Acta Psychiatr Scand 2014: 129: 257–274 © 2013 John Wiley & Sons A/S.

John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved ACTA PSYCHIATRICA SCANDINAVICA
DOI: 10.1111/acps.12172

Review
A systematic review of attachment and
psychosis: measurement, construct validity
and outcomes
Gumley AI, Taylor HEF, Schwannauer M, MacBeth A. A systematic A. I. Gumley1,2 H. E. F. Taylor1,2,
review of attachment and psychosis: measurement, construct validity M. Schwannauer3, A. MacBeth4
and outcomes. 1
University of Glasgow, 2NHS Greater Glasgow & Clyde,
Glasgow, 3University of Edinburgh, Edinburgh, and
Objective: This review sought to identify, summarise and critically 4
University of Aberdeen, Aberdeen, UK
evaluate studies that investigated attachment amongst individuals with
psychosis.
Method: The following computerised databases searched were
CINAHL < 1980 to December 2012; EMBASE < 1980 to December
2012; Ovid MEDLINE (R) < 1980 to December 2012;
PsychINFO < 1980 to December 2012; and Google Scholar < 1980 to
December 2012.
Results: We identified 22 papers describing 21 studies comprising 1453
participants, with a mean age of 35.0 years (range of 12–71 years), of
whom 68.4% (n = 994) were male. Of our sample, 1112 (76.5%) had a
diagnosis of schizophrenia. We found small to moderate associations
between greater attachment insecurity (as reflected in anxiety and
avoidance) and poorer engagement with services, more interpersonal Key words: psychoses; schizophrenia; review of the
problems, more avoidant coping strategies, more negative appraisals of literature
parenting experiences and more severe trauma. We also found small to Andrew I. Gumley, Mental Health and Wellbeing,
modest associations between attachment insecurity and more positive Institute of Health and Wellbeing, University of
and negative symptoms and greater affective symptom problems. Glasgow, Gartnavel Royal Hospital, 1055 Great Western
Conclusion: Attachment theory may be useful as a means of Road, Glasgow G12 0XH, UK.
E-mail: andrew.gumley@glasgow.ac.uk
understanding the developmental and interpersonal basis of recovery
and adaptation in the context of psychosis. However, further research
comprising more representative samples in their first episode and using
prospective designs is required. Accepted for publication June 3, 2013

Summations
• We found evidence supporting the construct validity of attachment measurement in people with
psychosis.
• We found small to moderate associations between attachment and outcomes including positive and
negative symptoms, depression and quality of life.
• Insecure (dismissing/avoidant) attachment may be a risk factor for problematic recovery following
psychosis.

Considerations
• There were methodological problems in the included studies including small samples of convenience,
cross-sectional designs and the tendency to preferentially report significant findings.
• A range of attachment measures were utilised making comparisons across studies difficult.
• There is a need for further studies of attachment in psychosis incorporating more representative sam-
pling, arising in the first-episode and/or ‘at-risk’ populations and using prospective follow-up.

257
Gumley et al.
Introduction
There is growing evidence that stressful develop-
mental experiences and traumatic life events
including sexual abuse, being in care and homeless-
ness are linked to increased vulnerability to devel-
oping psychosis (1, 2). Indeed, early adversity may
impact on later expression of psychosis by increas-
ing stress sensitivity to later stressful life events (3,
4). Attachment theory (5) has been successful in
understanding adaptation to the long-term impact
of adverse developmental experiences (e.g. abuse)
or stressful life events (e.g. loss) (6). Security of
attachment is a significant building block to resil-
ience and is linked to successful adaptation and
recovery following life adversity (7). Strong
evidence shows that insecure and disorganised
attachments are significant risk factors for psycho-
pathology including suicidal behaviour (8, 9).
Attachment theory is a developmental model of
interpersonal and psychological functioning, per-
sonal resilience and affect regulation, derived from
an understanding of the affectionate bonds created
in the context of close relationships, initially with
primary caregivers (5). Attachment theory pro-
vides a developmental understanding of affect
regulation, emerging from the evolutionary neces-
sity for the infant to establish a safe haven (for dis-
tress) and secure base (for exploration). Securely
attached infants utilise caregivers as a base to
explore and as a source of safeness in response to
perceived threat. In adulthood, this is character-
ised by a freedom and autonomy to reflect on and
explore painful feelings and a valuing of close
interpersonal relationships. Infants who are inse-
curely attached show a different pattern of affect
regulation. Ambivalent/resistant attachment is
characterised by heightened affective expression
(including feelings of anger and anxiety) and a
reluctance to explore the world reflected in clinging
to the caregiver. In adulthood, this is reflected in
preoccupation with attachment experiences and
heightened emotional expression. Infant avoidant
attachment represents a deactivation of the attach-
ment behaviours reflecting a relative indifference to
the attachment figure. In adulthood, avoidant or
dismissive attachment is characterised by minimis-
ing and avoidance of attachment-related experi-
ences, thoughts and memories. These strategies are
functional in their developmental context and are
key in the unfolding of interpersonal functioning,
resilience and constructive adaptation to threaten-
ing life events (6, 8).
An important review (10) found an over repre-
sentation of insecure attachment amongst individ-
uals with psychosis. However, the systematic
258
review did not distinguish between inferred attach-
ment-related experiences (e.g. self-reports of paren-
tal bonding) and attachment states of mind
as reflected in individuals’ appraisals of their
close personal relationships or their narratives
during attachment-related discourse. In the five
years since this review, there has been an increasing
interest in the phenomenology of attachment
amongst people with psychosis and its relationship
to key outcomes of interest including the influence
of social, cognitive, interpersonal and affective
factors on the development and course of psychosis.
Aims of the study
Therefore, this review sought to identify, summa-
rise and critically evaluate articles that have inves-
tigated attachment amongst individuals with
psychosis.
Questions. Specifically the following questions
were asked:
i) What are the characteristics of studies, which
have investigated attachment in psychosis?
ii) What measures have been used to characterise
attachment?
iii) What is the evidence for construct validity in
the assessment of attachment in psychosis?
iv) What is the evidence for the association of
attachment with important clinical outcomes
in psychosis?
Material and methods
Inclusion and exclusion criteria
Inclusion criteria were articles that included (i) a
measure of attachment, (ii) participants who expe-
rienced psychosis, (iii) participants who were
deemed at risk of developing psychosis (iv) were
published between 1980 and January 2013 and (v)
were written in English.
Exclusion criteria were (i) non-clinical/analogue
studies, (ii) qualitative data, (iii) single case studies
or dissertations, (iv) conference extracts, (v) book
chapters, (vi) unpublished studies, (vii) those with-
out a measure of attachment and (viii) attachment
was not assessed in relation to outcomes associated
to the experience of psychosis.
Outcomes
The outcomes for schizophrenia and psychosis
were identified from the National Institute for
Health and Clinical Excellence (11) schizophrenia
 Attachment and psychosis

guideline. The outcomes chosen were relevant to

the data from the studies and include psychiatric
symptoms, relapse/hospitalisation, engagement,
social functioning, psychosocial functioning,
insight and quality of life.
Search strategy
A systematic review was conducted by searching
computerised databases for relevant articles inves-
tigating the relationship between adult attachment
style and psychosis or schizophrenia. The follow-
ing computerised databases searched were
CINAHL < 1980 to December 2012; EMBASE
< 1980 to December 2012; Ovid MEDLINE
(R) < 1980 to December 2012; PsychINFO < 1980
to December 2012; and Google Scholar < 1980 to
December 2012.
The computerised search used the subject
headings (PSYCHOSIS) or (SCHIZOPHRENIA)
or (PSYCHOTIC DISORDER) combined with
(ADULT ATTACHMENT INTERVIEW) or
(ADULTATTACHMENT)or(ATTACHMENT).
Online titles and abstracts were reviewed after
Quality criteria
All selected articles were subjected to evaluation to
assess risk of bias and quality. This was based on
the Cochrane Consumers and Communication
Review Group data extraction template (12) and
Clinical Trials Assessment Measure (13). The
extraction sheet consisted of five sections to rate
the methodological quality of the introduction,
sample, procedure, analysis and discussion. All the
articles were rated using the extraction sheet by
two independent reviewers. Any disagreements
were resolved by discussions between the two
reviewers and consultation with a third reviewer
(AG).
Data handling
For the purposes of transparency, we standardised
all effect sizes using equations provided by Rosen-
thal, Rosnow and Rubin (14). Pearson’s r was
calculated by transforming
rffiffiffiffiffiffiffiffiffiffiffiffiffiffi t scores using the fol-
qffiffiffiffiffiffiffiffiffi
lowing equation t2
; F scores using FþdfF
ðt2 þdfÞ d

duplicates were removed. Articles that did not rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi

for Fdfn = 1 or dfn F for Fdf > 1, and v2
meet the inclusion criteria were discarded, and the dfn Fþdfd n
full text was obtained from articles that were qffiffiffiffi q ffiffiffiffiffiffiffiffi
ffi
using vN for df = 1 or v2vþN for df > 1.
2 2
potentially eligible. Hand searches of journals (e.g.
British Journal of Clinical Psychology, Schizophre-
nia Bulletin, Psychology and Psychotherapy: The-
ory, Research and Practice, Clinical Psychology Results
Review) and references for eligible articles were
conducted to identify further relevant articles that Literature search
may have been missed by the electronic search The search and exclusion process is summarised in
strategy. Fig. 1 below. We identified 41 potential papers

Search terms entered into electronic databases: CINAHL, EMBASE, Ovid

MEDLINE, PsychINFO and Google (n = 37)

Manual search of the

reference lists of the
articles identified in the
electronic search (n = 8)
Consultation with
experts (n = 2)
Articles identified for Articles met the
filtering using the inclusion criteria
inclusion and exclusion and are included in
criteria (n = 47) the review (n = 19)

Excluded
based on
criteria (n = 28)

Total excluded
from the
review (n = 28)

Fig. 1. Flowchart of the article selection process.

