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Sociability and attachment as distinct domains of the interpersonal relationships factor of the BASIS-24
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ScienceDirect Comprehensive Psychiatry 54 (2013) 1203 – 1209 www.elsevier.com/locate/comppsych
Sociability and attachment as distinct domains of the interpersonal relationships factor of the BASIS-24 Jon G. Allen a , J. Christopher Fowler a,⁎, B. Christopher Frueh a, b a
The Menninger Clinic and Baylor College of Medicine, Houston, TX, USA b The University of Hawaii, Hilo, HI, USA
Abstract The Behavior and Symptom Identification Scale (BASIS-24) was administered to 1972 patients in a private psychiatric hospital specializing in intensive treatment of several weeks’ duration. The study was designed to investigate the factor structure in a large inpatient population with a high burden of psychiatric illness. While largely replicating previous factor analyses, the study unexpectedly yielded two factors from the items comprising the interpersonal relationships factor, which were interpreted as assessing sociability and attachment. These two new factors showed differential relationships with other measures of interpersonal functioning (Inventory of Interpersonal Problems) and attachment (Relationship Questionnaire), and both factors were sensitive to improvement over the course of intensive inpatient treatment. These results suggest that different treatment interventions might be employed to target these two separable domains of potentially problematic interpersonal functioning. © 2013 Elsevier Inc. All rights reserved.
1. Introduction There is a broad acceptance now that mental health and psychiatric services, as in all general medical medicine, must be driven by objective and standardized measures of clinical outcomes [1–3] and an evidence-based practice approach [4]. Porter and Teisberg [5] are emphatic on this point: “Mandatory measurement and reporting of results is perhaps the single most important step in reforming the health care system” (p. 7, emphasis in original). The revised, 24-item Behavior and Symptom Identification Scale (BASIS-24) [6] is well suited for assessing outcomes of inpatient treatment for a number of reasons: it balances comprehensiveness and brevity; its developers have obtained extensive normative data from a large variety of institutions with varying levels of care; and it was developed with a consumer-oriented focus, that is, with item content based on problems for which inpatients commonly seek help. In addition, a series of studies demonstrated internal consistency and test–retest reliability as well as construct validity and sensitivity to changes associated with treatment [6–9].
⁎ Corresponding author. E-mail address: [email protected] (J.C. Fowler). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.05.018
Accordingly, we adopted the BASIS-24 as a broadspectrum measure in our research protocol to assess symptom profiles, level of functioning, and extent of change in a private psychiatric hospital that provides specialized treatment of patients with severe mental illness [1]. This outcomes project is designed not only to aggregate data for purposes of research and monitoring quality of care, but also to provide routine information to treating clinicians as well as individual patients regarding the severity of problems and extent of progress over the course of treatment. An initial analysis of the data showed statistically significant change on BASIS-24 total scores as well as each of its scales from admission to discharge, with positive effect sizes ranging from .36 to 1.44 [10]. The scoring algorithms for the BASIS-24 are designed to derive scores on six scales, the construction of which is supported by a factor analyses with a mixed sample of nearly four thousand inpatients and outpatients: depression/functioning, interpersonal relationships, self-harm, emotional lability, psychosis, and substance abuse [6]. This factor structure was supported by a subsequent confirmatory factor analysis based on a diverse sample of nearly six thousand inpatients and outpatients [8]; yet, questions remain regarding the factor structure of the measure when the sample consists entirely of an inpatient population with a
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high degree of illness burden. To aid the clinical interpretation of findings from the present adult inpatient outcomes project [1], the authors conducted an exploratory factor analysis to determine if the results of previous research on the BASIS-24 would be replicated in a population of patients referred for specialized intensive treatment for severe mental illnesses and high comorbidity of personality disorders. In this exploratory study, we hypothesized that the previous factor structure would be replicated, and this hypothesis was largely confirmed. Yet we found a potentially significant distinction within the domain of interpersonal functioning, namely, separate factors related to sociability and attachment. Given our discovery of two distinct BASIS-24 interpersonal scales, we conducted secondary analyses relating the new scales to two measures in our research protocol that were pertinent to assessing construct and discriminant validity. First we employed the Relationship Questionnaire (RQ) [11] to assess two domains that contribute to security of attachment: positive working model of self and positive working model of others. We hypothesized that the BASIS24 attachment scale would relate more strongly than the sociability scale to attachment security as measured by the RQ domains. Second, given prior research [12,13] demonstrating relationships between measures of attachment and the Inventory of Interpersonal Problems (IIP) [14], we explored the relations between the two BASIS-24 interpersonal factors and impairment in interpersonal functioning as measured by the IIP. We hypothesized that BASIS-24 scores indicative of poorer functioning (i.e., lower levels of attachment security and sociability) would be associated with greater overall disturbance of interpersonal functioning in the IIP and that, given the multidimensionality of the IIP, both BASIS-24 scales would relate significantly to interpersonal disturbance. Although we did not make hypotheses with regard to the individual IIP scales, we conducted exploratory analyses to investigate the possibility of differential associations. Finally, we explored the sensitivity of the two BASIS-24 scales to change over the course of inpatient treatment, hypothesizing that both would change significantly. 2. Method 2.1. Participants Persons enrolled in the study were adult psychiatric inpatients at The Menninger Clinic from January 2007 to April 2012. The sample consisted of 1972 inpatient adults (990 females and 982 males) engaged in an intensive multimodal treatment with typical lengths of stay ranging from four to eight weeks. Descriptions of the setting, treatment, and full description of measures are available in detail elsewhere [1]. Patients were included in the study regardless of symptom severity or co-morbid diagnoses. Average age at admission was 34 years (SD = 14.7).
