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. 2014 Dec 19;25(2):142–149. doi: 10.1017/S2045796014000730

Measuring attachment and parental bonding in psychosis and its clinical implications

S Mathews 1,2,†, J Onwumere 1,2,†, S Bissoli 3,†, M Ruggeri 3, E Kuipers 1, L Valmaggia 1,2,*
PMCID: PMC6998630  PMID: 25523269

Abstract

Background.

Attachment theory proposes that psychological functioning and affect regulations are influenced by the attachment we form with others. Early relationships with parents or caregivers lay the foundations for attachment styles. These styles are proposed to influence how we relate to others during our life can be modified by the relationships and events we experience in our lifespan. A secure attachment style is associated with a capacity to manage distress, comfort with autonomy and the ability to form relationships with others, whereas insecure attachment can lead to dysfunctional relationships, emotional and behaviour avoidance. Attachment theory provides a useful framework to inform our understanding of relationship difficulties in people with psychosis. This paper aims to complement recent systematic reviews by providing an overview of attachment theory, its application to psychosis, including an understanding of measurement issues and the clinical implications offered.

Method.

A narrative review was completed of the measures of attachment and parental bonding in psychosis. Its clinical implications are also discussed. The paper also explores the link between insecure attachment styles and illness course, social functioning and symptomatology. The following questions are addressed: What are the key attachment measures that have been used within the attachment and psychosis literature? What are the results of studies that have measured attachment or parental bonding in psychosis and what clinical implications can we derive from it? What are some of the key questions for future research from these findings in relation to the onset of psychosis research field?

Results.

The most commonly used measures of attachment in psychosis research are reviewed. Self-report questionnaires and semi-structured interviews have mainly been used to examine attachment styles in adult samples and in recent years comprise a measure specifically developed for a psychosis group. The review suggests that insecure attachment styles are common in psychosis samples. Key relationships were observed between insecure, avoidant and anxious attachment styles and psychosis development, expression and long-term outcome.

Conclusions.

Attachment theory can provide a useful framework to facilitate our understanding of interpersonal difficulties in psychosis that may predate its onset and impact on observed variability in outcomes, including treatment engagement. Greater attention should be given to the assessment of attachment needs and to the development of interventions that seek to compensate for these difficulties. However, further investigations are required on specifying the exact mechanisms by which specific attachment styles impact on the development of psychosis and its course.

Key words: Attachment style, attachment theory, parental bonding, psychosis, schizophrenia and onset of psychosis

Introduction

Attachment theory, as espoused by Bowlby (1969; 1973) is a lifespan developmental model of psychological functioning and affect regulation that emerges from the universal need to form affectional bonds within close relationships, initially with primary caregivers. During infancy, if the caregiver is perceived as available, responsive and sensitive to an individual's proximity seeking attempts, the individual will develop a secure attachment style that is associated with a capacity to manage distress, comfort with autonomy and the ability to form relationships with others (Shaver & Mikulincer, 2002; Mikulincer & Shaver, 2007). Conversely, if the caregiver is perceived as unavailable, unresponsive and insensitive to proximity-seeking attempts, an individual will either make use of hyperactivating strategies (e.g., eliciting care from an attachment partner through clinging and controlling responses) which can lead to the development of an insecure–ambivalent attachment style or deactivating strategies (e.g., distancing oneself from an attachment partner to handle a stressful situation alone) that can lead to the development of an insecure–avoidant attachment style (Shaver & Mikulincer, 2002; Mikulincer & Shaver, 2007). A fourth disorganised attachment style is said to reflect individuals who make use of both hyperactivating and deactivating strategies which is thought to represent fearful interactions with caregivers (Main & Solomon, 1986; 1990).