259
Gumley et al.
and the manual search identified 9 potential
papers. Of these, 28 were excluded after two
reviewers assessed the articles following the
inclusion and exclusion criteria (H.T & A.G). Rea-
sons for exclusion were as follows: non-clinical/
analogue studies (n = 7), participants not experi-
encing psychosis (n = 6), qualitative studies
(n = 3), unpublished thesis (n = 1), no attachment
measure (n = 9) and attachment not assessed in
relation to outcomes in psychosis (n = 2). Based
on this search strategy, 22 papers met the criteria
for inclusion into the review.
Included studies
There were 21 papers describing 20 studies that
met the inclusion criteria for this review: Arbuckle,
Berry, Taylor & Kennedy (15); Berry, Barrowc-
lough & Wearden (16, 17); Berry, Wearden, Bar-
rowclough, Oakland & Bradley (18); Blackburn,
Berry & Cohen (19); Couture Lecomte & Leclerc
(20); Dozier (21); Dozier, Cue & Barnett (22); Doz-
ier & Lee (23); Dozier, Lomax, Tyrrell & Lee (24);
Dozier, Stevenson, Lee & Velligan (25); Kvrgic,
Beck, Calvelti, Kossowsky, Stieglitz & Vauth (26);
MacBeth, Gumley & Schwannaeur (27); Mulligan
& Lavender (28); Picken, Berry, Tarrier & Bar-
rowclough (29); Ponizovsky, Nechamkin & Rosca
(30); Ponizovsky, Vitenberg, Baumgarten-Katz &
Grinshpoon (31); Tait, Birchwood & Trower (32);
Tyrrell, Dozier, Teague & Fallot (33); Quijada,
Tizon, Artigue, Kwapil & Barrantes-Vidal (34);
Owens, Haddock & Berry (35) and Kvrgic, Cavelti,
Beck, Rusch & Vaulth (36). Table 1 provides a
summary of included studies.
Study/participant characteristics
There were 1453 participants in the included stud-
ies. Based on data from 19 studies, the mean age of
the participants was 35.0 years (range of 12–
71 years). No data were provided on the age of 49
participants (4%) (23). Based on the data of 19
studies, 68.4% (n = 994) participants were male
and 28.1% (n = 409) were female. No data regard-
ing gender were provided for 42 participants (3.2%)
(21). The inclusion or exclusion criteria were not
explicitly stated for eight studies (15, 19, 21–24, 29,
30, 33).
All of the studies used a convenience sample,
and a variety of recruitment sites were identified.
Three studies (9.1%; n = 132) recruited from
inpatient services (15, 19, 30), six studies (37.4%;
n = 544) from out-patient/community services
(26–28, 31, 33, 36), four studies (20.0%; n = 291)
recruited from both inpatient and community set-
260
tings (17, 18, 20, 21), one study (2.1%; n = 31)
from a specialist at-risk team (34) and one study
(35) from 24-h rehabilitation services (3.3%;
n = 48). Six studies (16, 22/23–25, 29, 32) (27.9%;
n = 406) did not report the specific recruitment site
(16, 24, 32).
The diagnosis of the participants included
schizophrenia (57.6%; n = 837), schizophrenia
spectrum diagnosis (12.0%; n = 174), schizoaffec-
tive disorder (10.7%; n = 155), bipolar affective
disorder (7.0%; n = 101), at-risk mental state
(2.1%; n = 31), psychotic episode (0.9%; n = 13),
psychosis NOS (1.0%; n = 14), persistent delu-
sional disorder (0.1%; n = 2), atypical psychosis
(0.1%; n = 2), mania and psychotic symptoms
(0.1%; n = 1), recurrent depressive disorder and
psychotic symptoms (0.1%; n = 2), major depres-
sion (1.2%; n = 17), substance misuse (0.2%;
n = 3), Asperger’s syndrome (0.1%; n = 1), panic
disorder (0.1%; n = 1), conversion disorder (0.1%;
n = 1) and symptoms commonly associated with
psychosis (n = 5.0%; n = 73). The diagnoses of
682 participants were not confirmed using a stan-
dard diagnostic classification system (46.9%) (15,
16, 19, 20, 28, 29, 35, 36).
Education level was explicitly reported in nine
studies (16, 20, 25–27, 30, 31, 33, 34). Approxi-
mately 38.4% (n = 558) of participants received or
were in secondary education. No data were pro-
vided for 55.1% (n = 801) participants’ level of edu-
cation. Employment status was explicitly reported
in five studies (26, 27, 31, 35, 36). Approximately
60.0% (n = 247) were unemployed. No data were
provided for 71.6% (n = 1041) participants’
employment status. Medication was reported in
four studies (13.8%; n = 201) (26, 27, 30, 34). There
were six studies (15–17, 29, 32, 35) (28.1%;
n = 409), which provided the consent rate. The
characteristics of the participants who chose not to
take part were not noted in any study. Only one
study (32) (3.4%; n = 50) conducted an analysis
comparing the participants and those who refused
to participate or dropped out. In addition, one
study (16) provided a flow diagram of the recruit-
ment process (6.6%; n = 96).
Measurement
Psychosis Attachment Measure. Nine studies (15–
19, 26, 29, 35, 36) used the Psychosis Attachment
Measure (PAM) (37) self-report questionnaire
(54.6%; n = 793). Three self-report versions of the
PAM were used (PAM; attachment in general rela-
tionships, attachment towards key worker, and
attachment in relation to the mental health team)
and two informant versions (PAM; key worker
 Table 1. Summary of included studies

Number of Attachment Attachment measurement

Study participants Age (years) Gender measure constructs Key outcome measures Results

Arbuckle et al. (15) 24 M 32.4 (SD = 8.7) 15 m/9 f PAM Anxiety Avoidance PSYRATS, CDSS Attachment avoidance correlated with auditory hallucinations.
Self-reported attachment avoidance of team was associated with delusions.
Association between depression and avoidance.
Berry et al. (16) 96 M 44 (SD = 12.8) 66 m/30 f PAM Anxiety, avoidance IIP-32, SBS, WAI, PANSS Interpersonal problems related to attachment. Attachment anxiety related
to attention-seeking and avoidance related to hostility.
Attachment avoidance related to therapeutic alliance problems.
Total symptoms correlated with anxiety and avoidance.
Avoidance related to positive and negative symptoms and paranoia.
Berry et al. (17) 80 M 44 (SD = 13.3) 55 m/25 f PAM Anxiety, avoidance PANSS, CDSS, PBI, THQ Associations between attachment anxiety and parental overprotection, and
attachment avoidance and parental care.
Higher attachment anxiety in childhood trauma with significant others.
Depression associated with greater attachment anxiety.
Attachment was not associated with number of hospital admissions or
length of illness.
Berry et al. (18) 73 M 39.1 (SD = 11.3) 59 m/14 f PAM Anxiety, avoidance PSYRATS, PANSS Attachment avoidance related to critical, rejecting and threatening voices.
Attachment anxiety related to voice severity and distress.
Blackburn et al. (19) 78 M 39 (SD = 13.8) 62 m/16 f PAM, SAQ Anxiety, avoidance, PSYRATS, CDSS Attachment anxiety related to treatment adherence and positive clinician input.
security Attachment avoidance related to non-supportive clinician input.
Attachment avoidance related to positive symptoms.
Depression associated with anxiety and avoidance
Couture et al. (20) 96 M 23.7  4.7 63 m/33 f ASQ Autonomous, avoidant, CASIG Attachment anxiety associated with number of traumatic events,
preoccupied, ambivalent interpersonal trauma and severity of post-traumatic symptoms.
Dozier (21) 42 M 35 (21–60) No data AAI Q-sort Security, anxiety, avoidant, Clinician ratings Associations between attachment to services and security.
preoccupied Number of hospital admissions negatively correlated with
attachment to services.
Lower attachment to services in those under section.
Security to services associated with lower depression.
Attachment to service not associated with psychiatric symptoms.
Dozier et al. (22) 76 For n = 27, 45 m/31 f AAI, Q-sort Secure, insecure, Intervention interview Deactivating clients reported greater general life satisfaction than
M 35 (23–48) hyperactivating, vvclients rated as less deactivating.
deactivating. Deactivating clients reported more life satisfaction working with
less deactivating case managers.
Less deactivating case managers formed stronger alliances with
more deactivating clients.
No significant effects between hospitalisation and attachment were evident.
No association between attachment security and depression.
Dozier and Lee (23) As above As above As above AAI Q-sort Secure, insecure, BSI, QoL Compliance was associated with attachment security.
hyperactivating, Attachment avoidance was associated with reduced likelihood to seek
deactivating. help and poor use of treatment.
Attachment preoccupation was associated with more self-disclosure.