Table 1 Marital status, racial background, and diagnoses. Percentage Marital Status Single Married Divorced/separated Racial Background Caucasian Multiracial Latino Asian African American American Indian Declined to answer Psychiatric Diagnosis Major depressive Anxiety spectrum Bipolar Psychotic spectrum Substance use
58% 23% 16% 91% 6% 5% 1.2% 0.9% 0.5% 23% 64% 47% 16% 8% 56%
Additional demographic information is displayed in Table 1. Consistent with admission for intensive inpatient treatment, the patient population showed a high level of diagnostic comorbidity, with 85% diagnosed with at least two occurring disorders (M = 4.2, SD = 2.9) and 57% with comorbid Axis I and Axis II disorders (see Table 1 for proportions in major diagnostic groups). In addition to extensive diagnostic comorbidity, markers indicative of severe mental illness [15] in our study population included a high number of previous psychiatric hospitalizations (M = 2.4, SD = 7.1) and outpatient trials (M = 6.6, SD = 4.3). 2.2. Measures 2.2.1. BASIS-24 Patients rate each of the 24 items on 5-point scales with a time frame of the past week. The measure consists of six scales: Depression/Functioning, Relationships, Self-Harm, Emotional Lability, Psychosis, and Substance Abuse. Some items (e.g., coping with problems in your life) are rated on a scale of difficulty (i.e., from 0, no difficulty, to 4, extreme difficulty); others (e.g., feel sad or depressed) are rated on a scale of the proportion of time the person experienced the problem (i.e., from 0, none of the time, to 4, all of the time); and others (e.g., hear voices or see things) are rated on a scale of frequency (i.e., how often the person experienced the problem, from 0, never, to 4, always). The BASIS-24 is administered within 72 h of admission, and at 14 day intervals thereafter, and at discharge. 2.2.2. Relationship Questionnaire (RQ) The RQ [11] is a prototype measure derived by crossing two theoretical dimensions of attachment representations: model of self (positive/negative) and model of other (positive/negative). The measure provides respondents with descriptions of the four prototypical attachment styles: secure (ease in becoming emotionally close and depending
J.G. Allen et al. / Comprehensive Psychiatry 54 (2013) 1203–1209
on others as well as lack of worry about being alone or not accepted); dismissing (comfort without emotionally close relationships coupled with desire for self-sufficiency and independence); preoccupied (desire for emotional intimacy and discomfort with lack of close relationships coupled with experience that others are reluctant to be as close or to value the relationship as strongly); and fearful (discomfort with closeness associated with distrust about depending on others and worry about being hurt). Respondents select the prototype that best describes the way they generally are in close relationships, and they also rate each prototype on a 7point scale regarding the extent to which each description corresponds to their general relationship style. The questionnaire was administered at the time of admission to the hospital. The scale’s developers recommend utilizing the dimensions of self and other in most research applications. A negative model of self is associated with attachment-related anxiety based on doubts that the self is worthy of attention and affection, creating worries that relationship partners will not be available in times of need. Negative model of other is associated with attachment-related avoidance and is rooted in a person’s distrust of relationship partners’ goodwill, which causes him or her to maintain behavioral and emotional independence and distance from others. Individuals who score in a positive range for model of self and model of other are categorized as having a prototypic secure attachment style. 2.2.3. Inventory of Interpersonal Problems (IIP-32) To compare the two new BASIS relationship factors with a more extensive measure of disturbance in interpersonal functioning, we employed the 32-item form of the IIP [14,16]. This measure was designed to evaluate an array of interpersonal problems for which patients commonly seek psychotherapy. In addition to providing an overall score for the extent of interpersonal disturbance, the measure provides scores on eight scales arrayed around two dimensions (affiliation and dominance) that fit a circumplex model of interpersonal behavior: Domineering/Controlling (need to be in control, potentially to the point of being manipulative or aggressive, related to the fear of loss of control associated with threats to dignity, self-worth, or sense of identity); Vindictive/Self-Centered (hostile dominance associated with suspiciousness, irritability and anger, desire for revenge, and aggressive interactions); Cold/Distant (lack of affection, warmth and connection along with desire for freedom from social obligations and difficulty making long-term commitments); Socially Inhibited (social avoidance associated with anxiety and motivated by fear of disapproval, rejection, and humiliation); Nonassertive (lack of self-confidence, difficulty taking initiative, avoidance of social challenge, fear of exerting influence or power over others); Overly Accommodating (submissiveness to please others and maintain approval associated with avoidance of anger and conflict along with vulnerability to being exploited); Self-Sacrificing (excessively nurturing, generous and trusting along with
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difficulty maintaining boundaries and setting limits as well as expressing anger); and Intrusive/Needy (powerful needs for social engagement to the point of imposing on others, for example, in the form of excessive self-disclosure or taking inappropriate responsibility for solving others’ problems). Higher IIP scores indicate greater disturbance. For the present study, we employed the total score as well as scores from all eight scales. 2.3. Procedures Patients completed the measures as part of a battery of instruments described elsewhere [1]. The assessments are administered by research assistants on computers, and previous research has shown results of the computerized administration of the BASIS-24 to be acceptable to participants and highly correlated with the paper-and-pencil version [17]. The assessment is presented to patients as a routine part of their clinical care, and they are provided with profiles of their scores over time. In addition, they are informed that the findings are used to evaluate the effectiveness of treatment and for research purposes. The project is approved by the Institutional Review Board of the Baylor College of Medicine. 2.4. Data analyses All analyses were conducted using SPSS version 19.1 (IBM). BASIS-24 factor analysis replicated Eisen and colleagues’ strategy using Promax rotation with Kaiser normalization. Eigenvalue was set at 1.0 with a maximum of 25 iterations. The choice of exploratory factor analysis over confirmatory factor analysis (CFA) was based on the following considerations: 1. The large sample of data would likely lead to a rejection of the null hypothesis, and 2. CFA would not improve identification of alternate factor structure [18]. Simple bivariate Pearson correlations were computed for BASIS factor scores and attachment and interpersonal data. T-tests of effect size differences were computed on the correlations from a single sample using equation 3 developed by Humphreys [19].
3. Results The results of the factor analysis are presented in Table 2. With minor variations in loadings, three of the six factors from the current sample and the Eisen and colleagues’ [6,8] sample load on identical items: psychosis, substance abuse, and self-harm. Apart from our main interest, the interpersonal relationships domain, there are minor differences between samples. In the depression and functioning factor, the current sample loads on one additional item, that is, “thoughts racing through your head,” whereas, in Eisen and colleagues’ sample, this item loads on the emotional lability factor. In addition, in the current sample, the item, “think people are against you,” not only loads on the psychosis
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Table 2 Factor loadings for BASIS-24 items. Item Content
Depress
Manage day-to-day life Cope with problems in life Concentrate Get along with people in family Get along outside family Get along in social situations Feel close to another person Have someone to turn to Feel confident in yourself Feel sad or depressed Think about ending your life Feel nervous Thoughts racing through head Have special powers Hear voices or see things Think people are watching you Think people are against you Have mood swings Feel short-tempered Think about hurting yourself Have urge to drink/take drugs Talk to you about alcohol/drugs Hide your drinking or drug use Problems from drinking/drugs
.84 .81 .78
Sociab
Attach
Psychosis
Subst
Lability
Harm
.60 .91 .80 .89 .89 .65 .71 .91 .75 .46 .74 .79 .69 .45
.46 .72 .83 .91 .78 .81 .85 .87
Abbreviations: Depress = Depression/Functioning; Sociab = Sociability; Attach = Attachment; Subst = Substance Abuse; Lability = Emotional Lability; Harm = Self-Harm. Factor loadings b .40 omitted for clarity.
