. Winther Helgeland 19 patients meeting DSM-III-R criteria & Torgersen for schizophrenia, 14 patients with (1997) borderline personality disorder, and 15 non-clinical controls. Willinger et al. 36 patients meeting DSM-III-R criteria (2002) for schizophrenia or schizoaffective disorder and their siblings.

PBI

Tait et al. (2004)

50 patients during an acute episode of psychosis.

PBI PBI

PBI

PBI and Adult Attachment Scale (Collins, 1996)

Patients who perceived their parents positively tended to experience fewer relapses if they had frequent contact with them, and a more severe course if they did not; and the reserve was true for patients who perceived their parents negatively. PBI ratings were unrelated to age of onset. Found no effects of PBI in relation to relapse rates. Patients reported higher levels of parental overprotection than probands. Clinical samples reported less care and more overprotection than the non-clinical sample, but did not differ significantly from one another. Patients described their mothers as less caring and more overprotective than siblings. Significant high maternal overprotection remained after controlling for the influence of premorbid personality. Found insecure attachment was associated with recovery style and poorer engagement with services.

and colleagues' studies, Mickelson et al. (1997) also found a particularly high prevalence of avoidant attachment in their schizophrenia sample. Although this study had an advantage of a large representative sample, the use of Hazan and Shaver's (1987) three-category attachment measure precluded an investigation of the relative prevalence of dismissing avoidance, which is associated with beliefs about the importance of self-reliance, versus fearful avoidance, which is associated with a fear of rejection (Bartholomew, 1990). Fearful attachment may be more prevalent in samples with psychosis than dismissing attachment, as it is associated with a negative self-image as well as a negative view of others, and has been found to be related to other forms of psychopathology (Dozier et al., 1999). Dozier and colleagues' use of the Q-sort method of classifying the AAI also excluded the unresolved attachment category which has conceptual overlaps with the fearful prototype and similar links with psychopathology (Dozier et al., 1999). 6. How can attachment theory contribute to current psychological theories of psychosis? 6.1. Attachment style and social cognitive models of psychosis Cognitive models of psychosis emphasise the importance of self and other schemata, which involve negative beliefs about the self and how one can expect to be treated by others, in the development and maintenance of psychosis. These theories propose that childhood adversities, particularly those associated with close interpersonal relationships; or significant later interpersonal traumas lead individuals to develop beliefs about themselves as being vulnerable and others as being a source of threat, which then facilitate the development and maintenance of psychotic symptoms (Penn et al., 1997). There is evidence of low self-esteem in samples with psychosis (Barrowclough et al., 2003), and evidence to suggest that psychotic beliefs are more resistant to change if their content is consistent with negative beliefs about the self, others and the world (Bowins & Shugar, 1998). There is also evidence from a longitudinal study to suggest that low self-esteem is predictive of the onset of psychosis (Krabbendam et al., 2002), although there is limited empirical research investigating whether other aspects of social cognition, including beliefs about others, increase vulnerability. Furthermore, a number of studies have investigated the role of earlier parental experiences in psychosis using the Parental Bonding Instrument (PBI; Parker, Tupling, & Brown, 1979), which measures attachment-related experiences in childhood. These studies have found that individuals with schizophrenia report that their parents were less caring and more overprotective compared to non-clinical controls (Onstad, Skre, Torgersen, & Kringlen, 1994; Parker, Fairley, Greenwood, Jurd, & Silove, 1982; Willinger, Heiden, Meszaros, Formann, & Aschauer, 2002; Winther Helgeland, &