261
Attachment and psychosis
 Table 1. (Continued)

262
Number of Attachment Attachment measurement
Study participants Age (years) Gender measure constructs Key outcome measures Results

Dozier et al. (24) 34 M 34 (21–46) 24 m/10 f AAI Q-sort Security, insecurity, Problem-solving task Those relying on preoccupied strategies were perceived as having greater
Gumley et al.

hyperactivation, dependency needs than those relying on dismissing strategies.

deactivation Case manager security also accounted for variance in perceived
dependency needs.
Gender and diagnostic category did not appear to influence attachment
or perceived dependency.
Dozier et al. (25) 40 M 34 (21–51) 27 m/13 f AAI Q-sort Security, anxiety, FMSS, BSI Insecure attachment and deactivating strategies rated as more symptomatic.
repression, Secure attachment rated as having fewer delusions and deactivating
preoccupation strategies as looser in thinking.
Secure rated as less delusional, less likely to hear voices and less suspicious.
Dismissing rated as more delusional, likely to hear voices and suspicious.
Those able to evaluate attachment and use hyperactivating strategies
rated as less psychotic.
Kvrgic et al. (26) 127 M 44 (SD = 11.5) 84 m/43 f PAM Anxiety, avoidance PANSS, CDSS, Avoidant attachment was off task significantly more than others, was
BDI-II, SES, STAR more rejecting of their significant others and was more confused
following interactions with case managers.
Their significant others also felt less supported and saddened after tasks.
MacBeth et al. (27) 34 M 23.32 (SD = 7.6) 20 m/14 f AAI Secure, insecure, RF, PAS, SES, PANSS, Insecure attachment was not associated with familial EE.
autonomous, WHOQOL-BREF Overinvolved families associated with higher levels of repression
dismissing, and preoccupation.
unresolved Sample was less secure and more repressing than other samples.
preoccupied, Those with a schizophrenia diagnosis were more repressing than
affective disorders.
Those with repressing strategies reported fewer psychiatric symptoms.
Mulligan and 73 Males: M 39 55 m/18 f ASQ Secure, insecure PBI, RSQ Secure attachment displayed significantly higher reflective function
Lavender (28) (SD = 10.49), than individuals with avoidant attachment.
Female: M 48.63 Preoccupied attachment had significantly higher RF than individuals
(SD = 14.5) with avoidant attachment.
Association between attachment and engagement with service.
Secure attachment associated with better engagement than
avoidant attachment, but there was no difference between
secure and preoccupied attachment.
No differences between attachment classification & positive
or negative symptoms.
No differences between attachment and quality of life.
Picken et al. (29) 110 M 38 (18–61) 99 m/11 f PAM Anxiety, avoidance PDS Avoidance and preoccupied attachment associated with
lower quality of life.
Discomfort with closeness, need for approval and preoccupation
with relationships associated with lower quality of life.
Confidence in relationships associated with greater quality of life.
 Table 1. (Continued)

Number of Attachment Attachment measurement

Study participants Age (years) Gender measure constructs Key outcome measures Results

Ponizovsky et al. (30) 30 M 38.4 (SD = 10.2)
Ponizovsky et al. (31) 100 M 40.3 (SD = 11.2)
Tait et al. (32) 50 M 33.8 (SD = 12.0)
Tyrell et al. (33) 54 M 41 (25–62)
Quijada et al. (34) 31 M 15.7 (SD = 3.1),
Range = 12–25
Owens et al. (35) 49 M 38.1 (SD = 11/55)
Kvrgic et al. (36) 156 M 44.5 (SD = 11.67)
30 m AAQ Secure, avoidant, PANSS Association between high maternal care and secure attachment.
anxious/ambivalent Maternal care associated with discomfort with closeness, need for approval
and preoccupation with relationships.
A negative association between paternal care and discomfort with closeness.
Maternal overprotection associated with greater need for approval and preoccupation.
Paternal overprotection associated with discomfort with closeness.
Recovery style related to the relationships as secondary to achievement scale
70 m/30 f RQ Secure, fearful, preoccupied, PANSS, GHQ Avoidant or anxious/ambivalent attachment had greater severity of positive symptoms.
dismissing/avoidant Less positive symptoms related to secure attachment.
Avoidant attachment had more severe negative symptoms.
31 m/19 f RAAS Closeness, dependency, PBI, SES, RSQ, PANSS Delusion severity was predicted by preoccupied and fearful avoidant attachment.
anxiety, security Persecution/suspiciousness was predicted by preoccupied and fearful
avoidant attachment.
Hallucinations were significantly predicted by fearful avoidant attachment.
22 m/32 f AAI Q-sort Deactivating, QoL, WAI, GAF, BDI Associations between parental care and dependence, and closeness in relationships.
hyperactivating, Parental abuse inversely related to dependence and closeness.
autonomous, Rejection anxiety correlated with parental abuse and lack of care.
non-autonomous Insecure attachment was associated with likelihood to disengage and related
to avoidant coping style.
Sealing over associated with more anxiety about interpersonal rejection and
lower comfort with closeness and dependence.
Attachment anxiety related to positive symptoms.
23 m/8 f RQ Secure, fearful, PANSS, GAF, PSA Fearful (71%), preoccupied (16.1%), dismissing (6.4%) and secure (6.4%).
preoccupied, Preoccupied attachment correlated with psychotic symptoms.
dismissing/avoidant Fearful attachment correlated with disorganisation symptoms.
Secure, preoccupied and dismissing predicted change in psychotic
symptoms over 6 months.
Secure attachment predicted change in disorganisation.
Secure attachment predicted change in functioning
42 m/7 f PAM Anxiety/Avoidance WAI, PANAS, PANSS, DERS Attachment anxiety and therapeutic alliance were significant predictors of
emotion regulation problems, but not attachment avoidance, negative
emotion or psychotic symptoms.
102 m/54 f PAM Anxiety/Avoidance STAR, RAS, SED, BIS, Hierarchical multiple regressions revealed that more recovery orientation,
PANSS, BDI-II, MGAF less self-stigma and more insight independently were associated with a
better quality of the therapeutic alliance.
Clinical symptoms, adult attachment style, age and the duration of
treatment by current therapist were unrelated to the quality of the
therapeutic alliance.

BDI, Beck Depression Inventory; BDI-II, Beck Depression Inventory-II; BIS, Birchwood Insight Scale; BSI, Brief Symptom Inventory; CASIG, Client Assessment of Strengths Interests and Goals; CDSS, Calgary Depression Scale for Schizophrenia;
DERS, Difficulties in Emotion Regulations Scale; FMSS, Five Minute Speech Segment; GAF, Global Assessment of Functioning; GHQ, General Health Questionnaire; IIP-32, Inventory of Interpersonal Problems-II; MGAF, Modified Global Assessment
of Functioning; PANAS, Positive and Negative Affect Scale; PANSS, Positive and Negative Syndrome Scale; PAS, Premorbid Adjustment Scale; PBI, Parental Bonding Instrument; PDS, Posttraumatic Stress Diagnostic Scale; PSA, Premorbid Social
Adjustment; PSYRATS, Psychotic Symptoms Rating Scale; QoL, Quality of Life Interview; SES, Service Engagement Scale; RAS, Recovery Assessment Scale; RF, Reflective Functioning; RSQ, Recovery Style Questionnaire; SBS, Social Behaviour
Scale; SED, Self-Esteem Decrement Due to Self-Stigma subscale of Self-stigma in Mental Illness Scale; STAR, Scale to Assess the Therapeutic Relationship; THQ, Trauma History Questionnaire; WAI, Working Alliance Inventory; WHOQOL-BREF,
World Health Organisation Quality of Life – Brief Version.

263
Attachment and psychosis
Gumley et al.
and team) (15, 16). PAM items were derived from
existing self-report attachment measures, excluding
items referring to romantic relationships (38–40).
Respondents rate on a four-point Likert scale the
extent to which each statement describes how they
currently relate to key people in their life. The
PAM assesses two dimensions of anxious and avoi-
dant attachment. Total scores are calculated for
each dimension by averaging item scores, with
higher scores reflecting greater anxiety and avoid-
ance. Acceptable levels of internal consistency have
been demonstrated across the included studies,
with Cronbach’s alpha coefficients ranging from
0.70 to 0.86 for the anxiety dimension and from
0.60 to 0.91 for the avoidance dimension (15–19,
26, 29, 35, 36).
Adult Attachment Interview. Six studies (21, 22/23–
25, 27, 33) used the Adult Attachment Interview
(AAI; 19.3%; n = 280) (41). The AAI (41) is a
semi-structured interview, consisting of 20 ques-
tions and probes, allowing categorisation of an
adult individual’s state of mind with regard to
attachment. Attachment classifications are allo-
cated on the basis of the coherence of interview
response and nature of the representation of
attachment. Interview stability has been reported
at 4-year intervals (42). A key strength of the AAI
over other methods of assessing attachment is the
strong correspondence between parental AAI
responses and infant attachment security (41).
Maternal Coherence of Transcript score is the
most significant predictor of attachment security in
infancy (43). The AAI can be analysed in two dis-
tinctive ways, either by using the Q-sort method or
narrative approach.
The Q-sort method was used in five studies (21,
22/23–25, 33) using the attachment interview Q-set
(44). A Q-set consists of 100 items derived from
Main and Goldwyn’s (44) attachment classifica-
tions (see below), and these items are used to
describe each subject from most to least character-
istic. Two raters perform Q-sorts which are aver-
aged and then correlated with two attachment
dimensions. The first dimension differentiates the
attachment classification (security vs. insecurity
(anxiety) or autonomous vs. non-autonomous),
and the second dimension differentiates the strate-
gies used to reduce distress (deactivation vs. hyper
activation or avoidant (repression) vs. preoccupa-
tion). Kobak (44) compared the Main and Gold-
wyn (45) categorical system with the Q-sort
approach, discriminant function analysis revealed
an 88–94% concordance rate between the two
systems.
264
The narrative approach was used in one study
(27). Each interview is transcribed verbatim and
coded for attachment status by coders trained in
the AAI coding system (version 7.1) (46). Coding
relies on the scoring of overall coherence of nar-
rative as the key index of insecure attachment,
which is defined as the degree to which speakers
portray their attachment experiences in a coher-
ent and collaborative manner. Insecure attach-
ment is characterised by significant contradictions
and inconsistencies in attachment narratives or
may be reflected in passages that are exception-
ally short, long, irrelevant or difficult to follow
(41).
Transcripts are allocated one of three ‘organ-
ised’ categories: One ‘secure’ category – ‘freely
autonomous’ – and two ‘insecure’ categories – ‘dis-
missing’ and ‘preoccupied’ (45). In addition, tran-
scripts can be assigned a category of ‘unresolved’
with regard to trauma and loss, where the coher-
ence of an interviewee’s narrative breaks down. In
transcripts coded ‘Unresolved’, an ‘Organised’
category is also assigned.
Attachment Style Questionnaire. The Attachment
Style Questionnaire (ASQ) (47), used by two stud-
ies (20, 28) (11.6%; n = 169), is a self-report mea-
sure assessing an individual’s internal working
model of general relationships. The included stud-
ies (20, 28) showed moderate to good internal
consistency values. It can be used as a continuous
measure of attachment security or to divide partici-
pants according to four attachment style groups
including autonomous, avoidant, preoccupied and
ambivalent.
The Relationship Questionnaire. The Relationship
Questionnaire (RQ) (48) is used in two studies (31,
34) (9.0%; n = 131). This brief self-report ques-
tionnaire is an adaptation of the Adult Attachment
Questionnaire (AAQ) (49) and categorises adult
attachment styles through four brief statements.
Participants select the most self-descriptive state-
ment of their friendship patterns. In addition,
participants can rate how much each description
corresponds to their general relationships. The
four attachment styles are secure, fearful/avoidant,
preoccupied, and dismissing/avoidant.
Service Attachment Questionnaire. The Service
Attachment Questionnaire (SAQ) (50), used in one
study (19) (5.4%; n = 78), is a self-report measure
assessing the security of the attachment to staff
members and to the hospital. A higher score indi-
cates greater attachment security to service.