factor (as it does in the Eisen sample) but also cross-loads on the emotional lability factor. An unanticipated finding of primary interest in the current study is the splitting of the interpersonal relationships factor into two factors in the current sample. One of these factors, which we construe as sociability, consists of items referring to “getting along,” namely, with people in the family, outside the family, and in social situations. The other factor consists of two items, namely, feeling close to another person and having someone to turn to, both of which we construe as related to attachment, which entails emotional closeness coupled with a capacity to depend on others for comfort and support. Discovering this bifurcation of the original interpersonal relationships factor led us to construct two scales corresponding to these factors by averaging the weighted item totals that loaded on the factors. First, to assess discriminant validity, we related both new BASIS scales to the RQ and the IIP. Second, we examined the extent to which each of these new BASIS scales was sensitive to change over the course of treatment. Both BASIS relationship scores (attachment and sociability) correlated in the expected direction with RQ attachment dimensions (self and other). Specifically, lower levels of relationship disturbance on the BASIS were associated with greater security on the two RQ dimensions. As anticipated, the BASIS attachment scale correlated more strongly than the sociability scale with both dimensions of
the RQ, that is model of self (r = −.32 and −.20, respectively, n = 1117, p’s b .001) and model of other (r = −.30 and −.14, respectively, p’s b .001). The difference in the magnitude of the correlations was significant in both instances (t = 3.6, p = .0004 and t = 5.0, p = .0001, respectively). Similarly, both BASIS relationship scales correlated in the expected direction with the IIP octants. Specifically, lower levels of relationship disturbance on the BASIS were associated with lower levels of interpersonal disturbance on the IIP. Moreover, as depicted in Table 3, the BASIS attachment scale correlated somewhat more strongly than the sociability scale with the overall IIP score. Yet, as also shown in Table 3, there were differences among IIP scales in Table 3 Correlations of IIP-32 scores with BASIS-24 relationship scores. IIP Scores
Attachment
Sociability
Difference
Total Domineering/controlling Vindictive/self-centered Cold–Distant Socially Inhibited Nonassertive Overly accommodating Self-sacrificing Intrusive–needy
.36⁎⁎ .13⁎⁎ .25⁎⁎ .43⁎⁎ .32⁎⁎ .24⁎⁎ .23⁎⁎ .10⁎⁎ .05⁎
.31⁎⁎ .20⁎⁎ .24⁎⁎ .32⁎⁎ .29⁎⁎ .15⁎⁎ .14⁎⁎ .08⁎⁎ .13⁎⁎
t t t t t t t t t
⁎⁎ p b .01. ⁎ p b .05.
= = = = = = = = =
1.9, p 3.8, p 0.7, p 4.2, p 1.6, p 5.2, p 4.8, p 1.1, p 4.3, p
= = N = N = = N =
.05 .0001 .10 .0001 .10 .0001 .0001 .10 .0001
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the levels and relative strengths of the correlations with the BASIS scales. The magnitude of the correlations was significantly higher for attachment than sociability for three IIP scales: cold–distant, nonassertive, and overly accommodating; conversely, the magnitude of the correlations was significantly higher for sociability than attachment with two IIP scales: domineering/controlling and intrusive–needy. To examine the extent of change in the BASIS attachment and sociability scales, we computed the average scores for items on each factor at admission (pre-test) and discharge (post-test), and we found significant improvement in both at discharge. The means at admission and discharge for the attachment factor were 1.67 at admission and 0.95 at discharge (F = 264.9; df = 1, 1178; p b .001), and those for the sociability factor were 1.41 and 1.03, respectively (F = 113.6; df = 1, 1178; p b .001). Notably, although treatment was associated with improvement, the absolute scores on the BASIS interpersonal scales were relatively low (i.e., in the healthy range) throughout: the average scores for feeling close and having someone to turn to (attachment) and getting along (sociability) fell between “half of the time” and “most of the time” at admission; the average was “most of the time” at discharge. The effect size of the improvement in attachment security was .67, compared to an effect size of .41 for sociability, a difference that was statistically significant (t = 4.6, p = .0001).
4. Discussion We designed this study anticipating that we would replicate the factor analytic studies results of prior, mixed inpatient and outpatient sample studies of the BASIS-24. While generally replicating prior research, our sample yielded a bifurcation of the previous interpersonal relationships factor into two scales, one we interpreted as assessing sociability and the other assessing attachment aspects of relationships. Our finding that the interpersonal factor of the BASIS subsumes two distinct facets is consistent with attachment theory [20], which focuses relatively narrowly on the potential emotion-regulating aspects of relationships in providing a feeling of security in the face of danger and threat [21,22]. Hence secure attachment relationships entail a high degree of emotional closeness and confidence in being able to depend on the availability and responsiveness of the attachment figure in times of distress [23]. The two items we found to load together “Feel close to another person” and “Have someone to turn to” are consistent with the attachment aspect of relationships and, more specifically, assess globally the level of security in attachment relationships. Yet attachment is merely one among several facets of interpersonal relationships. Attachment is intertwined with caregiving, and the safe haven of attachment (i.e., affording comfort and security at times of threat or distress) also provides a secure base for exploration (e.g., as the toddler plays confidently as long as the caregiver is accessible).
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Exploration includes sociability, that is, exploration of interpersonal relationships. Underscoring the distinctness of these two aspects of relationships, the activation of attachment needs deactivates sociability in favor of seeking security [20]. We construe the three items referring to getting along with others (i.e., inside and outside the family and in social situations) as relating more to sociability than attachment. Admittedly, emotional closeness and being able to turn to another person do not necessarily entail attachment; for example, one could feel close without depending on another, and one could turn to another person for practical help rather than emotional help. Yet our finding that this factor relates more strongly than the sociability factor to a measure of attachment is consistent with our view of these items. Our findings relating the BASIS interpersonal scores to the IIP, which measures interpersonal disturbance, also merit comment. It is not surprising that lower levels of sociability (i.e., getting along) and attachment insecurity relate to more disturbed interpersonal functioning, as evidenced in the total IIP scores. Notably, there is a modest but statistically significant difference indicating that attachment insecurity is more highly related than lowered sociability to disturbed interpersonal functioning. This finding is consistent with an extensive literature relating different forms and degrees of attachment insecurity to problematic interpersonal functioning, from childhood [24] to adulthood [25]. Notably, the direction of this difference is the same for three of the IIP scales: cold–distant, nonassertive, and overly accommodating. Plainly, the avoidance of closeness (cold–distant) is a distinct form of attachment insecurity; yet the passivity associated with the nonassertive and overly compliant scales also can be understood as compromising attachment security insofar as it blocks the active and effective expression of attachment needs. On the other hand, impaired sociability relates more strongly than attachment insecurity to the domineering–controlling and intrusive–needy IIP scales, although the absolute magnitude of these correlations is low. Both of these intrusive behavior patterns are likely to generate conflict in relationships (i.e., to interfere with “getting along”). Apart from the main finding of interest in the interpersonal domain, the minor differences in factor structures between the present sample and Eisen and colleagues’ [6] sample bear comment. The current sample’s loading of the item, “thoughts racing through your head,” on the depression factor might reflect depressive rumination in this inpatient population characterized by severe depression. In Eisen and colleagues’ sample, this item loads on the emotional lability factor, which might reflect mania. In addition, in the current sample, the item, “think people are against you,” not only loads on the psychosis factor (as it does in Eisen’s sample) but also crossloads on the emotional lability factor, a finding that might reflect interpersonal conflict that is often associated with intense emotional lability in our patient population. It is not surprising that the intensive inpatient treatment setting in which this research was conducted is associated