These early experiences lay the foundations for an individual's internal mental representations or ‘working models’ of the self and others (Mikulincer, 1998) and go on to organise cognition, affect and behaviour in adult relationships (Waters & Cummings, 2000). Research to date has broadly characterised patterns of attachment as either secure or insecure (Ainsworth et al. 1978; Crowell & Treboux, 1995; Brennan et al. 1998) and, although open to revision following significant changes in caregiver interactions (Bowlby, 1969; 1973) or adverse life events (Waters and Cummings, 2000), attachment patterns are considered to be relatively stable across time within the general population (Waters & Cummings, 2000). Although secure and insecure attachment strategies are functional in their developmental context (Fraley, 2002), difficulties in caregiver bonding and attachment-related adverse childhood experiences (e.g., trauma or loss) have been linked to increased risk of later psychopathology in clinical groups (Greenberg, 1999; Morgan & Fisher, 2007; Read et al. 2009; Read & Gumley, 2010). Given these findings, there has been growing interest in exploring what influence attachment theory may play in furthering our understanding of the development of psychosis.

Two recent comprehensive systematic reviews of the attachment and psychosis literature (Gumley et al. 2014; Korver-Nieberg et al. 2014) have pointed towards the importance of understanding the influence that attachment styles may play in the aetiology, trajectory and recovery of psychosis. These authors concluded that there was evidence supporting the construct validity of attachment measurements in people with psychosis. They found small to moderate associations between attachment styles and outcomes, including positive and negative symptoms, depression and quality of life; and suggested that an insecure–avoidant attachment style may be a risk factor for problematic recovery following psychosis. Furthermore, they found that both insecure–anxious and insecure–avoidant attachment styles are associated with psychotic phenomenology and with an indication that insecurely attached individuals are more vulnerable to developing maladaptive coping strategies in relation to their recovery from psychosis (Gumley et al. 2014; Korver-Nieberg et al. 2014).

The aim of the present paper is to complement these two recent systematic reviews by exploring some of the key findings from the accumulating literature on attachment and psychosis and their relevance to further understanding the critical period of the development of psychosis. More specifically the following questions will be considered:

  • •

    What are the key attachment measures that have been used within the attachment and psychosis literature?

  • •

    What are the results of studies that have measured attachment or parental bonding in psychosis and what clinical implications can we derive from it?

  • •

    What are some of the key questions for future research from these findings in relation to the onset of psychosis research field?

What are the key attachment measures that have been used within the attachment and psychosis literature?

The adult attachment literature has focused on research using semi-structured interviews and self-report measures. The ability of these measures to accurately capture an individual's working model of attachment has raised debate within the literature as to whether they reflect interpersonal dispositions or account more for ways individuals act in close relationships (Pietromonaco & Barrett, 2000). More recent reviews of attachment measures (e.g., Fraley & Spieker, 2003; Main et al. 2005) have favoured dimensional approaches to delineating attachment styles and have cautioned that researchers need to consider the assumptions that a specific attachment measure makes in relation to attachment theory, and consider which relationships are under investigation before adopting a particular attachment measure as they may be targeting different constructs (Crowell & Hauser, 2008; Crowell et al. 1999; 2008).

The most commonly used measures of attachment in psychosis research are reviewed briefly below.

The original Hazan & Shaver (1987) self-report measure of attachment has been used extensively in attachment research. The questionnaire consists of three sets of statements, which delineate the attachment styles of security, insecure–avoidant and insecure–ambivalent. Despite its wide use, the authors have since recommended using more sophisticated measures, which have been developed more recently (http://internal.psychology.illinois.edu/~rcfraley/measures/measures.html).

One such measure is the Attachment Style Questionnaire (ASQ, Feeney et al. 1994). The ASQ is a 40-item self-report questionnaire that assesses the individual's internal working model of peer relationships. Participants rate their agreement with the statements on a 6-point Likert-type scale ranging from ‘Strongly Disagree’ to ‘Strongly Agree’. The ASQ has adequate reliability and good convergent validity with other attachment measures, family functioning measures and personality measures.

The most frequently used assessment measure of attachment is the Adult Attachment Interview (AAI, Main & Goldwyn, 1984), The AAI is a semi structured interview instrument that classifies adults into secure–autonomous, insecure–dismissing, insecure–preoccupied and unresolved attachment styles whereby the ‘coherence’ of their narrated description of their early attachment relationships are measured. Although the AAI is considered the ‘gold-standard’ measure of attachment it has been noted that when administered to individual's with psychosis, the results can be confounded by the presence of psychotic experiences (Dozier et al. 1999).

