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Attachment-based CBT models for psychosis: a PPI-informed approach for acute care settings

Published online by Cambridge University Press:  01 December 2022

Katherine Newman-Taylor*
Affiliation:
Psychology Department, University of Southampton, Highfield Campus, Southampton, UK Psychology Department, Southern Health NHSF Trust, College Keep, Southampton, UK
Sean Harper
Affiliation:
Psychology Department, NHS Lothian, Royal Edinburgh Hospital, Edinburgh, UK
Tess Maguire
Affiliation:
Psychology Department, University of Southampton, Highfield Campus, Southampton, UK Psychology Department, Southern Health NHSF Trust, College Keep, Southampton, UK
Katy Sivyer
Affiliation:
Psychology Department, University of Southampton, Highfield Campus, Southampton, UK
Christina Sapachlari
Affiliation:
Psychology Department, University of Southampton, Highfield Campus, Southampton, UK
Katherine B. Carnelley
Affiliation:
Psychology Department, University of Southampton, Highfield Campus, Southampton, UK
*
*Corresponding author. Email: knt@soton.ac.uk
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Abstract

People with psychosis often have prolonged in-patient1 admissions at high personal and economic costs. This is due in part to cognitive, affective and behavioural processes that delay recovery and discharge. For many, these processes are affected by enduring insecure attachment styles. People with insecure attachment struggle to manage strong feelings when unwell, and ward staff may struggle to know how best to offer support. Here, we outline the model of interpersonal process in cognitive therapy, and how this may be adapted to capture beliefs and behaviours associated with insecure attachment. Psychological interventions in acute care often fail due to implementation issues. For this reason, and in line with current guidance on developing complex interventions, we report on a series of Patient and Public Involvement (PPI) consultations with people with lived experience of psychosis, family members and ward staff on the potential utility of these attachment-based CBT models. The PPI meetings highlighted three themes: (1) the need to improve staff–patient interactions on wards; (2) continuity in staff–patient relationships is key to recovery; and (3) advantages and barriers to an attachment-based CBT approach. We conclude by describing how the models can be implemented in routine clinical practice, and generalised across services where interpersonal cognitive and behavioural processes may contribute to delays in people’s recovery.

Key learning aims

  1. (1) We need to adapt CBT models and skills to meet the needs of people in acute care.

  2. (2) People with psychosis, family members and ward staff highlight the need to improve staff–patient interactions on wards.

  3. (3) Attachment-based CBT models may be effective in conceptualising and responding more effectively to difficult interactions in these settings.

Type
Service Models, Forms of Delivery and Cultural Adaptations of CBT
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of the British Association for Behavioural and Cognitive Psychotherapies

CBT in acute care

If we are to extend the impact of cognitive behavioural therapy (CBT) across service settings, we need to adapt our psychological formulation and intervention skills to meet people’s needs in these different contexts.

UK acute mental health services aim to reduce risk, facilitate recovery and discharge people promptly (British Psychological Society, 2021; Royal College of Psychiatrists, 2016). Anyone who has worked on acute wards knows that it is often hard to facilitate safe and timely recovery and discharge, for a range of reasons including bed pressures, problems with clinical flow, and workforce shortages (British Psychological Society, 2021; Royal College of Psychiatrists, 2016).

People with psychosis tend to have prolonged hospital admissions (Crossley and Sweeney, Reference Crossley and Sweeney2020; Lay et al., Reference Lay, Lauber and Rössler2006), despite the now 20-year-old NHS Implementation Plan and target of 32-day maximum average stays (Department of Health, 1999; NHS England, 2019). In a recent retrospective cohort study of a large inner-city mental health NHS Trust, a psychosis diagnosis was associated with longer admissions, with an average length of stay of over two months (Crossley and Sweeney, Reference Crossley and Sweeney2020). Admissions can come at high personal (Berry et al., Reference Berry, Ford, Jellicoe-Jones and Haddock2013; Berry et al., Reference Berry, Ford, Jellicoe-Jones and Haddock2015; Loft and Lavender, Reference Loft and Lavender2016), and economic costs (Ride et al., Reference Ride, Kasteridis, Gutacker, Aragon Aragon and Jacobs2020), and are often experienced as unsafe and untherapeutic (Care Quality Commission, 2017; Care Quality Commission 2019).

We need to improve the quality of in-patient care in the UK (Care Quality Commission, 2019). In addition to addressing systemic problems of resource and clinical flow (British Psychological Society, 2021; Royal College of Psychiatrists, 2016), relationships with ward staff are likely to be key to effecting such change (Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; British Psychological Society, 2021). People with a diagnosis of schizophrenia in a forensic setting identified relationships with staff and family as central to their recovery (Laithwaite and Gumley, Reference Laithwaite and Gumley2007).