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with improved interpersonal functioning in both interpersonal domains measured by the BASIS, sociability and attachment. The treatment provided has a strong psychotherapeutic focus with a great deal of emphasis on group treatments (i.e., group psychotherapy, psychoeducational groups, skills groups, leisure groups, along with groupfocused approaches to substance abuse). All these treatments are conducted in the context of a therapeutic milieu. Hence the treatment as a whole is directed toward positive social engagement. It is notable, however, that the impact of the treatment is somewhat greater for the attachment than the sociability domain of the BASIS-24 relationship factor. This finding likely reflects the broad emphasis of the treatment on emotional confiding and making use of relationships for emotional support. In addition, active family work with romantic partners and parents is directed toward not only ameliorating conflict but also fostering greater security in seeking emotional support in key attachment relationships. The limitations of this study and the findings merit consideration. The two scales derived from the BASIS interpersonal relationships factor, sociability and attachment, consist of a small number of items (i.e., three and two, respectively). Although we found some evidence for discriminant validity with measures of attachment and disturbed interpersonal functioning, the magnitude of the differences was modest. More generally, the magnitude of many correlations between the BASIS interpersonal scales and the IIP scales was low. We included the IIP in our assessment protocol because we are addressing problematic interpersonal functioning that contributes to psychiatric disorder and need for inpatient treatment. A more direct test of the construct validity of the BASIS sociability scale would employ a more parallel measure, such as the extraversion scale of the Big Five Inventory [26]. Nonetheless, our findings demonstrate that the BASIS is sensitive to treatment change and draw attention to a substantively significant difference among items of the BASIS interpersonal relationships factor that has potential implications for the focus of intervention, namely, a focus on social engagement more generally versus a focus on attachment aspects of key relationships, with the latter having significant implications for emotion regulation—a core problem for patients with psychiatric disorders that include disturbed interpersonal functioning. Simply put, patients with this profile are likely to need treatment that addresses two domains of interpersonal functioning, as provided by the inpatient treatment in the current study. First, patients need care that facilitates social engagement, which is a primary function of a therapeutic community. Second, they need treatment interventions that foster greater reliance on key attachment relationships that provide a feeling of safety and security, the bedrock of emotion regulation. Such interventions are inherent in intensive therapeutic hospital treatment that includes not only individual and group psychotherapy but also active couples, marital, and family work. The treatment studied here—admittedly rare in
contemporary psychiatric hospital care—provides multimodal interventions conducive to addressing both domains of interpersonal functioning revealed by our factor analysis of the BASIS scale. References [1] Allen JG, Frueh BC, Ellis TE, Latini DM, Mahoney JS, Oldham JM, et al. Integrating outcomes assessment and research into clinical care in inpatient adult psychiatric treatment. Bull Menninger Clin 2009;73:259-95. [2] Fonagy P. Process and outcome in mental health care delivery: a model approach to treatment evaluation. Bull Menninger Clin 1999;63:288-304. [3] Rush AJJ, First MB, Blacker D, editors. Handbook of psychiatric measures (second edition). Washington, DC: American Psychiatric Publishing; 2008. [4] Frueh BC, Ford JD, Elhai JD, Grubaugh AL. An overview of evidencebased practice in adult mental health. In: Sturmey P, & Hersen M, editors. Handbook of evidence based practice in clinical psychology, volume II: adult disorders. New York: Wiley; 2012. p. 3-14. [5] Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston, MA: Harvard Business School Press; 2006. [6] Eisen SV, Normand S-L, Belanger AJ, Spiro A, Esch D. The revised Behavior and Symptom Identification Scale (BASIS-R): reliability and validity. Med Care 2004;42:1230-41. [7] Cameron IM, Cunningham JR, Crawford JM, Eagles JM, Eisen SV, Lawton K, et al. Psychometric properties of the BASIS-24 (Behaviour and Symptom Identification Scale-Revised) mental health outcome measure. Int J Psychiatry Clin Pract 2007;11:36-43. [8] Eisen SV, Gerena M. Reliability and validity of the BASIS-24 mental health survey for whites, African–Americans, and Latinos. J Behav Health Serv Res 2006;33:304-23. [9] Eisen SV, Ranganathan G, Seal P, Spiro A. Measuring clinically meaningful change following mental health treatment. J Behav Health Serv Res 2007;34:272-89. [10] Latini DM, Allen JG, Seo M, Mahoney JS, Ellis TE, Frueh BC. Psychosocial characteristics of psychiatric inpatients at admission and discharge: the Menninger Clinic Adult Outcomes Project. Bull Menninger Clin 2009;73:296-310. [11] Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61:226-44. [12] Horowitz LM, Rosenberg SE, Bartholomew K. Interpersonal problems, attachment styles, and outcome in brief dynamic psychotherapy. J Consult Clin Psychol 1993;61:549-60. [13] Haggerty G, Hilsenroth MJ, Vala-Stewart R. Attachment and interpersonal distress: examining the relationship between attachment styles and interpersonal problems in a clinical population. Clin Psychol Psychother 2009;16:1-9. [14] Horowitz LM, Alden LE, Wiggins JS, Pincus AL. Inventory of Interpersonal Problems manual. San Antonio, TX: Psychological Corporation; 2000. [15] Kessler RC, Green JG, Gruber MJ, Sampson NA, Bromet E, Cuitan M, et al. Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. Int J Methods Psychiatr Res 2010;19(S1):4-22. [16] Horowitz LM, Rosenberg SE, Baer BA, Ureno G, Villasenor VS. Inventory of Interpersonal Problems: psychometric properties and clinical applications. J Consult Clin Psychol 1988;56:885-92. [17] Goldstein LA, Gibbons MBC, Thompson SM, Scott K, Heintz L, Green P, et al. Outcome assessment via handheld computer in community mental health: consumer satisfaction and reliability. J Behav Health Serv Res 2011;38:414-23. [18] Hurley Amy E, Scandura Terri A, Schriesheim Chester A, Brannick Michael T, Seers Anson, Vandenberg Robert J, et al. Exploratory and
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confirmatory factor analysis: guidelines, issues, and alternatives. J Organ Behav 1997;18:667-83. Humphreys LG. Differences between correlations in a single sample: a correction and amplification. Psychol Rep 1978;43:657-8. Cassidy J. The nature of the child's ties. In: Cassidy J, & Shaver PR, editors. Handbook of attachment: theory, research, and clinical applications. New York: Guilford; 2008. p. 3-22. Bowlby J. The nature of the child's tie to his mother. Int J Psychoanal 1958;39:350-73. Bowlby J. Attachment and loss, volume I: attachment. 2nd ed. New York: Basic Books; 1982.