In recent years, a specific instrument called the Psychosis Attachment Measure (PAM) has been develop to assess attachment in psychosis (Berry et al. 2006; 2007a, b #50). The PAM is a 16-item self-reported attachment measure where items refer to thoughts, feelings and behaviours in close interpersonal relationships, but do not refer specifically to romantic relationships. Eight of the items assess the construct of avoidance (e.g., ‘I prefer not to let other people know my ‘true’ thoughts and feelings') and eight items assess the construct of anxiety (e.g., ‘I tend to get upset, anxious or angry if other people are not there when I need them’).

The Parental Bonding Instrument (PBI, Parker et al. 1979), which assesses perceived levels of parental care and overprotection, has also been widely used within the literature to review the influence of primary caregiver style and its association with the development of psychosis. As such it was also included within the current review. The PBI is a 25-item measure that measures an adult's retrospective account of the parenting they received up to the age of 16 years. Two scales termed ‘care’ and ‘overprotection’ (or ‘control’) measure core parental styles as perceived by the child in respect to care received from the mother and father, respectively. Parker et al. identified four quadrants with different attachment styles and demonstrated that the ‘affectionless control’ style (characterised by low care and high protection) was overexpressed in psychotic participants.

What are the results of studies that have measured attachment or parental bonding in psychosis and what clinical implications can we derive from it?

The details of the papers reviewed in this paper can be found in table 1.

Table 1.

Reviewed studies (grouped by assessment instrument and listed in chronological order)

Authors Participants Main results
Hazan & Shaver self-report measure of attachment
Ponizovsky et al. (2007) Thirty patients with schizophrenia and 30 age match controls Lower levels of secure attachment in patient group compared with controls. Patient groups reported greater levels of avoidant attachment styles
Avoidant attachment was positively linked to positive and negative symptomatology compared anxious/ambivalent symptomatology that was linked to positive symptomatology only. A younger age of onset and longer inpatient admissions were linked to insecure attachment styles
Attachment Style Questionnaire (ASQ)
Couture et al. (2007) Ninety-six patients with a first episode of psychosis and 66 healthy controls Patients reported greater attachment difficulties in peer relationships. They reported higher levels of pre-occupation (attachment anxiety), discomfort with closeness and a greater need for approval in peer relations compared with controls. Social functioning was related both to attachment and personality styles
Parental Bonding Questionnaire (PBI)
Parker et al. (1982) Case–control study of 72 patients with a clinical diagnosis of schizophrenia and 72 controls recruited from GP waiting rooms Compared with the control groups, the patient group rated their parents as less caring. Fathers were also reported to be more overprotective. Furthermore, patients who perceived both parents as been less caring were more likely to be readmitted to hospital at 9 months follow-up
Warner & Atkinson (1988) Sixty-two patients with schizophrenia Patients who reported positive perceptions of their parents recorded fewer relapses when they maintained frequent contact but a poorer illness outcome if contact was less frequent. The converse was true for service users reporting negative perceptions of their careers
Helgeland & Torgersen (1997) A mixed patient group comprising 19 patients with schizophrenia and
14 patients with borderline personality disorder and 15 non-clinical controls		 Compared with clinical controls, patient groups reported their parents as being less caring and more overprotective. No differences were
observed between the two clinical groups
Willinger et al. (2002) Thirty-six patients with schizophrenia or schizoaffective diagnosis and their siblings Mothers were described as less caring and over protective by patient group in comparison with reports from siblings
Onstad et al. (1994) Twelve monozygotic and 19 same dizygotic twin pairs discordant for schizophrenia Higher levels of parental over protection were reported by the patient groups compared with the non-clinical siblings
Adult Attachment Interview (AAI)
Dozier & Lee (1995) Seventy-six patients with severe psychopathology who experienced psychotic symptoms of delusions, hallucinations and suspiciousness Patients with dismissing attachment styles experienced more delusions, hallucinations and suspiciousness and were rated by case workers as ‘more psychotic’
MacBeth et al. (2011) Thirty-four Patients with first-episode psychosis Mixed insecure/dismissive attachments were predominant in the sample but no relationship observed between attachment styles and psychosis symptoms
Psychosis attachment measure
Berry et al. (2007a, b) Fifty-eight patients with psychosis Patients reported lower levels of attachment anxiety and higher levels of attachment avoidance towards key staff members when compared with parental relationships
Berry et al. (2008) Ninety-six patients with schizophrenia spectrum diagnosis Avoidant attachment style was linked to positive psychosis symptoms, paranoia and negative symptoms
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Early onset and longer admissions

Ponizovsky et al. set out to test whether insecure attachment styles were associated with diagnosis and illness course in a sample of male inpatients with a diagnosis of schizophrenia. They used the Hazan & Shaver self-report measure of attachment. Their findings suggested that patients with insecure attachment styles when compared with patients with secure attachments had a significantly earlier age of psychosis onset and longer admissions (Ponizovsky et al. 2007).