Internal consistency (19) and test–retest reliability
are acceptable (50).
Revised Adult Attachment Scale. The Revised Adult
Attachment Scale (RAAS) (51), used in one study
(32) (3.4%; n = 50), is a self-report measure of
adult attachment based on the AAQ descriptions.
It contains three subscales: closeness, dependence
and anxiety. Internal consistency is satisfactory
(32).
The Adult Attachment Questionnaire. The AAQ
(52), used in one study (30) (2.1%; n = 30), is a
self-selection measure of psychological and
emotional closeness in relationships, based on
secure, avoidant and anxious/ambivalent attach-
ment styles. Participants indicate which of three
short descriptions of the attachment styles best
describe their feelings in relationships. In addition,
participants can rate how much each description
corresponds to their general relationship style. The
AAQ shows satisfactory internal reliability and
test–retest reliability (30).
Construct validity
Evidence of construct validity for the attachment
measures used to investigate psychosis can be
shown through the association with other theoreti-
cally related measures. These measures included
domains of engagement with mental health
services, hospitalisation, interpersonal problems,
recovery/coping style, parental bonding, trauma,
premorbid adjustment and reflective functioning
(RF).
Engagement with mental health services. In terms of
construct validity, we would expect greater attach-
ment insecurity to be associated with poorer
engagement with services. Eight studies investi-
gated the association between attachment and
engagement with mental health services. Four
studies (21, 22, 27, 33) investigated engagement in
relation to attachment using the AAI. From
clinician ratings, Dozier et al. (21) found that
greater compliance with treatment was associated
with more attachment security (r = 0.37;
P < 0.05). Attachment avoidance was associated
with reduced likelihood to seek help (r = 0.55;
P < 0.01) and poor use of treatment (r = 0.32;
P < 0.05). Attachment preoccupation was associ-
ated with more self-disclosure (r = 0.50; P < 0.01).
MacBeth et al. (27) found an overall association
between attachment and engagement with services
(K  W: v2 = 7.11; df = 2; P = 0.029; r = 0.60).
Specifically, secure attachment was associated with
Attachment and psychosis
better engagement than avoidant attachment
(M  W: U = 11.5; P = 0.011). Also those classi-
fied as secure in their attachment had better treat-
ment adherence compared to preoccupied
attachment (M  W: U = 3; P = 0.018).
One further study (22) showed that these associ-
ations between attachment insecurity and engage-
ment problems may be partially accounted for by
the attachment security of the person’s case man-
ager. Participants relying on preoccupied strategies
were perceived by their case managers as being
more dependent (r = 0.61; P < 0.01). However,
case managers who were themselves more insecure
perceived clients who were more preoccupied as
having greater dependency needs than clients who
were dismissing (r = 0.80; P < 0.01). Tyrell et al.
(33) reported that less avoidant case managers
formed stronger alliances with more deactivating
clients than with less deactivating clients (r = 0.53;
P < 0.01).
Three studies (16, 19, 26) used the PAM to
investigate engagement with services. Berry et al.
(16) found that higher attachment avoidance was
associated with lower therapeutic alliance as rated
by patient (r = 0.44; P < 0.001) and by staff
(r = 0.33; P = 0.003). These effects were main-
tained when controlling for symptom severity.
Blackburn et al. (19) found associations between
better attachment to services and greater security
of attachment (r = 0.39; P < 0.001). Kvrgic et al.
(26) found higher attachment anxiety was associ-
ated with more treatment adherence (r = 0.20;
P = 0.02) (SES). Finally, Tait et al. (32) found that
greater insecurity of attachment was associated
with greater likelihood to disengage from mental
health services than secure attachment (t = 3.64;
P < 0.001; r = 0.21).
Hospitalisation. We expected to observe that
greater attachment insecurity would be associated
more severe indices of hospitalisation (e.g. more
frequent and longer hospitalisations and greater
likelihood of compulsory admission). Blackburn
et al. (19) found more hospital admissions were
related to less attachment to services (r = 0.33;
P = 0.004), and people sectioned under the Mental
Health Act reported lower levels of attachment to
services than those not under section (t = 3.27;
P = 0.002; r = 0.13). Ponizovsky et al. (30) found
those with more avoidant attachment spent longer
in psychiatric hospitals compared to those with
secure attachment (t = 2.29; P < 0.05; r = 0.20).
Interpersonal problems. In terms of construct valid-
ity, we would expect greater attachment insecurity
to be associated with more interpersonal problems.
265
Gumley et al.
Four studies investigated the association between
attachment and interpersonal problems. Two stud-
ies (24, 25) explored the AAI in relation to inter-
personal problems. Dozier et al. (24) used the
interpersonal problem-solving task which focused
on interactions with case managers. Those with
avoidant attachment were off task significantly
more than others (r = 0.54; P < 0.05), were more
rejecting of their significant others (r = 0.52;
P < 0.05) and were more confused following inter-
actions with case managers (r = 0.51; P < 0.05).
The significant others of clients with avoidant
attachment felt less supported (r = 0.53; P <
0.05) and more saddened (r = 0.57; P < 0.05) fol-
lowing the tasks. Dozier et al. (25) found increased
use of insecure attachment strategies (avoidance
and preoccupation) amongst families with greater
expressed emotion (overinvolvement; F = 3.44;
P < 0.05; r = 0.16).
Three studies (16, 20, 26) explored the PAM in
relation to interpersonal problems. Berry et al. (16)
showed associations between greater interpersonal
problems and increased attachment avoidance
(r = 0.28; P < 0.01) and anxiety (r = 0.58;
P < 0.001). Specifically, individuals with higher
attachment anxiety displayed more attention-
seeking behaviour, t(77) = 2.82; P = 0.006; r = 0.1,
and individuals with higher attachment avoidance
displayed more hostility, t(77) = 2.77; P = 0.007;
r = 0.1. These associations were maintained when
controlling for the influence of symptom severity.
Kvrgic et al. (26) found that higher attachment
anxiety was associated less positive clinician input
(r = 0.18; P < 0.05) and that attachment avoid-
ance was associated with non-supportive clinician
input (r = 0.19; P = 0.03), less positive clinician
input (r = 0.23; P = 0.01) and poorer relation-
ships with professionals (r = 0.25; P < 0.01).
Finally, Couture et al. (20) found inappropriate
community behaviour was associated with greater
discomfort with closeness (r = 0.31; P < 0.01).
Recovery/Coping style. Two studies (28, 32)
explored attachment in relation to recovery style.
McGlashan (53) defined ‘clinically distinct recovery
styles’ of ‘integration’ and ‘sealing over’ reflected in
the form and coherence of individuals’ narratives.
An Integrated recovery style is characterised by a
narrative which reflects awareness of the continuity
of experiences before, during and after psychosis, a
balanced perspective on the positive and negative
aspects of experience, where psychotic experiences
are a source of learning; and a curiosity about the
experience of psychosis itself which is linked to
enlisting supportive others in scaffolding under-
standing. In contrast, sealing over indicates active
266
attempts to isolate the experience of psychosis,
avoidance and minimisation of its influence on the
self. Integration and sealing over were understood
as coping styles applicable to other life events and
conflicts. Therefore, the regulation of painful emo-
tions – as reflected in thoughts, feelings and
memories associated with the experience of mental
illness – was fundamental to the original formula-
tion of recovery style. Therefore, in terms of con-
struct validity, we would expect greater security of
attachment to be associated with a tendency
towards an integrating recovery style and insecu-
rity of attachment (particularly dismissing) to be
associated with a sealing-over recovery style. Mul-
ligan and Lavender (28) found an association
between more avoidant recovery/coping style and
the ‘relationships as secondary to achievement’
subscale (r = 0.41; P < 0.01). Tait et al. (32)
found that insecure attachment was associated
with an avoidant coping style (sealing over). Seal-
ing over was associated with more anxiety about
interpersonal rejection (F = 12.20; P < 0.001;
r = 0.23), lower levels of comfort with closeness
(F = 7.43; P < 0.01; r = 0.16) and greater depen-
dence in relationships (F = 13.51; P < 0.001;
r = 0.24).
Given that a key function of the construct of
recovery style is the regulation of affect, we also
included the study by Owens et al. (35) in this sec-
tion. They found that attachment anxiety and ther-
apeutic alliance were significant predictors of
emotion regulation problems, but not attachment
avoidance, negative emotion or psychotic symp-
toms. Specifically, attachment avoidance was sig-
nificantly positively correlated with global emotion
regulation difficulties (r = 0.42; P = 0.003) includ-
ing non-acceptance of emotions (r = 0.37; P =
0.01), lack of emotional awareness (r = 0.54;
P < 0.001) and lack of emotional understanding
(r = 0.47; P = 0.001). Attachment anxiety was
associated with non-acceptance of emotions
(r = 0.72; P < 0.001), difficulties in engaging in
goal-directed behaviour when upset (r = 0.54;
P < 0.001), impulse control difficulties (r = 0.60;
P < 0.001), limited access to situationally appro-
priate emotion regulation strategies (r = 0.66;
P < 0.001) and lack of emotional clarity (r = 0.48;
P < 0.001).
Parental bonding. In terms of construct validity,
we would expect greater attachment insecurity to
be associated with increased reporting of difficul-
ties in parental relationships. Three studies (17, 28,
32) explored attachment and parental bonding
using the Parental Bonding Instrument (PBI).
Berry et al. (17) found associations between