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[23] Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of attachment: a psychological study of the strange situation. Hillsdale, NJ: Erlbaum; 1978. [24] Sroufe LA, Egeland B, Carlson EA, Collins WA. The development of the person: the Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford; 2005. [25] Mikulincer M, Shaver PR. Attachment in adulthood: structure, dynamics, and change. New York: Guilford; 2007. [26] John OP, Naumann LP, Soto CJ. Paradigm shift to the integrative big-five trait taxonomy, history, measurement, and conceptual issues. In: John OP, Robins RW, & Pervin LA, editors. Handbook of personality: theory and research 2008. New York, NY: Guilford Press; 2008. p. 114-58.
ScienceDirect Comprehensive Psychiatry 54 (2013) 1203 – 1209 www.elsevier.com/locate/comppsych
Sociability and attachment as distinct domains of the interpersonal relationships factor of the BASIS-24 Jon G. Allen a , J. Christopher Fowler a,⁎, B. Christopher Frueh a, b a
The Menninger Clinic and Baylor College of Medicine, Houston, TX, USA b The University of Hawaii, Hilo, HI, USA
Abstract The Behavior and Symptom Identification Scale (BASIS-24) was administered to 1972 patients in a private psychiatric hospital specializing in intensive treatment of several weeks’ duration. The study was designed to investigate the factor structure in a large inpatient population with a high burden of psychiatric illness. While largely replicating previous factor analyses, the study unexpectedly yielded two factors from the items comprising the interpersonal relationships factor, which were interpreted as assessing sociability and attachment. These two new factors showed differential relationships with other measures of interpersonal functioning (Inventory of Interpersonal Problems) and attachment (Relationship Questionnaire), and both factors were sensitive to improvement over the course of intensive inpatient treatment. These results suggest that different treatment interventions might be employed to target these two separable domains of potentially problematic interpersonal functioning. © 2013 Elsevier Inc. All rights reserved.
1. Introduction There is a broad acceptance now that mental health and psychiatric services, as in all general medical medicine, must be driven by objective and standardized measures of clinical outcomes [1–3] and an evidence-based practice approach [4]. Porter and Teisberg [5] are emphatic on this point: “Mandatory measurement and reporting of results is perhaps the single most important step in reforming the health care system” (p. 7, emphasis in original). The revised, 24-item Behavior and Symptom Identification Scale (BASIS-24) [6] is well suited for assessing outcomes of inpatient treatment for a number of reasons: it balances comprehensiveness and brevity; its developers have obtained extensive normative data from a large variety of institutions with varying levels of care; and it was developed with a consumer-oriented focus, that is, with item content based on problems for which inpatients commonly seek help. In addition, a series of studies demonstrated internal consistency and test–retest reliability as well as construct validity and sensitivity to changes associated with treatment [6–9].
⁎ Corresponding author. E-mail address: [email protected] (J.C. Fowler). 0010-440X/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2013.05.018
Accordingly, we adopted the BASIS-24 as a broadspectrum measure in our research protocol to assess symptom profiles, level of functioning, and extent of change in a private psychiatric hospital that provides specialized treatment of patients with severe mental illness [1]. This outcomes project is designed not only to aggregate data for purposes of research and monitoring quality of care, but also to provide routine information to treating clinicians as well as individual patients regarding the severity of problems and extent of progress over the course of treatment. An initial analysis of the data showed statistically significant change on BASIS-24 total scores as well as each of its scales from admission to discharge, with positive effect sizes ranging from .36 to 1.44 [10]. The scoring algorithms for the BASIS-24 are designed to derive scores on six scales, the construction of which is supported by a factor analyses with a mixed sample of nearly four thousand inpatients and outpatients: depression/functioning, interpersonal relationships, self-harm, emotional lability, psychosis, and substance abuse [6]. This factor structure was supported by a subsequent confirmatory factor analysis based on a diverse sample of nearly six thousand inpatients and outpatients [8]; yet, questions remain regarding the factor structure of the measure when the sample consists entirely of an inpatient population with a
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high degree of illness burden. To aid the clinical interpretation of findings from the present adult inpatient outcomes project [1], the authors conducted an exploratory factor analysis to determine if the results of previous research on the BASIS-24 would be replicated in a population of patients referred for specialized intensive treatment for severe mental illnesses and high comorbidity of personality disorders. In this exploratory study, we hypothesized that the previous factor structure would be replicated, and this hypothesis was largely confirmed. Yet we found a potentially significant distinction within the domain of interpersonal functioning, namely, separate factors related to sociability and attachment. Given our discovery of two distinct BASIS-24 interpersonal scales, we conducted secondary analyses relating the new scales to two measures in our research protocol that were pertinent to assessing construct and discriminant validity. First we employed the Relationship Questionnaire (RQ) [11] to assess two domains that contribute to security of attachment: positive working model of self and positive working model of others. We hypothesized that the BASIS24 attachment scale would relate more strongly than the sociability scale to attachment security as measured by the RQ domains. Second, given prior research [12,13] demonstrating relationships between measures of attachment and the Inventory of Interpersonal Problems (IIP) [14], we explored the relations between the two BASIS-24 interpersonal factors and impairment in interpersonal functioning as measured by the IIP. We hypothesized that BASIS-24 scores indicative of poorer functioning (i.e., lower levels of attachment security and sociability) would be associated with greater overall disturbance of interpersonal functioning in the IIP and that, given the multidimensionality of the IIP, both BASIS-24 scales would relate significantly to interpersonal disturbance. Although we did not make hypotheses with regard to the individual IIP scales, we conducted exploratory analyses to investigate the possibility of differential associations. Finally, we explored the sensitivity of the two BASIS-24 scales to change over the course of inpatient treatment, hypothesizing that both would change significantly. 2. Method 2.1. Participants Persons enrolled in the study were adult psychiatric inpatients at The Menninger Clinic from January 2007 to April 2012. The sample consisted of 1972 inpatient adults (990 females and 982 males) engaged in an intensive multimodal treatment with typical lengths of stay ranging from four to eight weeks. Descriptions of the setting, treatment, and full description of measures are available in detail elsewhere [1]. Patients were included in the study regardless of symptom severity or co-morbid diagnoses. Average age at admission was 34 years (SD = 14.7).