A sample of 72 patients with schizophrenia admitted consecutively across four psychiatric units was compared with a sample of controls recruited from General Practitioners using the PBI. Patients' representations of parenting styles impacted on illness onset and course. The results suggested that patients with psychosis were more likely to rate both parents as being less caring and fathers as being more overprotective. Furthermore, patients who rated both parents as being low caring and overprotective also tended to have an earlier age of initial hospitalisation for psychosis and at nine months following discharge, were also more likely to be readmitted (Parker et al. 1982). These findings were also replicated in study, which assessed 62 patients with a diagnosis of schizophrenia using the PBI. The results indicated that the patients who perceived their parents positively tended to experience fewer relapses (Warner & Atkinson, 1988).

Social functioning

The Attachment Style Questionnaire has been used to explore the role of attachment styles, personality characteristics and the implications for social functioning in 96 first episode psychosis service users and controls. Those in the clinical sample were more likely to report greater difficulties in their peer attachments when compared with their matched controls. Results also indicated that first episode psychosis service users reported higher levels of attachment anxiety, discomfort with closeness and a greater need for approval in peer relations compared with controls. Attachment and personality styles both played a role in social functioning (Couture et al. 2007).

Psychotic symptoms

Dozier and Lee interviewed 76 patients with psychosis using the AAI. Patients who were more reliant on hyperactivating strategies reported more psychotic symptoms than those using deactivating strategies. However, they found that patients with dismissing attachment styles, who made use of deactivating strategies, experienced more delusions, hallucinations and suspiciousness, and were rated by case workers as presenting as ‘more psychotic’ (Dozier & Lee, 1995).

MacBeth et al. (2011) also used the AAI to interview 34 patients with first-episode psychosis. They found that insecure/dismissive attachments were predominant in the sample but no relationship was observed between attachment styles and symptoms of psychosis.

Relationships with others

Researchers using the PAM studied a sample of 58 patients with psychosis on attachment dimensions of avoidance and anxiety in relation to psychiatric staff and parents. Scores on the two attachments dimensions varied depending on the type of relationship and the authors concluded that factors that influence variability in attachment relationships should be considered in treatment plans as it may be possible to support individuals with insecure attachment styles to develop more positive relationships with others (Berry et al. 2007b). In a second study, Berry et al. (2008) used a prospective design to assess attachment in 96 patients with psychosis. They found that higher levels of attachment anxiety and attachment avoidance predicted both symptom severity and difficulties in therapeutic relationships (Berry et al. 2006).

A study of parental bonding assessed a sample of 19 patients with schizophrenia, 14 with borderline disorders and 15 control participants with the PBI and similarly observed that patients with schizophrenia spectrum disorders reported less parental care and more overprotection (defined as low care and high control) than their non-clinical counterparts although the difference proved non-significant (Helgeland & Torgersen, 1997).

In a sample of 36 patients with schizophrenia or schizoaffective disorders compared with their siblings, Willinger et al. (2002) found that patients had a greater tendency to describe their mothers as being less caring and more overprotective towards them compared with descriptions from their healthy siblings. The perceptions of higher maternal overprotection remained a key factor even after controlling for the influence of premorbid personality.

Interestingly, a study examining 12 monozygotic and 19 same-sex zygotic twin pairs discordant for DSM-III-R schizophrenia found that patients reported higher levels of parental overprotection than their probands, raising the question of whether the differences in parental bonding could be explained by the presence of a psychotic disorder (Onstad et al. 1994).