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Torgersen, 1997). This reported parental style, which has been termed ‘affectionless control,’ has been associated with earlier onset of schizophrenia (Parker et al., 1982) and higher relapse rates (Parker et al., 1982; Warner & Atkinson, 1988). The findings are not, however, entirely consistent, with some studies failing to find an association between the PBI and age of onset (Warner & Atkinson, 1988), and relapse (Baker, Helmes, & Kazarian, 1984; Lebell et al., 1993). There is more consistent evidence linking interpersonal trauma either in childhood or adulthood to psychosis. There are high levels of traumatic interpersonal events, including sexual, physical, and emotional abuse in samples with severe mental health problems compared to the general population (Mueser et al., 1998). Moreover, traumatic events are correlated with negative outcomes in psychosis, including increased symptom severity, more substance use (Mueser et al., 1998), and higher relapse rates (Doeringet al., 1998). Furthermore, there is evidence linking the nature of traumatic experiences with the form and content of psychotic symptoms (Fowler, 2000). However, the mechanisms through which trauma influences vulnerability to and the course of psychosis are still a matter of ongoing debate (Read, Perry, Moskowitz, & Connolly, 2001). There are clear overlaps between the constructs of self and other schemata in cognitive models of psychosis and Bowlby's working models. Both constructs are hypothesised to guide attention, generate expectations, and influence interpretations of new experiences on the basis of stored constructions of past interpersonal interactions (Platts et al., 2002). However, working models differ from traditional conceptualisations of schemata, in that they reflect more motivated and affectively charged constructs, representing emotional states associated with interpersonal relationships as well as beliefs (Pietromonaco & Feldman Barrett, 2000). The construct of working models also places greater emphasis on the influence of relationships on self-image (Bretherton & Munholland, 1999). Drawing on Bowlby's theory concerning the nature of attachment working models and the importance of relationships in the formation of self-beliefs would therefore enhance understanding of the role of social cognition in the development and maintenance of psychosis (Drayton, Birchwood, & Trower, 1998). Moreover, we suggest that insights derived from attachment theory could fill gaps in existing conceptualisations of psychosis, in particular by illuminating the relative importance of different types of interpersonal events in influencing social cognition. For example, interpersonal trauma involving significant others during childhood should be a stronger predictor of negative interpersonal beliefs and thus vulnerability to psychosis than trauma in later life or trauma involving non-significant others (Pietromonaco & Feldman Barrett, 2000). Attachment theory also makes testable predictions about associations between specific experiences with caregivers and specific beliefs about the self and others (Bartholomew, 1990). For example, one would predict that, if significant others were consistently rejecting, individuals would develop negative beliefs about themselves and others, whereas if significant others were inconsistent in responding to distress, individuals would develop negative beliefs about the self, but more positive beliefs about others, including the need to emphasise distress in order to elicit responses in others (Bartholomew, 1990, 1997). An association between childhood experiences with parents and attachment in adult relationships in a sample with psychosis has recently been reported (Tait, Birchwood, & Trower, 2004). These authors found relationships between poor parental care and parental abuse on a modified version of the PBI (Parker et al., 1997), and attachment insecurity, as measured by the difficulties with dependency, difficulties with close relationships, and rejection anxiety subscales of a revised version of the Adult Attachment Scale (AAS; Collins, 1996), which is a self-report measure of attachment focusing on close relationships. This research could be usefully extended by investigating how non-familial interpersonal traumas and trauma in adulthood interact with parental care to predict attachment styles in psychosis. Moreover, studies need to move beyond investigating correlates of attachment styles in psychosis, and use longitudinal designs to demonstrate the way in which relationships with parents, attachment style and trauma contribute to the onset and maintenance of psychosis. 6.2. Attachment style and expressed emotion in psychosis The term “Expressed Emotion” (EE) refers to a set of emotional responses towards patients, and is measured from respondents' speech and certain non-verbal cues. The influence of familial EE on the course of psychosis is well-established, with particular categories of EE (namely hostility, high levels of criticism and emotional over involvement) associated with more frequent relapse (Butzlaff & Hooley, 1998; Wearden, Tarrier, Barrowclough, Zastowny, & Rahill, 2000). Although the predictive validity of EE is well-established, many aspects of the theory, including how high EE responses develop, and mechanisms by which EE influences relapse, are still poorly understood (Barrowclough & Hooley, 2003).