The purpose of psychological formulation is to articulate the intra- and interpersonal processes that maintain distress – that keep people ‘stuck’ in problematic cycles of thoughts, feelings and behaviours – as a basis for change if the person so chooses. In acute care, formulations can be developed with the ward team to make sense of the individual’s experience, facilitate therapeutic staff–patient interactions, and improve recovery outcomes (Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; British Psychological Society, 2021). This is particularly important given that in-patient staff often report being unsure how best to support people who struggle to seek and accept help (Boniwell et al., Reference Boniwell, Etheridge, Bagshaw, Sullivan and Watt2015).

The limited evidence to date suggests that psychological approaches can improve psychosis, anxiety and depression, and reduce readmissions (Paterson et al., Reference Paterson, Karatzias, Dickson, Harper, Dougall and Hutton2018), but that significant challenges to embedding interventions in routine clinical practice seriously limit impact (Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; Paterson et al., Reference Paterson, Karatzias, Harper, Dougall, Dickson and Hutton2019). Novel interventions or forms of service delivery designed for acute care therefore need to consider issues of implementation as a priority.

Attachment style affects cognitive, affective and behavioural patterns in psychosis

Bucci et al. (Reference Bucci, Roberts, Danquah and Berry2014) argue that we can improve mental health care by taking account of people’s attachment styles. As infants, we are pre-disposed to form emotional bonds with caregivers, which increase likelihood of survival and capacity to explore the world (Bowlby, Reference Bowlby1969). Broadly responsive and consistent caregiving is associated with a secure attachment style, characterised by beliefs that one is safe, others are helpful, and emotions are manageable (Ainsworth et al., Reference Ainsworth, Blehar, Waters and Wall1978). Inconsistent caregiving is associated with an insecure-anxious attachment style, characterised by beliefs about being unsafe and unloved, others being unreliable, and emotions being overwhelming. Where caregivers have often been physically or emotionally absent, infants may develop an insecure-avoidant style, with beliefs about the need to cope alone, that others are rejecting (sometimes harmful), and that emotions are overwhelming. At times of distress, people who are securely attached are able to manage difficult feelings and seek help when needed (Kobak and Sceery, Reference Kobak and Sceery1988). People who are anxiously attached have learnt to escalate emotional expression (e.g. by ruminating or catastrophising) as a means of seeking the help they need, and those who are avoidantly attached suppress their emotions and are self-reliant even when needing help (Mikulincer and Shaver, Reference Mikulincer, Shaver, Mikulincer and Shaver2016). Our attachment styles endure into adulthood, although may be shaped by later relationships (Fraley and Duggan, Reference Fraley, Dugan, Thompson, Simpson and Berlin2021).

Psychosis is associated with insecure attachment in cross-sectional (Korver-Nieberg et al., Reference Korver-Nieberg, Berry, Meijer, de Haan and Ponizovsky2015; Wickham et al., Reference Wickham, Sitko and Bentall2015) and longitudinal studies (Gumley et al., Reference Gumley, Schwannauer, Macbeth, Fisher, Clark, Rattrie and Birchwood2014a). People with psychosis who also have an insecure attachment style are likely to have more severe symptoms (Ponizovsky et al., Reference Ponizovsky, Nechamkin and Rosca2007), struggle to engage in recommended treatments (Berry et al., Reference Berry, Barrowclough and Wearden2007; Dozier, Reference Dozier1990; Gumley et al., Reference Gumley, Taylor, Schwannaeur and MacBeth2014b; Tait et al., Reference Tait, Birchwood and Trower2004), and have longer hospital admissions (Ponizovsky et al., Reference Ponizovsky, Nechamkin and Rosca2007). Given the need to improve the quality of in-patient care, it would seem sensible to target the needs of people with psychosis and insecure attachment, who are typically more unwell, less well engaged, and admitted for longer periods.

Acute wards are usually busy and can be unpredictable. Staff often experience competing and conflicting demands which can result in high levels of stress and uncertainty regarding their role and how best to offer support (Wyder et al., Reference Wyder, Ehrlich, Crompton, McArthur, Delaforce, Dziopa and Powell2017). In these environments, staff responses may inadvertently compound the impact of insecure attachment on people’s recovery. However, when nursing staff are able to be available and responsive, this has a considerable impact on the person’s sense of safety and wellbeing (Cutler et al., Reference Cutler, Sim, Halcomb, Moxham and Stephens2020).

What does CBT have to offer?

If we are to utilise the principles of CBT to improve the quality of in-patient care for people with psychosis, we need models that incorporate the cognitive, affective and interpersonal behaviours characteristic of insecure attachment patterns. Ideally, we would also want to anticipate staff responses where these unwittingly contribute to the maintenance of distress and delay recovery.