greater attachment anxiety (PAM) and more
parental overprotection (r = 0.24; P = 0.03), but
this was not maintained when controlling for
depression. Greater attachment avoidance (PAM)
was related to perceived lack of parental care
(r = 0.31; P = 0.005) which was maintained
when potential confounds were controlled.
Mulligan and Lavender (28) found an associa-
tion between higher maternal care and lower
discomfort with closeness (r = 0.25; P < 0.05),
less need for approval (r = 0.34; P < 0.05) and
less preoccupation with relationships (r = 0.24;
P < 0.05; ASQ). Lower paternal care was associ-
ated with greater discomfort with closeness (ASQ;
r = 0.22; P < 0.05). Maternal overprotection
(intrusive and controlling) was associated with
greater need for approval (r = 0.24; P < 0.05) and
greater preoccupation with relationships (ASQ;
r = 0.32; P < 0.05). Finally, paternal overprotec-
tion was associated with greater discomfort with
closeness (r = 0.35; P < 0.05).
Tait et al. (32) found associations between
greater parental care and more dependence
(r = 0.58–0.61; P < 0.01) and closeness in relation-
ships (r = 0.62; P < 0.01). In contrast, parental
abuse was related to less dependence (r = 0.41 to
0.58; P < 0.01) and closeness (r = 0.31 to
0.54; P < 0.05). Furthermore, anxiety about
rejection was related to greater parental abuse
(r = 0.45–0.54; P < 0.01) and lower care
(r = 0.57 to 0.60; P < 0.01).
Trauma. In terms of construct validity, we would
expect greater attachment insecurity to be associ-
ated with more experiences of trauma. Two studies
(17, 29) explored attachment in relation to trauma.
Berry et al. (17) found higher levels of attachment
anxiety in those who had experienced trauma with
significant others in childhood compared to those
who had experienced trauma with significant
others in adulthood, non-significant others and
those with no interpersonal trauma, F(3,
76) = 3.43; P = 0.021; r = 0.13. Picken et al. (29)
found that attachment anxiety was associated with
total number of traumatic events (r = 0.38;
P < 0.01), interpersonal traumatic events
(r = 0.37; P < 0.01) and severity of post-traumatic
symptoms (r = 0.36; P < 0.01).
Premorbid adjustment. In terms of construct
validity, we would expect greater attachment inse-
curity to be associated with poorer premorbid
functioning. Two studies (27, 34) explored associa-
tions with premorbid adjustment. MacBeth et al.
(27) found no associations between AAI and
Attachment and psychosis
premorbid functioning. Although Quijada et al.
(34) measured attachment and premorbid adjust-
ment, associations were not reported.
Reflective functioning. Reflective functioning refers
to an individual’s understanding of the thoughts,
feelings, intentions and goals of self and others and
the interaction of these phenomena within the con-
text of attachment relationships. We would expect
greater attachment security to be associated with
higher levels of RF. One study (27) investigated
the association between AAI and RF and found
that with regard to mentalisation, the median score
for RF was 3 (IQR = 1–5, range 0–7), equivalent
to questionable or low RF. When three-category
classifications of attachment were scrutinised, sig-
nificant differences between groups emerged for
RF score (K  W: v2 = 9.5; P = 0.009; r = 0.73).
Post hoc analyses indicated that individuals
with secure attachment classifications displayed
significantly higher RF than individuals with inse-
cure/dismissing attachment (M  W: U = 40.0;
P = 0.012). Individuals with insecure/preoccupied
attachment classifications also displayed signifi-
cantly higher RF than individuals with insecure/
dismissing classifications (M  W: U = 14.0;
P = 0.038).
Dimensions of outcome
Attachment security was investigated in relation to
a number of outcomes including positive, negative
and disorganisation symptoms, depression and
quality of life.
Positive, negative and disorganisation symptoms. Ten
studies explored associations between attachment
and psychiatric symptoms. Five studies (15–18,
26) used the PAM in relation to positive and nega-
tive symptoms. Berry et al. (16) found an associa-
tion between more psychiatric symptoms and
higher attachment anxiety (r = 0.20; P = 0.047)
and avoidance (r = 0.31; P = 0.002). Only attach-
ment avoidance was associated with more positive
symptoms (r = 0.35; P ≤ 0.001), negative symp-
toms (r = 0.24; P = 0.019) and paranoia (r = 0.39;
P ≤ 0.001). Paranoia was associated with attach-
ment avoidance independent of severity of illness.
Furthermore, there was an association between
change in attachment anxiety and change in total
symptoms over 6 months (r = 0.30; P = 0.027),
and specifically, change in the hallucinations was
associated with changes in attachment anxiety
(rs = 0.30; P = 0.026). Kvrgic et al. (26) found
associations were only found between attachment
267
Gumley et al.
avoidance and positive symptoms (r = 0.18;
P = 00.04).
Berry et al. (17) found that more psychiatric
symptoms were not associated with attachment
anxiety (r = 0.21; P = 0.068) although the magni-
tude of association was similar to other studies
(16), suggesting problems related to statistical
power. However, more psychiatric symptoms were
associated with greater attachment avoidance (r =
0.27; P = 0.016). Berry et al. (18) found higher
attachment avoidance in participants who reported
critical or rejecting voices (t = 3.14; P < 0.002;
r = 0.12) or threatening voices (t = 5.25;
P < 0.001; r = 0.28) than in those without. Higher
attachment anxiety was associated with greater
severity of voices (r = 0.29; P = 0.014) and greater
distress in relation to voices (r = 0.32; P = 0.005).
Arbuckle et al. (15) found key worker informant-
reported attachment avoidance was related to
auditory hallucinations (rs = 0.63; P = 0.01). Fur-
thermore, self-reported attachment avoidance of
team relationships was associated with greater
duration, frequency, intensity, conviction and dis-
ruption of delusional thoughts (rs = 0.42;
P = 0.49).
Two studies (23, 25) explored associations
between symptoms and attachment as measured
by the AAI. Dozier et al. (25) found that the
participants’ greater attachment avoidance was
associated with self-reporting fewer psychiatric
symptoms (Brief Symptom Inventory, BSI; all
P < 0.05 but effect sizes not reported). Dozier
et al. (23) found that attachment avoidance was
associated with lower self-report of psychiatric
symptoms using the BSI (r = 0.23 to 0.41).
However, when others rated symptoms, those
with avoidant attachment had psychiatric
symptoms including conceptual disorganisation
(r = 0.35), delusions (r = 0.30), hallucinations
(r = 0.30) and suspiciousness (r = 0.55). Attachment
security was linked to less delusions (r = 0.33),
hallucinations (r = 0.35) and suspiciousness
(r = 0.41).
When using the AAQ (30), those classified with
an avoidant (t = 3.35; P < 0.01; r = 0.28) or preoc-
cupied (t = 2.01; P < 0.05; r = 0.12) attachment
style had a greater severity of positive symptoms
than those with a secure attachment style. Further-
more, those with avoidant attachment also had
more severe negative symptoms (t = 2.36; P < 0.05;
r = 0.16) compared to anxious ambivalent or secure
attachment styles.
Two studies employed the RQ to explore associ-
ations with symptoms. Ponizovsky et al. (31)
found that greater severity of delusions was pre-
dicted by more preoccupied attachment
268
(r2 = 0.06–0.08; P < 0.01) and more avoidant
attachment (r2 = 0.05–0.08; P < 0.01). In addition,
greater persecution/suspiciousness was predicted
by more preoccupied (r2 = 0.20; P < 0.0001) and
more avoidant (r2 = 0.17; P < 0.0001) attachment.
Greater hallucinations were predicted by more
avoidant attachment (r2 = 0.20; P < 0.0001). Tait
et al. (32) found that higher attachment anxiety
was associated with more positive symptoms
(r = 0.31; P = 0.03). Quijada et al. (34) did not
find any associations between attachment proto-
types and psychotic symptoms or functioning
although the sample size may not have been suffi-
cient to detect small to moderate effect sizes, which
were signalled in the data. Controlling for baseline
symptoms and premorbid social adjustment,
secure, preoccupied and dismissing attachment
accounted for 20.4% of the variance in psychotic
symptom change scores (over 6 months). Secure
attachment accounted for 19.3% of change in
functioning scores over 6 months.
Therefore, to summarise, we find good evidence
to support the association between attachment
avoidance and psychiatric symptoms in four stud-
ies (16, 17, 23, 25), with positive symptoms in six
studies (15, 16, 18, 26, 30, 31) and negative symp-
toms in two studies (16, 30). Questionnaire-based
methods find that increased attachment avoidance
is associated with increased symptom reporting
(15–18, 26, 30, 31), whereas studies using the AAI
show that avoidant attachment is associated with
reduced reporting of symptoms (23, 25) by partici-
pants themselves but now by case managers or
family members. We find modest evidence to sup-
port an association between attachment anxiety/
preoccupation and psychiatric symptoms in one
study (16) and positive symptoms in four studies
(18, 30–32). No studies have reported associations
between attachment and disorganisation symp-
toms.
Affective symptoms. Three studies (15, 17, 26)
explored the PAM in relation to depression and
one study (30) in relation to emotion regulation.
Arbuckle et al. (15) found an association between
greater depression and more attachment avoidance
in general (rs = 0.41; P = 0.046) and avoidance of
key worker relationships specifically (rs = 0.55;
P = 0.01). Berry et al. (17) found that greater
depression was associated with more attachment
avoidance (r = 0.27; P = 0.018) and attachment
anxiety (r = 0.43; P < 0.001). Kvrgic et al. (26)
found that depression was associated with attach-
ment anxiety (r = 0.27–0.41; P < 0.001) and avoid-
ance (r = 0.19–0.29; P < 0.03). Blackburn et al.
(19) found that more attachment to services (SAQ)