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With its emphasis on the dynamic nature of social relationships, attachment theory provides a unified framework for understanding both the influence of relatives' own interpersonal experiences on the development of EE and the way in which the patient's own interpersonal style may elicit high EE responses in others. There is some evidence to suggest that EE is associated with relatives' own characteristics (Hooley and Hiller, 2000), and their own childhood experiences with parents. For example, insecure attachments to parents are hypothesised to lead to the development of critical or over involved parenting styles with one's own children (Diamond & Doane, 1994; Paley, Shapiro, & Worrall-Davies, 2000). Patterson, Birchwood and Cochrane (2000) propose that both criticism and over involvement are coping strategies motivated by relatives' perceptions of loss and changes in attachment relationships following the onset of psychosis. However, further work is required to elucidate whether and how relatives' own attachment security and attachment to the patient determine critical or over involved responses. It has been suggested that relatives' attributions of patients' behaviour and symptoms may determine EE. Work with relatives of patients with psychosis has demonstrated associations between internal, controllable attributions for behaviour and criticism; and external, uncontrollable attributions and over involvement (Barrowclough & Hooley, 2003). There is evidence that individuals with secure attachment styles attribute negative events to situational factors, while individuals with insecure styles are more likely to attribute events to either internal or other-blaming external factors (Collins, 1996). Relatives with more insecure styles would therefore be more prone to criticism or over involvement. Patients' own attachment styles could also elicit different attributions and therefore levels of expressed emotion. For example, individuals with dismissing attachment styles who project themselves as being self-sufficient and independent may bias relatives towards other-blaming attributions and therefore criticism. There is some preliminary evidence to support associations between maternal high EE and insecure attachment in childhood (Jacobsen, Hibbs & Ziegenhain, 2000) and familial high EE and insecure attachment in severe mental illness (Dozier et al., 1991). Dozier et al. (1991) examined the relationship between patients' attachment states of mind measured using the AAI and familial EE measured using the Five Minute Speech Sample (FMSS; Magana et al., 1986). The sample comprised 40 patients with a range of severe and enduring mental health problems, including 21 participants with schizophrenia and key relatives. Patients with dismissing and preoccupied attachment strategies were more likely to have family members who were rated as over involved on the FMSS. Dozier et al. (1991) argue that in the case of preoccupied patients, over involvement in relatives develops in response to overt expressions of distress; and in the case of dismissing patients, it may develop as relatives perceive the individual's underlying neediness or attempt to compensate for his or her lack of reliance on other sources of support. Over involvement on the part of relatives is hypothesised to perpetuate the use of both preoccupied and dismissing attachment strategies by patients, through confirming beliefs about vulnerability in the former case and through promoting withdrawal to avoid emotional intensity in the latter case (Dozier et al., 1991). The authors failed to find a significant relationship between relatives' criticism and patients' attachment strategies. However, as only 6 relatives were rated as critical and there were only 21 relatives in the sample overall, it is difficult to draw any firm conclusions from the study. We also suggest that attachment theory provides a framework for understanding the role of both cognition and affect in determining vulnerability to interpersonal stress and therefore relapse of psychosis. Barrowclough and Hooley (2003) argue that relatives' overt criticism of patients may trigger relapse through a cognitive route by enhancing feelings of poor self-worth. They further argue that high levels of over involvement or attempts to control behaviour are highly stressful for vulnerable individuals thus triggering relapse through an emotional route. Stress associated with high EE responses and other psychosocial events is hypothesised to lead to relapse through physiological mechanisms, such as elevated autonomic arousal and there is evidence of physiological hypersensitivity in samples with psychosis (Tarrier & Turpin, 1992). The importance of affect and associated physiological changes is also increasingly being recognised in other cognitive theories of psychosis, with recent models even positing a role for emotional dysregulation in the development of positive symptoms (Garety et al., 2001). Negative beliefs about the self and others associated with insecure attachment would increase sensitivity to criticism and negative responses from others. Difficulties in regulating affect and subsequent hyperarousal associated with insecure attachment styles would also increase sensitivity to stress in the social environment (Mikulincer, Shaver, & Pereg, 2003). 6.3. Attachment style and therapeutic alliance in psychosis The quality of the therapeutic relationship is a key determinant of outcome in psychosis and work is ongoing to identify the factors which influence therapeutic or ‘working’ alliance (Svensson & Hansson, 1999; Tattan & Tarrier,