Table 1 Marital status, racial background, and diagnoses. Percentage Marital Status Single Married Divorced/separated Racial Background Caucasian Multiracial Latino Asian African American American Indian Declined to answer Psychiatric Diagnosis Major depressive Anxiety spectrum Bipolar Psychotic spectrum Substance use
58% 23% 16% 91% 6% 5% 1.2% 0.9% 0.5% 23% 64% 47% 16% 8% 56%
Additional demographic information is displayed in Table 1. Consistent with admission for intensive inpatient treatment, the patient population showed a high level of diagnostic comorbidity, with 85% diagnosed with at least two occurring disorders (M = 4.2, SD = 2.9) and 57% with comorbid Axis I and Axis II disorders (see Table 1 for proportions in major diagnostic groups). In addition to extensive diagnostic comorbidity, markers indicative of severe mental illness [15] in our study population included a high number of previous psychiatric hospitalizations (M = 2.4, SD = 7.1) and outpatient trials (M = 6.6, SD = 4.3). 2.2. Measures 2.2.1. BASIS-24 Patients rate each of the 24 items on 5-point scales with a time frame of the past week. The measure consists of six scales: Depression/Functioning, Relationships, Self-Harm, Emotional Lability, Psychosis, and Substance Abuse. Some items (e.g., coping with problems in your life) are rated on a scale of difficulty (i.e., from 0, no difficulty, to 4, extreme difficulty); others (e.g., feel sad or depressed) are rated on a scale of the proportion of time the person experienced the problem (i.e., from 0, none of the time, to 4, all of the time); and others (e.g., hear voices or see things) are rated on a scale of frequency (i.e., how often the person experienced the problem, from 0, never, to 4, always). The BASIS-24 is administered within 72 h of admission, and at 14 day intervals thereafter, and at discharge. 2.2.2. Relationship Questionnaire (RQ) The RQ [11] is a prototype measure derived by crossing two theoretical dimensions of attachment representations: model of self (positive/negative) and model of other (positive/negative). The measure provides respondents with descriptions of the four prototypical attachment styles: secure (ease in becoming emotionally close and depending
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on others as well as lack of worry about being alone or not accepted); dismissing (comfort without emotionally close relationships coupled with desire for self-sufficiency and independence); preoccupied (desire for emotional intimacy and discomfort with lack of close relationships coupled with experience that others are reluctant to be as close or to value the relationship as strongly); and fearful (discomfort with closeness associated with distrust about depending on others and worry about being hurt). Respondents select the prototype that best describes the way they generally are in close relationships, and they also rate each prototype on a 7point scale regarding the extent to which each description corresponds to their general relationship style. The questionnaire was administered at the time of admission to the hospital. The scale’s developers recommend utilizing the dimensions of self and other in most research applications. A negative model of self is associated with attachment-related anxiety based on doubts that the self is worthy of attention and affection, creating worries that relationship partners will not be available in times of need. Negative model of other is associated with attachment-related avoidance and is rooted in a person’s distrust of relationship partners’ goodwill, which causes him or her to maintain behavioral and emotional independence and distance from others. Individuals who score in a positive range for model of self and model of other are categorized as having a prototypic secure attachment style. 2.2.3. Inventory of Interpersonal Problems (IIP-32) To compare the two new BASIS relationship factors with a more extensive measure of disturbance in interpersonal functioning, we employed the 32-item form of the IIP [14,16]. This measure was designed to evaluate an array of interpersonal problems for which patients commonly seek psychotherapy. In addition to providing an overall score for the extent of interpersonal disturbance, the measure provides scores on eight scales arrayed around two dimensions (affiliation and dominance) that fit a circumplex model of interpersonal behavior: Domineering/Controlling (need to be in control, potentially to the point of being manipulative or aggressive, related to the fear of loss of control associated with threats to dignity, self-worth, or sense of identity); Vindictive/Self-Centered (hostile dominance associated with suspiciousness, irritability and anger, desire for revenge, and aggressive interactions); Cold/Distant (lack of affection, warmth and connection along with desire for freedom from social obligations and difficulty making long-term commitments); Socially Inhibited (social avoidance associated with anxiety and motivated by fear of disapproval, rejection, and humiliation); Nonassertive (lack of self-confidence, difficulty taking initiative, avoidance of social challenge, fear of exerting influence or power over others); Overly Accommodating (submissiveness to please others and maintain approval associated with avoidance of anger and conflict along with vulnerability to being exploited); Self-Sacrificing (excessively nurturing, generous and trusting along with
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difficulty maintaining boundaries and setting limits as well as expressing anger); and Intrusive/Needy (powerful needs for social engagement to the point of imposing on others, for example, in the form of excessive self-disclosure or taking inappropriate responsibility for solving others’ problems). Higher IIP scores indicate greater disturbance. For the present study, we employed the total score as well as scores from all eight scales. 2.3. Procedures Patients completed the measures as part of a battery of instruments described elsewhere [1]. The assessments are administered by research assistants on computers, and previous research has shown results of the computerized administration of the BASIS-24 to be acceptable to participants and highly correlated with the paper-and-pencil version [17]. The assessment is presented to patients as a routine part of their clinical care, and they are provided with profiles of their scores over time. In addition, they are informed that the findings are used to evaluate the effectiveness of treatment and for research purposes. The project is approved by the Institutional Review Board of the Baylor College of Medicine. 2.4. Data analyses All analyses were conducted using SPSS version 19.1 (IBM). BASIS-24 factor analysis replicated Eisen and colleagues’ strategy using Promax rotation with Kaiser normalization. Eigenvalue was set at 1.0 with a maximum of 25 iterations. The choice of exploratory factor analysis over confirmatory factor analysis (CFA) was based on the following considerations: 1. The large sample of data would likely lead to a rejection of the null hypothesis, and 2. CFA would not improve identification of alternate factor structure [18]. Simple bivariate Pearson correlations were computed for BASIS factor scores and attachment and interpersonal data. T-tests of effect size differences were computed on the correlations from a single sample using equation 3 developed by Humphreys [19].
3. Results The results of the factor analysis are presented in Table 2. With minor variations in loadings, three of the six factors from the current sample and the Eisen and colleagues’ [6,8] sample load on identical items: psychosis, substance abuse, and self-harm. Apart from our main interest, the interpersonal relationships domain, there are minor differences between samples. In the depression and functioning factor, the current sample loads on one additional item, that is, “thoughts racing through your head,” whereas, in Eisen and colleagues’ sample, this item loads on the emotional lability factor. In addition, in the current sample, the item, “think people are against you,” not only loads on the psychosis
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Table 2 Factor loadings for BASIS-24 items. Item Content
Depress
Manage day-to-day life Cope with problems in life Concentrate Get along with people in family Get along outside family Get along in social situations Feel close to another person Have someone to turn to Feel confident in yourself Feel sad or depressed Think about ending your life Feel nervous Thoughts racing through head Have special powers Hear voices or see things Think people are watching you Think people are against you Have mood swings Feel short-tempered Think about hurting yourself Have urge to drink/take drugs Talk to you about alcohol/drugs Hide your drinking or drug use Problems from drinking/drugs
.84 .81 .78
Sociab
Attach
Psychosis
Subst
Lability
Harm
.60 .91 .80 .89 .89 .65 .71 .91 .75 .46 .74 .79 .69 .45
.46 .72 .83 .91 .78 .81 .85 .87
Abbreviations: Depress = Depression/Functioning; Sociab = Sociability; Attach = Attachment; Subst = Substance Abuse; Lability = Emotional Lability; Harm = Self-Harm. Factor loadings b .40 omitted for clarity.