Clinical implications

In combination, these studies indicate a relationship between childhood attachment, patient reflections on parenting style and psychosis. Significant relationships were found between recollections of early attachment relationships and attachment style (Berry et al. 2007b). Individuals rated as having insecure attachment styles in adulthood were also more likely to describe early caregiving relationships as being characterised by rejecting or inconsistent parenting (Fonagy et al. 1994). In line with Bowlby's attachment theory (Bowlby, 1969; 1973), it seems that recollections of adverse early experiences with primary caregivers are likely to limit the capacity to form secure attachments in adulthood as these studies suggest that individuals who perceived their caregivers as insensitive or indifferent to their distress were more likely to experience difficulties in relating to others.

Within the field of psychosis an individual's attachment style has been suggested as a clinically relevant construct in relation to the development, course and treatment of psychosis. More specifically it has been suggested that the attachment experience of individuals with psychosis is an important construct for understanding how social information is processed and how mentalisation skills are developed within this population (Korver-Nieberg et al. 2014). Gumley's systematic review of attachment and psychosis found that individuals with psychosis who had a secure attachment had better engagement and greater treatment adherence, whereas insecure attachment was found to be related to disengagement with treatment services and avoidant attachment was related to help-seeking difficulties, poorer use of treatment, longer hospital admissions and lower-rated therapeutic alliance. Their findings also suggested that the attachment system is activated in the relationships that individuals develop with their service providers and as such, highlight attachment theory as a useful framework in which to consider recovery within individuals with psychosis. These authors further note the importance of services being aware of how these systems may be activated within individuals as a means to provide ‘an attuned response to the needs of individuals’ and establish ‘a safe haven and secure base for recovery’ (Gumley et al. 2014).

What are some of the key questions for future research from these findings in relation to the onset of psychosis research field?

Attachment studies in psychosis have mainly focused on multiple episode samples where the results have invariably been confounded by the presence of secondary disabilities impacting upon quality of social relationships. The extent to which insecure/avoidant representations predominate in first episode samples requires further study. Establishing the distribution of secure and insecure attachment representations in first onset psychosis groups, and implicit within this the cognitive–affective–interpersonal model that each attachment classification represents, could provide a basis for tailoring treatment models towards the specific needs of the individual. Future research in attachment in psychosis should also consider that various attachment styles are assessed by different instruments. Instruments such as the Hazan and Shaver measure were developed within the social psychology research tradition, others came from a developmental psychology tradition (e.g., AAI; Roisman et al. 2007; Crowell et al. 2008). To date only the PAM was developed specifically to measure attachment styles in individuals with psychosis (Berry et al. 2008). Finally, future research should evaluate the strength and weaknesses of self-report measures versus semi-structured interview measures of attachment in psychosis research.

Limitations

The studies reviewed in this paper suggest that insecure attachment representations are evident at different illness phases including during the at-risk mental state (Couture et al. 2007; Gajwani et al. 2013). They are linked to a poorer quality of interpersonal relationships and less integrated recovery styles (Berry et al. 2007b; Gumley et al. 2014). Thus, insecure attachment styles may serve as a vulnerability factor for both the development and persistence of psychosis. Recent data from at-risk psychosis populations (e.g., O'Brien et al. 2006; Tienari et al. 2004; McFarlane & Cook, 2007) attests to the important role played by family relationships in the expression and course of psychosis symptomatology. However, as most attachment studies are cross-sectional, it is equally possible that having a more severe course of illness can render individuals more likely to develop and/or recall difficulties in attachment relationships.

Concluding remarks

In conclusion, reports of caregiver attachment difficulties may play an important role in the development of psychosis. The narrative review speaks to the importance of greater attention being given to the assessment and understanding of attachment needs and difficulties that are experienced and reported during the early years, and it emphasises the need to develop interventions that seek to compensate for these difficulties. Secure attachment may confer advantages in facilitating how individuals make sense of their experiences and their readiness to engage with therapeutic interventions and seek help. In contrast, individuals presenting with insecure attachment representations may find the reciprocal process of engagement with clinicians threatening or overwhelming, and consequently may disengage from services to regulate affect. An understanding of attachment representations may therefore be relevant to understanding differences in recovery trajectories in the first few years after treatment for psychosis is initiated, particularly in understanding the role help seeking may play in accelerating or forestalling relapse (Gumley et al. 2010; Onwumere et al. 2011).