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2000). In the general psychological literature, there is a growing body of evidence linking social relationships, and more specifically attachment style, with alliance (Dolan, Arnkoff, & Glass, 1993; Korfmacher, Adam, Ogawa, & Egeland, 1997). There is also some evidence to suggest that attachment styles influence the quality of therapeutic relationships in patients with psychosis. For example, Dozier (1990) found that security of attachment was associated with compliance with treatment programmes in a sample of 42 participants with severe and mental health problems, including 12 individuals with a diagnosis of schizophrenia. Dismissing attachment was associated with clinicianreported rejection of treatment providers, poorer use of treatment, and less self-disclosure. Preoccupied attachment was associated with clinician-reported demanding behaviours, but was also related to non-compliance, which the author attributes to possible feelings of anger underlying dependence. An observational study by Dozier, Lomax, Tyrrell, and Lee (2001) supported the link between dismissing attachment and difficulties in the therapeutic process. This study investigated the relationship between patients' attachment state of mind as measured by the AAI Q-sort method and interactions in therapeutic tasks in a sample of 34 individuals with a range of severe and enduring mental health problems, including 10 with a diagnosis of schizophrenia, and either a case manager or a relative. Patients with dismissing attachment spent less time on therapeutic tasks when interacting with case managers and reported more confusion following interactions. Furthermore, Tait et al. (2004) reported that insecure adult attachment defined in terms of closeness, dependency, and anxiety dimensions on the AAS (Collins, 1996) was related to poorer engagement with services, as measured by the Service Engagement Scale (SES; Tait, Birchwood, & Trower, 2002), which includes measures of patients' collaboration, help-seeking behaviour and treatment adherence. Future research should extend these findings by investigating the links between specific attachment prototypes and styles of engagement, and should pay attention to potential differences between two types of avoidant attachment, dismissing and fearful. Parallels may be drawn with research investigating attachment in a preventative parenting intervention for families with high levels of deprivation. This research found that mothers with unresolved representations on the AAI, akin to Bartholomew's (1990) fearful category, avoided seeking help until situations were out of control; whereas mothers with dismissing representations attended interventions, but were emotionally disengaged (Korfmacher et al., 1997). Attachment theory also contributes to the understanding of working alliance by providing a framework to conceptualise the way in which therapist and client factors interact in determining the quality of relationships. There is empirical evidence to suggest that therapist attachment style is influential in the development of therapeutic relationship (Dunkle & Friedlander, 1996). Specifically focusing on case managers of patients with severe and enduring mental health problems, Dozier et al. (1994) found that those rated as secure on the AAI were less likely to interact with patients in ways that could potentially reinforce either preoccupied or dismissing attachment strategies. Compared to secure case managers, insecure case managers' descriptions of client interventions suggested they attended more to dependency needs and intervened to a greater degree with preoccupied than dismissing clients. Furthermore, Tyrrell et al. (1999) found that case managers and patients with a range of psychiatric diagnoses, including schizophrenia, who differed on the dimension of dismissing attachment, as measured by the AAI, reported better therapeutic alliance than dyads with similar attachment strategies. 6.4. Attachment style and interpersonal functioning in psychosis Longitudinal studies suggest that difficulties in interpersonal functioning, such as interpersonal isolation, communication abnormalities, and disturbed peer relationships predispose individuals to the development of psychosis (Harvey, 2001; Mason et al., 2004). There is also evidence to suggest that social competence in psychosis is associated with outcome (Penn et al., 1997). Attachment theory makes predictions about relationships between earlier interpersonal experiences and current interpersonal styles, and the way in which maladaptive patterns of relating are maintained. It also provides a framework for conceptualising the functional nature of interpersonal difficulties in psychosis, as interpersonal difficulties associated with each attachment style are construed in terms of attachment strategies that were developed as adaptive responses in previous interpersonal relationships (Mallinckrodt, 2000). Findings in the general attachment literature have shown that attachment styles are predictive of specific configurations of interpersonal problems which should be replicated in samples with psychosis. For example, dismissing attachment styles have been associated with hostility, preoccupied attachment styles have been associated with over intrusiveness, and fearful attachment styles have been associated with lack of assertiveness (Bartholomew & Horowitz, 1991; Horowitz, Rosenberg, & Bartholomew, 1993).