factor (as it does in the Eisen sample) but also cross-loads on the emotional lability factor. An unanticipated finding of primary interest in the current study is the splitting of the interpersonal relationships factor into two factors in the current sample. One of these factors, which we construe as sociability, consists of items referring to “getting along,” namely, with people in the family, outside the family, and in social situations. The other factor consists of two items, namely, feeling close to another person and having someone to turn to, both of which we construe as related to attachment, which entails emotional closeness coupled with a capacity to depend on others for comfort and support. Discovering this bifurcation of the original interpersonal relationships factor led us to construct two scales corresponding to these factors by averaging the weighted item totals that loaded on the factors. First, to assess discriminant validity, we related both new BASIS scales to the RQ and the IIP. Second, we examined the extent to which each of these new BASIS scales was sensitive to change over the course of treatment. Both BASIS relationship scores (attachment and sociability) correlated in the expected direction with RQ attachment dimensions (self and other). Specifically, lower levels of relationship disturbance on the BASIS were associated with greater security on the two RQ dimensions. As anticipated, the BASIS attachment scale correlated more strongly than the sociability scale with both dimensions of
the RQ, that is model of self (r = −.32 and −.20, respectively, n = 1117, p’s b .001) and model of other (r = −.30 and −.14, respectively, p’s b .001). The difference in the magnitude of the correlations was significant in both instances (t = 3.6, p = .0004 and t = 5.0, p = .0001, respectively). Similarly, both BASIS relationship scales correlated in the expected direction with the IIP octants. Specifically, lower levels of relationship disturbance on the BASIS were associated with lower levels of interpersonal disturbance on the IIP. Moreover, as depicted in Table 3, the BASIS attachment scale correlated somewhat more strongly than the sociability scale with the overall IIP score. Yet, as also shown in Table 3, there were differences among IIP scales in Table 3 Correlations of IIP-32 scores with BASIS-24 relationship scores. IIP Scores
Attachment
Sociability
Difference
Total Domineering/controlling Vindictive/self-centered Cold–Distant Socially Inhibited Nonassertive Overly accommodating Self-sacrificing Intrusive–needy
.36⁎⁎ .13⁎⁎ .25⁎⁎ .43⁎⁎ .32⁎⁎ .24⁎⁎ .23⁎⁎ .10⁎⁎ .05⁎
.31⁎⁎ .20⁎⁎ .24⁎⁎ .32⁎⁎ .29⁎⁎ .15⁎⁎ .14⁎⁎ .08⁎⁎ .13⁎⁎
t t t t t t t t t
⁎⁎ p b .01. ⁎ p b .05.
= = = = = = = = =
1.9, p 3.8, p 0.7, p 4.2, p 1.6, p 5.2, p 4.8, p 1.1, p 4.3, p
= = N = N = = N =
.05 .0001 .10 .0001 .10 .0001 .0001 .10 .0001
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the levels and relative strengths of the correlations with the BASIS scales. The magnitude of the correlations was significantly higher for attachment than sociability for three IIP scales: cold–distant, nonassertive, and overly accommodating; conversely, the magnitude of the correlations was significantly higher for sociability than attachment with two IIP scales: domineering/controlling and intrusive–needy. To examine the extent of change in the BASIS attachment and sociability scales, we computed the average scores for items on each factor at admission (pre-test) and discharge (post-test), and we found significant improvement in both at discharge. The means at admission and discharge for the attachment factor were 1.67 at admission and 0.95 at discharge (F = 264.9; df = 1, 1178; p b .001), and those for the sociability factor were 1.41 and 1.03, respectively (F = 113.6; df = 1, 1178; p b .001). Notably, although treatment was associated with improvement, the absolute scores on the BASIS interpersonal scales were relatively low (i.e., in the healthy range) throughout: the average scores for feeling close and having someone to turn to (attachment) and getting along (sociability) fell between “half of the time” and “most of the time” at admission; the average was “most of the time” at discharge. The effect size of the improvement in attachment security was .67, compared to an effect size of .41 for sociability, a difference that was statistically significant (t = 4.6, p = .0001).
4. Discussion We designed this study anticipating that we would replicate the factor analytic studies results of prior, mixed inpatient and outpatient sample studies of the BASIS-24. While generally replicating prior research, our sample yielded a bifurcation of the previous interpersonal relationships factor into two scales, one we interpreted as assessing sociability and the other assessing attachment aspects of relationships. Our finding that the interpersonal factor of the BASIS subsumes two distinct facets is consistent with attachment theory [20], which focuses relatively narrowly on the potential emotion-regulating aspects of relationships in providing a feeling of security in the face of danger and threat [21,22]. Hence secure attachment relationships entail a high degree of emotional closeness and confidence in being able to depend on the availability and responsiveness of the attachment figure in times of distress [23]. The two items we found to load together “Feel close to another person” and “Have someone to turn to” are consistent with the attachment aspect of relationships and, more specifically, assess globally the level of security in attachment relationships. Yet attachment is merely one among several facets of interpersonal relationships. Attachment is intertwined with caregiving, and the safe haven of attachment (i.e., affording comfort and security at times of threat or distress) also provides a secure base for exploration (e.g., as the toddler plays confidently as long as the caregiver is accessible).
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Exploration includes sociability, that is, exploration of interpersonal relationships. Underscoring the distinctness of these two aspects of relationships, the activation of attachment needs deactivates sociability in favor of seeking security [20]. We construe the three items referring to getting along with others (i.e., inside and outside the family and in social situations) as relating more to sociability than attachment. Admittedly, emotional closeness and being able to turn to another person do not necessarily entail attachment; for example, one could feel close without depending on another, and one could turn to another person for practical help rather than emotional help. Yet our finding that this factor relates more strongly than the sociability factor to a measure of attachment is consistent with our view of these items. Our findings relating the BASIS interpersonal scores to the IIP, which measures interpersonal disturbance, also merit comment. It is not surprising that lower levels of sociability (i.e., getting along) and attachment insecurity relate to more disturbed interpersonal functioning, as evidenced in the total IIP scores. Notably, there is a modest but statistically significant difference indicating that attachment insecurity is more highly related than lowered sociability to disturbed interpersonal functioning. This finding is consistent with an extensive literature relating different forms and degrees of attachment insecurity to problematic interpersonal functioning, from childhood [24] to adulthood [25]. Notably, the direction of this difference is the same for three of the IIP scales: cold–distant, nonassertive, and overly accommodating. Plainly, the avoidance of closeness (cold–distant) is a distinct form of attachment insecurity; yet the passivity associated with the nonassertive and overly compliant scales also can be understood as compromising attachment security insofar as it blocks the active and effective expression of attachment needs. On the other hand, impaired sociability relates more strongly than attachment insecurity to the domineering–controlling and intrusive–needy IIP scales, although the absolute magnitude of these correlations is low. Both of these intrusive behavior patterns are likely to generate conflict in relationships (i.e., to interfere with “getting along”). Apart from the main finding of interest in the interpersonal domain, the minor differences in factor structures between the present sample and Eisen and colleagues’ [6] sample bear comment. The current sample’s loading of the item, “thoughts racing through your head,” on the depression factor might reflect depressive rumination in this inpatient population characterized by severe depression. In Eisen and colleagues’ sample, this item loads on the emotional lability factor, which might reflect mania. In addition, in the current sample, the item, “think people are against you,” not only loads on the psychosis factor (as it does in Eisen’s sample) but also crossloads on the emotional lability factor, a finding that might reflect interpersonal conflict that is often associated with intense emotional lability in our patient population. It is not surprising that the intensive inpatient treatment setting in which this research was conducted is associated