Acknowledgements

We acknowledge the Fondazione CariVerona for their support (please see also below Financial Support).

Financial support

This study was supported by the Fondazione CariVerona, who provided a 3-year grant to the WHO Collaborating Centre for Research and Training in Mental Health and Service Organization at the University of Verona, directed by Professor Michele Tansella. The grant ‘Promoting research to improve quality of care. The Verona WHO Centre for mental health research’, supports the main research projects of the following Units of the Verona WHO Centre: Psychiatric Case Register, Geographical Epidemiology & Mental Health Economics (Head: Professor Francesco Amaddeo); Clinical Psychopharmacology & Drug Epidemiology (Head: Professor Corrado Barbui); Environmental, Clinical and Genetic Determinants of Outcome of Mental Disorders (Head: Professor Mirella Ruggeri).

Conflict of Interest

None.

References

  1. Ainsworth MS, Blehar MC, Waters E, Wall S (1978). Patterns of Attachment: A Psychological Study of the Strange Situation. Erlbaum: Hillsdale, NJ. [Google Scholar]
  2. Berry K, Wearden A, Barrowclough C, Liversidge T (2006). Attachment styles, interpersonal relationships and psychotic phenomena in a non-clinical student sample. Personality and Individual Differences 41, 707–718. [Google Scholar]
  3. Berry K, Band R, Corcoran R, Barrowclough C, Wearden A (2007a). Attachment styles, earlier interpersonal relationships and schizotypy in a non-clinical sample. Psychology and Psychotherapy Practice 80, 963–976. [DOI] [PubMed] [Google Scholar]
  4. Berry K, Wearden A, Barrowclough C (2007b). Adult attachment styles and psychosis: an investigation of associations between general attachment styles and attachment relationships with specific others. Social Psychiatry and Psychiatric Epidemiology 42, 972–976. [DOI] [PubMed] [Google Scholar]
  5. Berry K, Barrowclough C, Wearden A (2008). Attachment theory: a framework for understanding symptoms and interpersonal relationships in psychosis. Behaviour Research and Therapy 46, 1275–1282. [DOI] [PubMed] [Google Scholar]
  6. Bowlby J (1969). Attachment and Loss, Vol. 1: Attachment. Basic books: New York. [Google Scholar]
  7. Bowlby J (1973). Attachment and Loss, Vol. 2: Separation. Basic books: New York. [Google Scholar]
  8. Brennan KA, Clark CL, Shaver PR (1998). Self-report measurement of adult romantic attachment: an integrative overview In Attachment Theory and Close Relationships (ed. Simpson JA and Rholes WS). Guilford Press: New York. [Google Scholar]
  9. Couture S, Lecomte T, Leclerc C (2007). Personality characteristics and attachment in first episode psychosis: impact on social functioning. Journal of Nervous and Mental Disease 195, 631–939. [DOI] [PubMed] [Google Scholar]
  10. Crowell JA, Hauser ST (2008). AAIs in a high-risk sample: stability and relation to functioning from adolescence to 39 years In Clinical Applications of the Adult Attachment Interview (ed. Steele H and Steele M). Guilford Press: New York. [Google Scholar]
  11. Crowell JA, Treboux D (1995). A review of adult attachment measures: implications for theory and research. Social Development 4, 294–327. [Google Scholar]
  12. Crowell JA, Treboux D, Waters E (1999). The adult attachment interview and the relationship questionnaire: relations to reports of mothers and partners. Personal Relationships 6, 1–18. [Google Scholar]
  13. Crowell JA, Fraley RC, Shaver PR (2008). Measures of individual differences in adolescent and adult attachment In Handbook of Attachment: Theory, Research and Clinical Applications, 2nd edn. (ed. Cassidy J and Shaver PR). Guilford Press: New York. [Google Scholar]
  14. Dozier M, Lee SW (1995). Discrepancies between self- and other-report of psychiatric symptomatology: effects of dismissing attachment strategies. Win, 1995. Development and Psychopathology 7, 217–226. [Google Scholar]