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6.5. Attachment style and coping style in psychosis The way individuals cope with stressors is important in determining the onset and course of psychosis (Nuechterlein & Dawson, 1984). Attachment styles have been conceptualised in terms of different methods of affect regulation and attachment style has been shown to predict coping styles (Mikulincer & Florian, 1998). Moreover, attachment theory has the potential to develop existing stress-vulnerability model conceptualisations of coping, by generating specific predictions about the interpersonal experiences that are associated with different methods of coping and the ways in which beliefs about the self and others determine coping styles. For example, one would predict that individuals with avoidant attachment styles would have negative expectations about help-seeking and would attempt to regulate distress through avoidant coping styles which are associated with poorer outcomes. Individuals with preoccupied attachment styles would have more positive beliefs about help-seeking, but may still be relatively ineffective in regulating distress through seeking support or methods of self-regulation (Mikulincer & Florian, 1998). In support of the relationship between dismissing-avoidant attachment and reduced social support seeking, Dozier and Lee (1995) found that individuals with dismissing attachment were less likely to report distress than individuals with preoccupied attachment, although researchers rating research interviews judged the former to be more symptomatic. 6.6. Attachment style and recovery in psychosis There is evidence to suggest that individuals recovering from psychosis adopt either an integrative or a ‘sealing over’ recovery style (McGlashan, 1987). The former is associated with recognition of the links between previous psychotic and present experiences; whereas the latter is associated with a lack of desire to understand psychotic experiences. Integrative recovery styles are related to lower relapse rates and better social functioning than ‘sealing over’ styles (McGlashan, 1987). Drayton et al. (1998) found that compared to individuals with an integrative style, individuals with a ‘sealing over’ style made significantly more negative self-evaluations and described their parents as less caring on the PBI. They argued that attachment theory can help explain the development of different styles of recovery. Possibly, individuals with a ‘sealing over’ recovery style do not have a sufficient sense of internal security to explore and make links with their psychotic experiences without being overwhelmed, and suggest that this can be traced back to insecurity in earlier attachment experiences. Tait et al.'s (2004) study, described previously, replicated Drayton et al.'s (1998) findings in relation to negative self-evaluation and parental care; and also found that measures of insecure adult attachment were related to ‘sealing over’ recovery styles. Attachment theory provides a framework for explaining the capacity to regulate emotional distress, and therefore potentially, the development of adaptive versus maladaptive recovery styles. 6.7. Summary We propose that applying Bowlby's conceptualisations of the affective and interpersonal nature of working models to existing social cognitive models of psychosis would enhance theoretical developments, and would generate specific, testable predictions in a number of areas. We suggest that the attachment theory would improve interpersonal models of psychosis, as it would help us understand the relative importance of different types of interpersonal events in the development of specific beliefs about the self and others. In particular, attachment theory could illuminate the relative importance of childhood compared to adulthood trauma, and of trauma or negative relationship experiences involving significant others compared to non-familial trauma. We further argue that attachment theory could help explain the development of different attributional styles and consequent high EE responses in significant others, as well as providing a framework for explaining how EE triggers relapse at both cognitive and emotional levels. There is already evidence to suggest that patient and key worker attachment styles influence the quality of therapeutic relationships and therefore impact on clinical outcomes. Attachment theory also has the potential to explain the development and maintenance of interpersonal difficulties in psychosis, if empirical studies replicate associations between attachment styles and specific configurations of interpersonal problems in samples with psychosis. Finally, we argue that attachment theory can explain the development of different styles of coping with stress. Although attachment and coping studies need to be replicated in samples with psychosis, there is already evidence to support hypothesised relationships between dismissing attachment and failure to report distress, and insecure attachment and a ‘sealing over’ recovery style.