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with improved interpersonal functioning in both interpersonal domains measured by the BASIS, sociability and attachment. The treatment provided has a strong psychotherapeutic focus with a great deal of emphasis on group treatments (i.e., group psychotherapy, psychoeducational groups, skills groups, leisure groups, along with groupfocused approaches to substance abuse). All these treatments are conducted in the context of a therapeutic milieu. Hence the treatment as a whole is directed toward positive social engagement. It is notable, however, that the impact of the treatment is somewhat greater for the attachment than the sociability domain of the BASIS-24 relationship factor. This finding likely reflects the broad emphasis of the treatment on emotional confiding and making use of relationships for emotional support. In addition, active family work with romantic partners and parents is directed toward not only ameliorating conflict but also fostering greater security in seeking emotional support in key attachment relationships. The limitations of this study and the findings merit consideration. The two scales derived from the BASIS interpersonal relationships factor, sociability and attachment, consist of a small number of items (i.e., three and two, respectively). Although we found some evidence for discriminant validity with measures of attachment and disturbed interpersonal functioning, the magnitude of the differences was modest. More generally, the magnitude of many correlations between the BASIS interpersonal scales and the IIP scales was low. We included the IIP in our assessment protocol because we are addressing problematic interpersonal functioning that contributes to psychiatric disorder and need for inpatient treatment. A more direct test of the construct validity of the BASIS sociability scale would employ a more parallel measure, such as the extraversion scale of the Big Five Inventory [26]. Nonetheless, our findings demonstrate that the BASIS is sensitive to treatment change and draw attention to a substantively significant difference among items of the BASIS interpersonal relationships factor that has potential implications for the focus of intervention, namely, a focus on social engagement more generally versus a focus on attachment aspects of key relationships, with the latter having significant implications for emotion regulation—a core problem for patients with psychiatric disorders that include disturbed interpersonal functioning. Simply put, patients with this profile are likely to need treatment that addresses two domains of interpersonal functioning, as provided by the inpatient treatment in the current study. First, patients need care that facilitates social engagement, which is a primary function of a therapeutic community. Second, they need treatment interventions that foster greater reliance on key attachment relationships that provide a feeling of safety and security, the bedrock of emotion regulation. Such interventions are inherent in intensive therapeutic hospital treatment that includes not only individual and group psychotherapy but also active couples, marital, and family work. The treatment studied here—admittedly rare in
contemporary psychiatric hospital care—provides multimodal interventions conducive to addressing both domains of interpersonal functioning revealed by our factor analysis of the BASIS scale. References [1] Allen JG, Frueh BC, Ellis TE, Latini DM, Mahoney JS, Oldham JM, et al. Integrating outcomes assessment and research into clinical care in inpatient adult psychiatric treatment. Bull Menninger Clin 2009;73:259-95. [2] Fonagy P. Process and outcome in mental health care delivery: a model approach to treatment evaluation. Bull Menninger Clin 1999;63:288-304. [3] Rush AJJ, First MB, Blacker D, editors. Handbook of psychiatric measures (second edition). Washington, DC: American Psychiatric Publishing; 2008. [4] Frueh BC, Ford JD, Elhai JD, Grubaugh AL. An overview of evidencebased practice in adult mental health. In: Sturmey P, & Hersen M, editors. Handbook of evidence based practice in clinical psychology, volume II: adult disorders. New York: Wiley; 2012. p. 3-14. [5] Porter ME, Teisberg EO. Redefining health care: creating value-based competition on results. Boston, MA: Harvard Business School Press; 2006. [6] Eisen SV, Normand S-L, Belanger AJ, Spiro A, Esch D. The revised Behavior and Symptom Identification Scale (BASIS-R): reliability and validity. Med Care 2004;42:1230-41. [7] Cameron IM, Cunningham JR, Crawford JM, Eagles JM, Eisen SV, Lawton K, et al. Psychometric properties of the BASIS-24 (Behaviour and Symptom Identification Scale-Revised) mental health outcome measure. Int J Psychiatry Clin Pract 2007;11:36-43. [8] Eisen SV, Gerena M. Reliability and validity of the BASIS-24 mental health survey for whites, African–Americans, and Latinos. J Behav Health Serv Res 2006;33:304-23. [9] Eisen SV, Ranganathan G, Seal P, Spiro A. Measuring clinically meaningful change following mental health treatment. J Behav Health Serv Res 2007;34:272-89. [10] Latini DM, Allen JG, Seo M, Mahoney JS, Ellis TE, Frueh BC. Psychosocial characteristics of psychiatric inpatients at admission and discharge: the Menninger Clinic Adult Outcomes Project. Bull Menninger Clin 2009;73:296-310. [11] Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991;61:226-44. [12] Horowitz LM, Rosenberg SE, Bartholomew K. Interpersonal problems, attachment styles, and outcome in brief dynamic psychotherapy. J Consult Clin Psychol 1993;61:549-60. [13] Haggerty G, Hilsenroth MJ, Vala-Stewart R. Attachment and interpersonal distress: examining the relationship between attachment styles and interpersonal problems in a clinical population. Clin Psychol Psychother 2009;16:1-9. [14] Horowitz LM, Alden LE, Wiggins JS, Pincus AL. Inventory of Interpersonal Problems manual. San Antonio, TX: Psychological Corporation; 2000. [15] Kessler RC, Green JG, Gruber MJ, Sampson NA, Bromet E, Cuitan M, et al. Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative. Int J Methods Psychiatr Res 2010;19(S1):4-22. [16] Horowitz LM, Rosenberg SE, Baer BA, Ureno G, Villasenor VS. Inventory of Interpersonal Problems: psychometric properties and clinical applications. J Consult Clin Psychol 1988;56:885-92. [17] Goldstein LA, Gibbons MBC, Thompson SM, Scott K, Heintz L, Green P, et al. Outcome assessment via handheld computer in community mental health: consumer satisfaction and reliability. J Behav Health Serv Res 2011;38:414-23. [18] Hurley Amy E, Scandura Terri A, Schriesheim Chester A, Brannick Michael T, Seers Anson, Vandenberg Robert J, et al. Exploratory and
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[23] Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of attachment: a psychological study of the strange situation. Hillsdale, NJ: Erlbaum; 1978. [24] Sroufe LA, Egeland B, Carlson EA, Collins WA. The development of the person: the Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York: Guilford; 2005. [25] Mikulincer M, Shaver PR. Attachment in adulthood: structure, dynamics, and change. New York: Guilford; 2007. [26] John OP, Naumann LP, Soto CJ. Paradigm shift to the integrative big-five trait taxonomy, history, measurement, and conceptual issues. In: John OP, Robins RW, & Pervin LA, editors. Handbook of personality: theory and research 2008. New York, NY: Guilford Press; 2008. p. 114-58.