  15. Dozier M, Stovall KC, Albus KE (1999). Attachment and psychopathology in adulthood In Handbook of Attachment: Theory, Research, and Clinical Applications (ed. Cassidy J. and Shaver PR). Guilford Press: New York. [Google Scholar]
  16. Feeney JA, Noller P, Hanrahan M (1994). Assessing adult attachment In Attachment in Adults: Clinical and Developmental Perspectives (ed. Sperling MB and Berman WH). Guilford Press: New York. [Google Scholar]
  17. Fonagy P, Steele M, Steele H, Higgitt A, Target M (1994). The Emanuel Miller Memorial Lecture 1992: the theory and practice of resilience. Child Psychology & Psychiatry & Allied Disciplines 35, 231–257. [DOI] [PubMed] [Google Scholar]
  18. Fraley RC (2002). Attachment stability from infancy to adulthood: meta-analysis and dynamic modeling of developmental mechanisms. Personality and Social Psychology Review 6, 123–151. [Google Scholar]
  19. Fraley RC, Spieker SJ (2003). What are the differences between dimensional and categorical models of individual differences in attachment? Developmental Psychology 39, 423–429. [Google Scholar]
  20. Gajwani R, Patterson P, Birchwood M (2013) ‘Attachment: developmental pathways to affective dysregulation in young people at ultra-high risk of developing psychosis’. British Journal of Clinical Psychology, 52, 424–437. [DOI] [PubMed] [Google Scholar]
  21. Greenberg MT (1999). Attachment and psychopathology in childhood In Handbook of Attachment: Theory, Research, and Clinical Applications (ed. Cassidy J and Shaver PR) New York, NY, US: Guilford Press. [Google Scholar]
  22. Gumley A, Braehler C, Laithwite H (2010). A compassion focused model of recovery after psychosis. International Journal of Cognitive Psychotherapy 3, 186–201. [Google Scholar]
  23. Gumley AI, Taylor HE, Schwannauer M, Macbeth A (2014). A systematic review of attachment and psychosis: measurement, construct validity and outcomes. Acta Psychiatrica Scandinavica 129, 257–374. [DOI] [PubMed] [Google Scholar]
  24. Hazan C, Shaver P (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology 52, 511–524. [DOI] [PubMed] [Google Scholar]
  25. Helgeland MIW, Torgersen S (1997). Maternal representations of patients with schizophrenia as measured by the Parental Bonding Instrument. Scandinavian Journal of Psychology 38, 39–43. [DOI] [PubMed] [Google Scholar]
  26. Korver-Nieberg N, Berry K, Meijer CJ, Haan LD (2014). Adult attachment and psychotic phenomenology in clinical and non-clinical samples: a systematic review. Psychology and Psychotherapy 87, 127–154. [DOI] [PubMed] [Google Scholar]
  27. MacBeth A, Gumley A, Schwannauer M, Fisher R (2011). Attachment states of mind, mentalization, and their correlates in a first-episode psychosis sample. Psychiatry and Psychotherapy 84, 42–57. (Discussion 98–110). [DOI] [PubMed] [Google Scholar]
  28. Main M, Goldwyn R (1984). Adult Attachment Scoring and Classification System. University of California: Los Angeles. [Google Scholar]
  29. Main M, Solomon J (1986). Discovery of an insecure-disoriented attachment pattern In Affective Development in Infancy (ed. Brazelton TB and Yogman MW). Ablex: Norwood, NJ. [Google Scholar]
  30. Main M, Solomon J (1990). Procedures for identifying disorganised/disoriented infants in the AInsworth Strange Situation In Attachment in Preschool Years: Theory, Research and Interventions (ed. Greenberg MT, Cicchetti D and Cummings EM). University of Chicago Press: Chicago. [Google Scholar]
  31. Main M, Hesse E, Kaplan N (2005). Predictability of attachment behavior and representational processes at 1, 6, and 19 years of age: the Berkeley Longitudinal Study In Attachment from Infancy to Adulthood: The major Longitudinal Studies (eds. Grossmann KE, Grossmann K and Waters E). Guilford: New York. [Google Scholar]
  32. McFarlane WR, Cook WL (2007). Family expressed emotion prior to onset of psychosis. Family Process 46, 185–197. [DOI] [PubMed] [Google Scholar]