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7. How can attachment theory inform the understanding of specific symptoms in psychosis? We next consider how attachment theory can help inform our understanding of mechanisms underlying specific symptoms associated with psychosis, including: paranoia; voice hearing; and negative symptoms. Trower and Chadwick (1995) propose a distinction between ‘poor me’ paranoia, which is associated with a belief that persecution is undeserved and is related to high self-esteem, and ‘bad me’ paranoia, which is associated with a belief that persecution is deserved and is related to low self-esteem. In attachment terms, different types of beliefs about persecution are thought to develop from earlier life experiences. The two types of paranoia may therefore be conceptualised in terms of dismissing and fearful attachment styles, both of which are associated with negative beliefs about others, but which differ in terms of self-view. Specific associations between dismissing attachment and ‘poor me' paranoia and fearful attachment and ‘bad me' paranoia in clinical samples would support these hypothesised relationships. Distress in relation to voice hearing has been associated with beliefs about voices' omnipotence and malevolence (Birchwood & Chadwick, 1997). Furthermore, Birchwood and colleagues argue that distress is determined by the individual's relationship with voices, which is influenced by interpersonal schemata developed as a result of previous relationship experiences (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000). These authors have produced evidence to suggest that the perceived power differential between the self and the social world is a key predictor of the power differential between the voice hearer and voices. Working models of attachment, which represent previous interpersonal experiences, would therefore be potentially significant factors in influencing an individual's relationship with voices and subsequent levels of distress (Birchwood et al., 2000). Individuals with a fearful attachment style, which is characterised by low self-efficacy and a negative view of others, would therefore be more likely to believe voices are powerful and malevolent and thus experience higher levels of distress. This hypothesis needs to be tested in studies investigating attachment and experiences of voices. Negative symptoms result in significant levels of impairment and are often resistant to treatment (Provencher & Mueser, 1997). There are several competing hypotheses of negative symptoms, but one hypothesis which opens up the possibility of carrying out psychological interventions to target them, conceptualises social withdrawal and emotional blunting as methods of coping with the stress associated with positive psychotic symptoms (Andreasen, Flaum, Swayze, Tyrell, & Arndt, 1990). As individuals with dismissing attachment styles are hypothesised to use avoidance in response to distress (Bartholomew, 1990), dismissing attachment styles could therefore increase vulnerability to negative symptoms. In support of a relationship between attachment styles and symptoms in psychosis, research with non-clinical samples has found associations between avoidant attachment style and negative schizotypy, which is characterised by social withdrawal; and between anxious attachment style and non-clinical experiences of voices and paranoia (Berry, Wearden, Barrowclough, & Liversidge, 2006; Wilson & Costanzo, 1996). Additionally, our own study found a relationship between avoidance in attachment relationships and paranoia when controlling for negative affect, supporting the theory that avoidant attachment could play a role in the development of paranoia in psychosis. It would be useful to replicate this study in a clinical sample. In summary, there are indications that specific types of insecure attachment predispose individuals to the development of different symptom profiles associated with psychosis or once developed be a key factor involved in their maintenance. However, future studies need to investigate the relationships between attachment styles and specific symptoms in samples with psychosis before the utility of attachment theory in increasing our understanding of underlying mechanisms can be established. 8. Clinical implications In a population where a significant proportion of patients are difficult to engage (Frank & Gunderson, 1990), attachment theory has considerable potential relevance for clinical work with individuals with psychosis, adding to our understanding of how interpersonal styles might impede engagement with services and therapies (Slade, 1999). Moreover, attachment theory generates hypotheses about the types of therapeutic interactions that would modify attachment styles or maximise the potential for therapeutic change with individuals with different types of insecure attachment (Mallinckrodt, 2000). For example, individuals with dismissing attachment would benefit from interventions which encourage them to focus on their emotional reactions, whereas those with preoccupied attachment