was associated with lower depression (r = 0.37;
P = 0.001).
Quality of life. Three studies explored associations
between attachment and quality of life (20, 27, 33).
Tyrrell et al. (33) found that greater attachment
avoidance was associated with reporting better
greater quality of life (r = 0.38; P < 0.01). In con-
trast, Couture et al. (20) found that avoidant and
preoccupied attachment (ASQ) was associated with
lower quality of life (r = 0.342 and 0.341;
P < 0.01). Specifically, greater discomfort with
closeness (r = 0.477; P < 0.01), need for approval
(r = 0.267; P < 0.05) and preoccupation with
relationships (r = 0.301; P < 0.05) were associ-
ated with lower quality of life. Having more confi-
dence in relationships (ASQ) was associated with
improved quality of life (r = 0.332; P < 0.01). Also
worse social and independent living (CASIG) was
associated with greater avoidance (r = 0.241;
P < 0.05) and discomfort with closeness (r = 0.233;
P < 0.05), whilst it was better with greater confi-
dence (r = 0.267; P < 0.05).
MacBeth et al. (27) explored associations
between RF, present in AAI narratives and found
that higher RF scores (reflecting improved mentali-
sation) were significantly negatively correlated with
WHO-QoL physical quality of life (r = 0.478;
P = 0.005) and psychological quality of life
(r = 0.407; P = 0.019).
Discussion
We sought to identify, summarise and critically
evaluate studies that have investigated attachment
amongst individuals with psychosis. Specifically,
we sought to characterise these studies, explore
attachment measurement and investigate evidence
construct validity and finally explore associations
between attachment and dimensions of outcome in
people with psychosis. We identified 22 papers
describing 21 studies comprising 1453 participants,
with a mean age of 35.0 years (range 12–71 years),
of whom 68.4% (n = 994) were male. Of our
sample, 1112 (76.5%) had a diagnosis of schizo-
phrenia. We identified a number of important
methodological problems in the current literature.
All of the studies with two exceptions (16, 34) were
cross-sectional. All but three studies (20, 27, 34)
were conducted with participants with established
or chronic psychosis. Reporting of participant flow
including rates of consent was rare with the excep-
tion of two studies (16, 30). Other reporting prob-
lems were noted including the description of
inclusion and exclusion criteria, medication, diag-
nosis and educational level. Finally, data reporting
Attachment and psychosis
was not consistent, and in particular, there was a
tendency in studies to only report significant
findings.
Across the 21 studies we identified, there were 7
different measures of attachment were employed
including the PAM (54.6%; n = 793), AAI
(19.3%; n = 280), ASQ (11.6%; n = 169), RQ
(9.0%; n = 131), RAAS (3.4%; n = 50) and the
AAQ (2.1% n = 30). One study (19) used the SAQ
(5.4%; n = 78) in addition to the PAM. Attach-
ment measurement varied from self-report ques-
tionnaires (PAM, ASQ, RQ, SAQ, RAAS, AAQ)
to semi-structured interviews (AAI) and from
dimensional descriptions of attachment (AAI Q-
Sort, PAM, ASQ, SAQ, RAAS) to categorical
descriptions (AAI, RQ, AAQ). There are also dif-
ferences in approach each measure uses, whether it
is based on the person’s current state of mind with
respect to attachment as reflected in attachment-
related discourse (AAI) or self-reported percep-
tions of current relationships (52).
Self-report- and interview-based approaches to
the assessment of attachment reflect different epis-
temological traditions with the former emerging
from in the context of social psychology and indi-
vidual differences and the later in the context of
developmental psychology. These measurement
differences reflect differing approaches to the
conceptual and theoretical understanding of
attachment. Therefore, both approaches make
important contributions to the literature (54–56).
Self-report measures have the advantage of ease of
administration but can be subject to biases arising
from the attachment system itself where individu-
als who are avoidant of attachment can tend to
self-report their attachment as autonomously
secure. Some studies attempted to account for this
by using both self-reported and informant-
reported measures of attachment (15, 16). In addi-
tion, the overlapping semantic content between
items such on measures of psychosis (e.g. feeling
suspicious of others) and measures of attachment
(e.g. feeling insecure in relationships) may increase
effect size estimates. In contrast, narrative
approaches to attachment measurement (AAI)
assess the coherence of the portrayal of attachment
relationships at the semantic and autobiographical
memory level. It is well established that AAI has
strong predictive validity with infant attachment
security (42, 43). A key criticism of the AAI is the
time taken for to train interviewers and complete
the AAI is considerably longer than self-report
measures. Importantly, self-report measures and
the AAI have a very weak association (0.09) (56).
Despite this, data from the AAI showing associa-
tions with psychotic symptoms (23) are reassuring
269
Gumley et al.
in that they reflect similar effect size estimates to
those found in self-report studies.
Despite these methodological differences arising
from the measurement of attachment, we observed
remarkable consistency of findings across the
studies we identified. We found good evidence sup-
porting the construct validity of attachment mea-
surement amongst individuals with psychosis.
Insecure attachment was moderately associated
with poorer engagement with services and more
interpersonal problems. We also found small to
moderate associations between insecure attach-
ment and more negative representations of paren-
tal bonding and experiences of trauma. Finally, we
found small to moderate associations between
insecure attachment and greater positive and nega-
tive symptoms, greater depression and poorer
quality of life.
An attachment theory conceptualisation of recovery
from psychosis. As we stated in the outset of this
manuscript, there is now much evidence to show
that traumatic experiences contribute towards the
development of vulnerability to developing psycho-
sis (1, 2) and that early adversity may impact on
later expression of psychosis by increasing stress
sensitivity to later stressful life events (3, 4). Our
findings that insecure strategies are associated with
more negative parental representations (17, 28, 32)
and greater trauma (17, 29) are of importance in
terms of bringing a developmental understanding
of the influence of early trauma and abuse in the
development of individuals’ patterns of adaptation
and coping as reflected in the their attachment secu-
rity. These associations are important as attach-
ment theory provides a framework to understand
processes of affect regulation that contributes
towards stress sensitivity and coping. Therefore,
vulnerability to the development of psychosis might
be best understood within the context of this devel-
opmentally based affect regulation system. These
attachment strategies in turn shape the unfolding
of symptom expression and recovery. We found
good evidence to suggest that attachment avoid-
ance was associated with psychiatric symptoms,
positive symptoms and, to a lesser extent, negative
symptoms (15–18, 23, 25, 26, 30, 31).
Recovery from psychosis unfolds in the context
of individuals’ engagement with services, and it is
in the relationships between individuals with psy-
chosis and their service providers that the attach-
ment system expresses itself. Life events involving
threat, loss, separation and illness activate the
attachment system, and this is reflected in organ-
ised (and disorganised) patterns of affect regula-
tion in the context of interpersonal relationships.
270
Thus, the service providers’ capacities to provide
an attuned response to the needs of individuals in
context of their affective expression will determine
the extent to which services can provide a safe
haven and secure base for recovery. In this review,
we found that those with secure attachment had
better engagement and greater treatment adher-
ence (21, 27) and insecure attachment was related
to disengagement (30, 32). Specifically, avoidant
attachment was related to problems in seeking
help, poor use of treatment, longer hospital admis-
sions and lower-rated therapeutic alliance (16, 21,
30) and lack of acceptance and awareness of emo-
tions (35). Preoccupied attachment or attachment
anxiety was related to greater disclosure and more
treatment adherence than avoidance (21, 26, 27)
and greater emotion regulation difficulties (35).
Insecure attachment was also related to the
amount and type of input offered by clinicians
(26). Individuals with dismissing (avoidant) attach-
ment states of mind also experienced greater
confusion in response to meeting with their case
managers (24). We also found that those with dis-
missing (avoidant) attachment had difficulties with
interpersonal problem-solving, inappropriate or
hostile behaviour and had poorer relationships
(16, 20, 22, 24, 26, 27).
A key aspect of the attachment system is the
individuals’ capacity for mentalisation or RF (57,
58). Impoverished RF arising from dismissing
(avoidant) attachment (27) creates a challenge for
service providers to provide attuned support par-
ticularly where the avoidant attachment strategy is
deployed in the service of individuals’ autonomy
and independence at the cost of close interpersonal
relationships (including help-seeking) and a more
nuanced understandings of thinking, affect and
memory. Therefore, attempts by service providers
to engage these individuals in mental health
services or discuss emotional experiences may be
experienced as a threat to this group of individuals.
This may trigger disengagement and further resis-
tance. Those with dismissing (avoidant) attach-
ment had more positive and negative symptoms,
paranoia and delusions (15–18, 23, 30, 31). Using
the AAI, those with attachment avoidance self-
reported fewer symptoms but were rated as more
symptomatic by others (23, 25). These findings are
of importance here. Disengagement in context of
continuing symptoms combined with greater diffi-
culties in help-seeking (28, 32) may then provoke
more assertive and ultimately coercive service
responses. Those with more admissions and com-
pulsory treatment orders had poorer attachment to
services (19). Therefore, insecure attachment (par-
ticularly dismissing avoidant) may be a key risk