  33. Mikulincer M (1998). Adult attachment style and individual differences in functional versus dysfunctional experiences of anger. Journal of Personality and Social Psychology 74, 513–524. [DOI] [PubMed] [Google Scholar]
  34. Mikulincer M, Shaver PR (2007). Attachment, group-related processes, and psychotherapy. International Journal of Group Psychotherapy 57, 233–245. [DOI] [PubMed] [Google Scholar]
  35. Morgan C, Fisher H (2007). Environmental factors in schizophrenia: childhood trauma – a critical review. Schizophrenia Bulletin 33, 3–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. O'Brien MP, Gordon JL, Bearden CE, Lopez SR, Kopelowicz A, Cannon TD (2006). Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis. Schizophrenia Research 81, 269–275. [DOI] [PubMed] [Google Scholar]
  37. Onstad S, Skre I, Torgersen S, Kringlen E (1994). Family interaction: parental representation in schizophrenic patients. Acta Psychiatrica Scandinavica, Supplementum 384, 67–70. [DOI] [PubMed] [Google Scholar]
  38. Onwumere J, Bebbington P, Kuipers E (2011). Family interventions in early psychosis: specificity and effectiveness. Epidemiology and Psychiatric Sciences 20, 113–119. [DOI] [PubMed] [Google Scholar]
  39. Parker G, Tupling H, Brown LB (1979). A parental bonding instrument. British Journal of Medical Psychology 52, 1–10. [Google Scholar]
  40. Parker G, Fairley M, Greenwood J, Jurd S, Silove D (1982). Parental representations of schizophrenics and their association with onset and course of schizophrenia. British Journal of Psychiatry 141, 573–581. [DOI] [PubMed] [Google Scholar]
  41. Pietromonaco PR, Barrett LF (2000). Attachment theory as an organizing framework: a view from different levels of analysis. Review of General Psychology 4, 107–110. [Google Scholar]
  42. Ponizovsky AM, Nechamkin Y, Rosca P. (2007) Attachment styles are associated with symptomatology and course of schizophrenia in male inpatients. American Journal of Orthopsychiatry, 77, 324–331. [DOI] [PubMed] [Google Scholar]
  43. Read J, Gumley A (2010). Can attachment theory help explain the relationship between childhood adversity and psychosis? In Telling Stories? Attachment-Based Approaches to the Treatment of Psychosis (ed. Benamer S). Karnac Books: London. [Google Scholar]
  44. Read J, Bentall RP, Fosse R (2009). Time to abandon the bio-bio-bio model of psychosis: exploring the epigenetic and psychological mechanisms by which adverse life events lead to psychotic symptoms. Epidemiology and Psychiatric Sciences 18, 299–310. [PubMed] [Google Scholar]
  45. Roisman GI, Holland A, Fortuna K, Fraley C, Clausell E, Clarke A (2007). The Adult Attachment Interview and self-reports of attachment style: an empirical reapproachement. Journal of Personality and Social Psychology 92, 678–697. [DOI] [PubMed] [Google Scholar]
  46. Shaver PR, Mikulincer M (2002). Dialogue on adult attachment: diversity and integration. Attachment and Human Development 4, 243–257. [DOI] [PubMed] [Google Scholar]
  47. Tienari P, Wynne LC, Sorri A, Lahti I, Laksy K, Moring J, Naarala M, Nieminen P, Wahlberg KE (2004). Genotype–environment interaction in schizophrenia-spectrum disorder. Long-term follow-up study of Finnish adoptees. British Journal of Psychiatry 184, 216–222. [DOI] [PubMed] [Google Scholar]
  48. Warner R, Atkinson M (1988). The relationship between schizophrenic patients' perceptions of their parents and the course of their illness. British Journal of Psychiatry 153, 344–353. [DOI] [PubMed] [Google Scholar]
  49. Waters E, Cummings EM (2000). A secure base from which to explore close relationships. Child Development 71, 164–172. [DOI] [PubMed] [Google Scholar]
  50. Willinger U, Heiden AM, Meszaros K, Formann AK, Aschauer HN (2002). Maternal bonding behaviour in schizophrenia and schizoaffective disorder, considering premorbid personality traits. Australian and New Zealand Journal of Psychiatry 36, 663–668. [DOI] [PubMed] [Google Scholar]

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