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would benefit from approaches which minimise the focus on emotional distress (Tyrrell, Dozier, Teague, & Fallot, 1999). There is also evidence to suggest that attachment working models can change as a result of significant interpersonal experiences and psychological therapy is hypothesised to provide a means of revising maladaptive beliefs and strategies of affect regulation (Mallinckrodt, 2000). Attachment theory is useful for conceptualising which features of therapeutic relationships are likely to be important determinants of change across a wide range of interventions. It emphasises the need to provide a secure base to enable individuals to reflect on their past experiences (Farber, Lippert, & Nevas, 1995), and highlights the importance of clarity of communication, sensitivity, appropriate responses to distress, and consistency in clinical practice in both psychotherapy and psychiatric settings (Goodwin, 2003). Finally, insights gained from attachment theory open up the possibility of understanding and reducing negative patient–staff interactions (Adshead, 1998). If clinicians can see behaviours as functional in the context of past history, 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). Sable (1992) also highlights the benefits of helping clients recognise that working models and methods of coping with affect which were initially adaptive may be over generalised or outdated. 9. Conceptual issues It has been argued that attachment theory is useful in increasing our understanding of the development and course of psychosis and specific symptoms associated with diagnosis. However, further research is needed to address a number of conceptual issues that relate to both attachment theory in general, and the role of attachment styles in psychosis. There is a lack of clarity about how flexible working models are and under what conditions they change, including the role that attachment style plays in mediating or moderating the effects of stressful events (Pietromonaco & Feldman Barrett, 2000). There is a need for further empirical investigation of the extent to which attachment styles can be modified as a result of therapeutic relationships and the effective ingredients of change (Mallinckrodt, 2000). As individuals have relationships with different attachment figures, future research needs to clarify how representations of different attachment relationships are organised and how these relate to the individual's general attachment style (Cook, 2000). Attachment theory is not a theory of relationships generally, so it is therefore important to make clear distinctions between attachment and other aspects of relationships, such as companionship and a sense of alliance (Cassidy, 1999). It is also important to distinguish between attachment, and other related, but distinct theoretical constructs, such as personality (Crowell et al., 1999). Indeed, critics of attachment theory have argued that measures of adult attachment styles are proxy measures of personality traits (Crowell & Treboux, 1995). The available evidence suggests that individuals who are securely attached are less neurotic and more extraverted than those who are anxious or avoidant in their attachment relationships (Shaver & Brennan, 1992). However, attachment dimensions are not redundant to the five factors of personality and are in fact better predictors of relationship variables (Shaver & Brennan, 1992). Further studies investigating the predictive validity of attachment styles relative to other similar constructs, such as interpersonal styles and schemata are also warranted. Attachment theory can be less critical of patients than approaches which emphasise the role of innate individual differences in the development of psychosis. Nevertheless, as attachment theory was developed on the basis of research investigating mother–child relationships, it has a tendency to be ‘parental blaming’ and ‘maternal blaming’ in particular (Bolen, 2000). The dynamic nature of parental and child characteristics and the way they interact with wider social factors, such as deprivation and non-familial traumas, to determine the quality of relationships and attachment security therefore needs to be emphasised in applying this theoretical framework to the study of psychosis and deflecting blame away from either the individuals themselves or their parents (Cook, 2000). 10. Methodological limitations Existing studies investigating attachment theory and attachment styles in psychosis in particular have methodological limitations which need to be addressed through future research. The majority of studies carried out by Dozier and colleagues have sampled individuals with a range of different diagnoses, often with a relatively small proportion of individuals with a diagnosis of psychosis, and the extent to which different samples reported overlap is not clear. The authors' findings therefore need to be replicated in larger, more homogeneous samples. There also are difficulties related