feature for the unfolding of problematical recov-
ery, which expresses itself primarily through the
individual’s interpersonal relationships including
those with service providers. In keeping with this,
Owens et al. (35) found that attachment anxiety
and therapeutic alliance were significant predictors
of emotion regulation problems.
Strengths and limitations of current review. The
strengths of the current review included the
systematic search strategy, the exclusion of non-
clinical data and the focus on construct validity
and outcomes. All of the studies were rated for risk
of bias by two independent raters and a third
reviewer. Limitations of our review were the search
parameters, for example, written in English lan-
guage, may have resulted in publication and lan-
guage bias by overlooking relevant evidence. The
measure developed for rating the risk of bias, and
quality in included studies was developed specifi-
cally for this review based on previously validated
measures and standards (13, 14). Therefore, valid-
ity of this measure is not established. In addition,
the heterogeneity of measures used to assess symp-
toms and functioning prevented us from applying
meta-analytic techniques to the data set. A final
major limitation was the bias within the studies
tendency to report significant findings.
Research implications. The continuity of attach-
ment stability from infancy through to adulthood
remains an important area of investigation. The
stability of secure attachment appears quite robust
in the context of environments that are stable and
psychologically benign. However, significant dis-
continuities in attachment are observed in high-
risk samples that the transition from security to
insecurity is accounted for by living in environ-
ments characterised by poverty and deprivation,
and increased stressful life events. In this context,
increasing insecurity or the maintenance of insecu-
rity is associated with challenging life events and
environments (59–61). Our findings highlight the
importance of attachment theory in understanding
the (a) prediction of transition to psychosis in
those at risk of developing psychosis and (b) the
evolution of recovery in the context of first-episode
psychosis. Given the importance of attachment
theory as a framework to understand resilience,
coping and affect regulation, there is an important
task to understand how attachment shapes recov-
ery over time, and for this reason, prospective
studies comprising well-characterised ‘at-risk’ and/
or first-episode cohorts are required.
Further research is also required exploring how
attachment strategies exert themselves in the
Attachment and psychosis
context of individuals’ relationships with services
and indeed the way in which services respond to
these attachment strategies. This interaction
between service users and service providers may
provide an important lense through which to
understand the expression of recovery including its
barriers over time. Furthermore, we did not find
any studies of attachment and psychosis, which
explored individuals’ peer and/or intimate relation-
ships. This appears to be a striking omission in the
literature. One recent study (62) found that
amongst those with psychosis, friendship network
was small, but the quality of friendships was
mostly positive and highly valued. The level of
emotional commitment to a relationship was more
important than psychiatric symptoms in predicting
whether or not participants had friends. In addi-
tion, larger and more representative sample sizes
and replicated studies are required. To improve the
transparency of data, there needs to be standardi-
sation in the reporting of significant and non-sig-
nificant findings. This would help to develop a
comprehensive understanding of the ways in which
attachment theory relates to processes of recovery
from psychosis. Research also needs to investigate
whether attachment is a suitable target for psycho-
logical therapies and indeed whether it is a desir-
able or relevant factor amenable to change.
Clinical implications. The data outlined in this sys-
tematic review signal an important conceptual shift
in understanding and formulation individuals’
engagement with mental health services. Current
understandings of engagement, which emphasise
concepts such as collaboration, adherence and
help-seeking (32) or task, bonds and goals (63)
could be enhanced by understanding engagement
from an attachment-based perspective. For exam-
ple, Goodwin et al. (50) emphasise importance of
safe haven in their measure of service attachment.
However, features of secure attachment emphasise
both safe haven (for expression of distress) and
secure base (for promoting autonomy, exploration
and curiosity). From a developmental stance, it is
this interplay between safe haven and secure base,
which underpins freely autonomous and secure
attachment (41, 46). Arguably secure base behav-
iour as reflected in recovery orientation (36) was a
better predictor of therapeutic alliance than attach-
ment avoidance.
These results highlight the importance of under-
standing attachment as part of an assessment and
to utilise attachment theory to understand
processes of affect regulation and recovery.
Attachment theory is a model of resilience, not a
model of psychopathology and contributes to the
271
Gumley et al.
formulation of an individual’s affective, cognitive
and interpersonal functioning. This would provide
hypotheses regarding the interpersonal interactions
during intervention that would benefit those with
insecure attachment, for example avoidant attach-
ment may benefit from increasing focus on emo-
tion (33), and also highlight the importance of
integrating interpersonal interventions into exist-
ing evidence-based practice.
Furthermore, attachment theory may also be
useful to understand the relationship between staff,
service users’ and the team and provide a theoreti-
cal model to incorporate the interplay between
developmental, interpersonal, coping and systemic
factors as their influence and are influenced by the
functioning of clinical services. This would inform
the therapeutic alliance and offer a way of concep-
tualising barriers to engagement or interpersonal
difficulties within a model of resilience. In addition,
it may help staff to reflect on their own interper-
sonal style and influence on service users, including
the importance of creating a safe haven for distress
and a secure base exploration and recovery.
In conclusion, this review has considered how
attachment has been measured and related to out-
comes in psychosis. We found evidence to support
the construct validity of attachment in people with
psychosis and also evidence of small to moderate
effect sizes that attachment (in)security is related to
positive and negative symptom severity, severity of
depression and quality of life. We also found sig-
nificant methodological challenges in the literature,
which mean that researchers and clinicians need to
be cautious in generalising from these studies.
Despite this, attachment does provide a promising
construct for understanding and measuring the
developmental and interpersonal origins of resil-
ience and affect regulation, and further research is
merited particularly in larger, more representative,
first-episode and/or ‘at-risk’ populations in the
context of prospective follow-up.
References
* Included Articles.
1. Bebbington P, Bhugra D, Brugha T et al. Psychosis, victim-
ization and childhood disadvantage: evidence from the
second British National Survey of Psychiatric Morbidity.
Br J Psychiatry 2004;185:220–226.
2. Varese F, Smeets F, Drukker M et al. Childhood adversi-
ties increase the risk of psychosis: a meta-analysis of
patient-control, prospective- and cross-sectional
cohort studies. Schizophr Bull 2012; DOI: 10.1093/schbul/
sbs050.
3. Lataster J, Myin-Germeys I, Lieb R, Wittchen H-U, van Os
J. Adversity and psychosis: a 10-year prospective study
investigating synergism between early and recent adversity
psychosis. Acta Psychiatr Scand 2012;125:388–399.
272
4. Lardinois M, Lataster T, Mengelers R, van Os J,
Myin-Germeys I. Childhood trauma and increased stress
sensitivity in psychosis. Acta Psychiatr Scand
2011;123:28–35.
5. Bowlby J. Attachment and loss: Vol. 3. Loss, sadness and
depression. London: Pimlico, 1980.
6. Fraley RC. Attachment stability from infancy to
adulthood: meta-analysis and dynamic modeling of devel-
opmental mechanisms. Pers Soc Psychol Rev 2002;6:123–
151.
7. Rutten BPF, Hammels C, Geschwind N et al. Resilience in
mental health: linking psychological and neurobiological
perspectives. Acta Psychiatr Scand 2013;128:3–20.
8. Van Bakermans-Kranenburg MJ, IJzendoorn MH. The first
10,000 Adult Attachment Interviews: distributions of adult
attachment representations in non-clinical and clinical
groups. Attach Hum Dev 2009;11:223–263.
9. Lizardi D, Grunebaum MF, Burke A et al. The effect of
social adjustment and attachment style on suicidal behav-
iour. Acta Psychiatr Scand 2011;124:295–300.
10. Berry K, Barrowclough C, Wearden A. A review of the
role of adult attachment style in psychosis: unexplored
issues and questions for further research. Clin Psychol Rev
2007a;27:458–475.
11. NICE Schizophrenia. Core Interventions in the Treatment
and Management of Schizophrenia in Adults in Primary
and Secondary Care: NICE clinical guideline 82. (Inter-
net). 2009 (cited March 2012). Available from: www.nice.
org.uk/CG82 (NICE guideline).
12. Cochrane Collaboration. Cochrane Consumers and Com-
munication Review Group: Data Extraction Template for
Cochrane Reviews. (Internet). 2011 (cited October 2011).
Available from: cccrg.cochrane.org/author-resources.
[Accessed June 15, 2013].
13. Tarrier N, Wykes T. Is there any evidence that cognitive
behaviour therapy is an effective treatment for schizophre-
nia. A cautious or cautionary tale? Behav Res Ther
2004;42:1377–1401.
14. Rosenthal R, Rosnow RL, Rubin DB. Contrasts and effect
sizes in behavioral research: a correlational approach.
New York: Cambridge University Press, 2000.
15. *Arbuckle R, Berry K, Taylor JL, Kennedy S. Service user
attachments to psychiatric key workers and teams. Soc
Psychiatry Psychiatr Epidemiol 2012;47:817–825.
16. *Berry K, Barrowclough C, Wearden A. Attachment the-
ory: a framework for understanding symptoms and inter-
personal relationships in psychosis. Behav Res Ther
2008;46:1275–1282.
17. *Berry K, Barrowclough C, Wearden A. Adult attachment,
perceived earlier experiences of care giving and trauma in
people with psychosis. J Ment Health 2009;18:280–287.
18. *Berry K, Wearden A, Barrowclough C, Oakland L, Brad-
ley J. An investigation of adult attachment and the nature
of relationships with voices. Br J Clin Psychol
2012;51:280–291.
19. *Blackburn C, Berry K, Cohen K. Factors correlated with
client attachment to mental health services. J Nerv Ment
Dis 2010;198:572–575.
20. *Couture S, Lecomte T, Leclerc C. Personality characteris-
tics and attachment in first episode psychosis. J Nerv Ment
Dis 2007;195:631–639.
21. *Dozier M. Attachment organisation and treatment use
for adults with serious psychopathological disorders. Dev
Psychopathol 1990;2:47–60.
22. *Dozier M, Cue K, Barnett L. Clinicians as caregivers: role
of attachment organization in treatment. J Consult Clin
Psychol 1994;62:793–800.

23. *Dozier M, Lee SW. Discrepancies between self- and
other-report of psychiatric symptomatology: effects of
dismissing attachment strategies. Dev Psychopathol
1995;7:217–226.
24. *Dozier M, Lomax L, Tyrrell CL, Lee SW. The challenge
of treatment for clients with dismissing states of mind.
Attach Hum Dev 2001;3:62–76.
25. *Dozier M, Stevenson AL, Lee SW, Velligan DI. Attach-
ment organisation and familial over involvement for
adults with serious psychopathological disorders. Dev
Psychopathol 1991;3:475–489.
26. *Kvrgic S, Beck EM, Cavelti M, Kossowsky J, Stieglitz
RD, Vauth R. Focusing on the adult attachment in schizo-
phrenia in community mental health centres: validation of
the Psychosis Attachment Measure (PAM) in a German-
speaking sample. Int J Soc Psychiatry 2011;10:1–12.
27. *MacBeth A, Gumley A, Schwannauer M, Fisher R.
Attachment states of mind, mentalization, and their corre-
lates in a first episode psychosis sample. Psychol Psycho-
ther Theor Res Pract 2010;84:42–57.
28. *Mulligan A, Lavender T. An investigation into the rela-
tionship between attachment, gender and recovery form
psychosis in a stable community-based sample. Clin Psy-
chol Psychother 2010;17:269–284.
29. *Picken AL, Berry K, Tarrier N, Barrowclough C. Trau-
matic events, posttraumatic stress disorder, attachment
style, and working alliance in a sample of people with psy-
chosis. J Nerv Ment Dis 2010;198:775–778.
30. *Ponizovsky AM, Nechamkin Y, Rosca P. Attachment pat-
terns are associated with symptomatology and course of
schizophrenia in male inpatients. Am J Orthopsychiatry
2007;77:324–331.
31. *Ponizovsky AM, Vitenberg E, Baumgarten-Katz I, Grinsh-
poon A. Attachment styles and affect regulation among
outpatients with schizophrenia: relationships to sympto-
mology and emotional distress. Psychol Psychother Theor
Res Pract 2011. 2013;86:164–182.
32. *Tait L, Birchwood M, Trower P. Adapting to the chal-
lenge of psychosis: personal resilience and the use of seal-
ing over (avoidant) coping strategies. Br J Psychiatry
2004;185:410–415.
33. *Tyrrell CL, Dozier M, Teague GB, Fallot RD. Effective
treatment relationships for persons with serious psychiat-
ric disorders: the importance of attachment states of mind.
J Consult Clin Psychol 1999;67:725–733.
34. *Quijada Y, Tizon JL, Artigue J, Kwapil T, Barrantes-
Vidal N. Attachment style predicts 6-month improvement
in persons with at risk mental states for psychosis. Early
Interv Psychiatry 2012;6:442–449.
35. *Owens KA, Haddock G, Berry K. The role of therapeutic
alliance in the regulation of emotion in psychosis. An
attachment perspective. Clin Psychol Psychother 2013;
20:523–530.
36. *Kvrgic S, Cavelti M, Beck E-M, Rusch N, Vaulth R.
Therapeutic alliance in schizophrenia: the role of recovery
orientation, self-stigma, and insight. Psych Res 2013;
209:15–20.
37. Berry K, Wearden A, Barrowclough C, Liversidge T.
Attachment styles, interpersonal relationships and psy-
chotic phenomena in a non-clinical student sample. Pers
Individ Dif 2006;41:707–718.
38. Brennan KA, Clark CL, Shaver PR. Self-report measures
of adult attachment: an integrative overview. In: Simpson
JA, Rhodes WS, eds. Attachment theory and close rela-
tionships. London: Guilford Press, 1998:46–76.
39. Berry K, Barrowclough C, Wearden A. Adult attachment
styles and psychosis: an investigation of associations
Attachment and psychosis
between general attachment styles and attachment rela-
tionships with specific others. Soc Psychiatry Psychiatr
Epidemiol 2007b;42:972–976.
40. Berry K, Band R, Corcoran R, Barrowclough C, Wearden
A. Attachment styles, interpersonal relationships and
schizotypy in a non-clinical sample. Psychol Psychother
Theor Res Pract 2007c;80:563–576.
41. George C, Kaplan N, Main M. Adult Attachment Inter-
view. Berkley: Department of Psychology, University of
California, 1997.
42. Crowell JA, Waters E, Treboux D et al. Discriminant
validity of the Adult Attachment Interview. Child Dev
1996;67:2584–2599.
43. Fonagy P, Steele H, Steele M. Maternal representations of
attachment during pregnancy predict the organisation of
infant-mother attachment at one year of age. Child Dev
1991;62:891–905.
44. Kobak RR. The attachment interview Q-set. Unpublished
document. Delaware: University of Delaware, 1989.
45. Hesse E. The adult attachment interview: protocol,
method of analysis and empirical studies. In: Cassidy J &
Shaver PR, eds. Handbook of attachment: theory,
research and clinical applications. New York: The Guild-
ford Press, 2008:552–598.
46. Main M, Goldwyn R, Hesse E. Adult attachment scoring
and classification systems (Version 7.1). Unpublished
manuscript. Berkeley: University of California, 2002.
47. Paquette D, Bigras M, Parent S. Validation of the ASQ
and the prevalence of the styles of adult attachment in a
French-speaking sample in Montreal. Can J Behav Sci
2001;33:88–96.
48. Bartholomew K, Horowitz LM. Attachment styles among
young adults: a test of a four category model. J Pers Soc
Psychol 1991;61:226–244.
49. Hazan C, Shaver P. Romantic love conceptualized as an
attachment process. J Pers Soc Psychol 1987;52:511–524.
50. Goodwin I, Holmes G, Cochrane R, Mason O. The ability of
adult mental health services to meet clients’ attachment
needs: the development and implementation of the Service
Attachment Questionnaire. Psychol Psychother Theor Res
Pract 2003;76:145–161.
51. Collins NL. Working models of attachment: implications
for explanation, emotion and behaviour. J Pers Soc Psy-
chol 1996;71:810–832.
52. Garbarino JJ. Comparisons of the constructs and psycho-
metric properties of selected measures of adult attachment.
Meas Eval Counsl Dev 1998;31:28–45.
53. McGlashan TH, Levy ST, Carpenter WT. Integration and
sealing over: clinically distinct recovery styles from schizo-
phrenia. Arch Gen Psychiatry 1975;32:1269–1272.
54. Ainsworth MDS, Blehar M, Waters E, Wall S. Patterns
of attachment: a psychological study of the strange situa-
tion. Hillsdale, NJ: Erlbaum, 1978.
55. Crowell JA, Fraley RC, Shaver PR. Measurement of Indi-
vidual Differences in Adolescent and Adult Attachment.
In: Cassidy J, Shaver PR. Handbook of attachment: the-
ory, research and clinical applications. London: The
Guilford Press, 2008:599–634.
56. Roisman GI, Holland A, Fortuna K, Fraley RC, Clausell
E, Clarke A. The Adult Attachment Interview and
self-reports of attachment style: an empirical rapproche-
ment. J Pers Soc Psychol 2007;92:678–697.
57. Fonagy P, Target M. The mentalization-focussed
approach to self pathology. J Pers Disord 2006;20:544–
576.
58. Liotti G, Gilbert P. Mentalizing, motivation, and social
mentalities. Theoretical considerations and implications
273
Gumley et al.
for psychotherapy. Psychol Psychother Theor Res Pract
2011;84;9–25.
59. Waters E, Hamilton CE, Weinfield NS. The stability of
attachment security from infancy to adolescence and early
adulthood: general introduction. Child Dev 2000;71:678–
683.
60. Allen JP, McElhaney KB, Kuperminc GP, Jodl KM. Stabil-
ity and change in attachment security across adolescence.
Child Dev 2004;75:1792–1805.
61. Weinfield NS, Sroufe LA, Egeland B. Attachment from
infancy to early adulthood in a high risk sample: continu-
274
ity, discontinuity and their correlates. Child Dev
2000;71:695–702.
62. Harley EW, Boardman J, Craig T. Friendship in people
with schizophrenia: a survey. Soc Psychiatry Psychiatr
Epidemiol 2012;47:1291–1299.
63. Goldberg RW, Rollins AL, McNary SW. The working alli-
ance inventory: modification and use with people with
serious mental illnesses in a vocational rehabilitation
programme. Psychiatr Rehabil J 2004;27:267–270.
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