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to the measurement of attachment styles in psychosis. The use of the AAI to measure attachment status can be criticised as individuals' level of security is determined on the basis of the coherence of their narrative. Samples of patients with schizophrenia, especially when thought disorder is present, may produce more incoherent narratives irrespective of attachment status, thus leading to an over classification of insecure attachment (Dozier et al., 1999). Furthermore, the use of the Q-sort classification method, as opposed to the traditional AAI method of classifying attachment, precludes an investigation of the prevalence of unresolved attachment. As indicated previously, the latter category has conceptual overlaps with Bartholomew's (1990, 1997) fearful prototype, and has been shown to be highly prevalent in other psychiatric groups (Dozier et al., 1999). The AAI can also be criticised for its focus on parental relationships during childhood. Although the AAI classifications are hypothesised to represent attachment states of mind with respect to a range of different interpersonal relationships, the interview schedule primarily focuses on the individual's experiences of being parented in childhood, thus excluding other information about attachment working models. Attachment in adult relationships is potentially a more significant construct to investigate in psychosis than attachment to parents in childhood, as an individual's attachment style measured with reference to current relationships is hypothesised to be more influential than attachment to parents in interpersonal functioning (Carnelley, Pietromonaco, & Jaffe, 1994; Difilippo & Overholser, 2002). Although the PBI is reported to have good reliability and validity in samples with psychosis (Parker et al, 1982), it too can be criticised as a measure of current attachment security due to its focus on past parental relationships. Moreover, the retrospective nature of the instrument makes it difficult to rule out the influence of recall biases on reports of parenting or the influence of premorbid personality on parenting behaviour (Parker et al, 1982). Measures developed on the basis of Bartholomew's (1990, 1997) model, such as the Relationship Styles Questionnaire (RSQ; Griffin & Bartholomew, 1994a) assess attachment through self-reported beliefs, thoughts, and behaviours in current interpersonal relationships and distinguish between fearful and dismissing-avoidant attachment. These and other self-report measures have been criticised for their focus on conscious thoughts, feelings and behaviours, as there is evidence to suggest that individuals may lack insight into their motives and behaviour, or may under report symptoms of distress (Crowell et al., 1999). These criticisms are particularly relevant in psychosis research, as the diagnosis has been associated with limited insight into difficulties (Amador et al., 1994). One method of assessing attachment processes without requiring individuals to consciously reflect on their own attachment style would be to ask informants to rate attachment style on the basis of their interactions with an individual (Banai, Weller, & Mikulincer, 1998). The Relationship Questionnaire (RQ; Bartholomew & Horowitz, 1991) has been used to measure friends' and romantic partners' attachment with evidence of a reasonable degree of convergence between self and informant ratings in non-clinical samples (Griffin & Bartholomew, 1994b). Future studies would therefore benefit from exploring attachment representations in psychosis using both self-report and informant-reported measures based on Bartholomew's model. A second methodological issue that needs to be considered in interpreting the existing literature and resolved through further research, is the fact that studies investigating attachment styles in psychosis are cross-sectional, which precludes inferences concerning causation. It is therefore equally plausible that the experience of psychosis itself leads to insecure attachment. Indeed, psychosis itself has been conceptualised as a traumatic event and is associated with significant changes in interpersonal relationships (Morrison, Bowe, Larkin, & Nothard, 1999; Rooke & Birchwood 1998). Alternatively, a third variable, such as neuroticism or other personality characteristics may influence the development of both insecure attachment and psychosis (Krabbendam et al., 2002; Shaver & Brennan, 1992). Longitudinal research is essential in establishing the direction of the relationships between different attachment styles and their hypothesised correlates, including psychopathology, social cognition, interpersonal relationships and affect regulation. A further reason to question a direct causal link between attachment style and psychosis is that insecure attachment is associated with a range of psychiatric conditions, suggesting that it is a non-specific risk factor for psychopathology. Research has tended to find a high level of insecure attachment in depression, (Muller, Lemieux, & Sicoli, 2001; van Buren & Cooley, 2002), anxiety (Muller et al., 2001; van Buren & Cooley, 2002), eating disorders (Brennan & Shaver, 1995; Muller et al., 2001), and borderline personality disorder (Fonagy et al., 1996). Conversely, not all individuals with insecure attachment styles develop psychosis or other forms of psychopathology (Belsky & Nezworski, 1988). Therefore 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 other risk and resilience factors (Dozier, 1990).

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11. Conclusions This review has argued that attachment theory has the potential to provide a useful theoretical framework for conceptualising the influence of social cognitive, interpersonal and affective factors on the development and course of psychosis, thus integrating and enhancing current psychological models. Moreover, insights derived from attachment theory have significant clinical implications, in terms of informing both psychological formulations and interventions with individuals with specific types of insecure attachment. However, there is currently limited research investigating attachment styles in psychosis and the majority of studies that do exist have small unrepresentative samples. The majority of studies also assess attachment using the AAI which has questionable validity in samples with psychosis, and all published studies use cross-sectional, retrospective designs. 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