We can use cognitive behavioural models to map out these processes, but such formulations do not typically capture key interpersonal processes, and may be too complex for people to hold in mind in busy acute settings. Safran (Safran, Reference Safran1990a, Reference Safran1990b; Safran and Segal, Reference Safran and Segal1996) criticised traditional CBT for paying insufficient attention to interpersonal processes when seeking to account for mental health problems, given the innately interpersonal nature of human beings. Safran sought to integrate these processes in cognitive theory and practice, highlighting the role of ‘interpersonal schemas’ – generalised representations of self-other relationships based on formative experiences that guide information processing and behaviours in social interactions. These interpersonal schemas drive self-perpetuating cycles of thoughts, feelings and behaviours that will be familiar to CBT therapists. For example, the belief ‘others judge me negatively’ is likely to elicit anxiety and behaviours such as wariness or avoidance of others. This in turn may evoke reciprocal responses in other people such as withdrawing (possibly having judged the person to be socially uncomfortable) and giving up on attempts to be friendly, thereby maintaining the schema either directly or indirectly (in the absence of disconfirmatory evidence).

These ‘cognitive interpersonal cycles’ may be particularly useful in formulating psychosis, which is often experienced as inherently interpersonal – paranoia constitutes interpersonal threat beliefs, and hallucinations are by definition experienced as other. Additionally, the explicit mapping of others’ responses is likely to be valuable in ward settings where staff–patient interactions can become problematic (cf. Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; British Psychological Society, 2021). Finally, the simplicity of the cycles is well suited to demanding environments where we can easily lose sight of more complex formulations. The model of interpersonal process has proved theoretically valuable but (perhaps surprisingly) has had limited impact on routine clinical practice to date.

Currently, there are no established psychologically informed approaches to working with people with psychosis and insecure attachment in acute care (Bucci et al., Reference Bucci, Roberts, Danquah and Berry2014). The cognitive interpersonal cycles provide a means of delivering CBT in these settings by clarifying the cognitive, affective and interpersonal behaviours associated with anxious and avoidant attachment, and means of addressing these both directly (with people with psychosis) and indirectly (with ward staff).

Attachment-based CBT models for psychosis in acute care

We developed the attachment-based CBT models drawing on the intra- and interpersonal responses to distress predicted by attachment theory (Bowlby, Reference Bowlby1969; Bowlby, Reference Bowlby1973; Bowlby, Reference Bowlby1988), means of engendering a sense of interpersonal safety (Arriaga et al., Reference Arriaga, Kumashiro, Simpson and Overall2017), and the cognitive interpersonal cycles proposed by Safran (Safran, Reference Safran1990a, Reference Safran1990b; Safran and Segal, Reference Safran and Segal1996). Importantly, Safran (Reference Safran1990b) described interpersonal schema as cognitively oriented elaborations of the ‘internal working models’ of attachment theory (Bowlby, Reference Bowlby1969). We have elaborated these further by making explicit the emotion regulation strategies used in anxious and avoidant insecure attachment (clarifying likely behaviours used ‘on the inside’ as well as ‘on the outside’), and how these might be enacted by people with psychosis in acute care.

Figure 1 demonstrates attachment-based CBT formulation models. The cognitive interpersonal cycles are represented in blue. The top blue box names self and other beliefs (each inherently interpersonal but kept separate for simplicity). When triggered by distress (such as hallucinatory experience, paranoid thoughts, or threatening ward environments – in orange), these beliefs are activated along with attachment-congruent emotional regulation and behavioural responses. These in turn elicit reciprocal responses (or ‘pulls’) from others which are likely to reinforce the person’s beliefs about self and others, either directly or through the absence of disconfirmatory evidence. In green, we have outlined the person’s immediate and subsequent psychological needs, and how ward staff might respond most effectively to facilitate these.

Figure 1. Attachment-based CBT formulation models

The models highlight the importance of supporting people with insecure-anxious attachment to learn to (1) trust themselves, (2) regulate emotions, and (3) make use of help more effectively. People with insecure-avoidant attachment can be supported to learn to (1) trust others, (2) express emotions, and (3) request and accept help when needed.

The models can be used to develop a shared understanding of the person’s intra- and interpersonal needs, developed jointly with the person themselves wherever possible, as the basis for shaping more effective emotion regulation and relational responses to support recovery and appropriate discharge (cf. Arriaga et al., Reference Arriaga, Kumashiro, Simpson and Overall2017).

Patient and Public Involvement

The UK Medical Research Council (MRC) and National Institute for Health and Care Research (NIHR) recommend collaboration with key stakeholders to inform the development of complex interventions (Skivington et al., Reference Skivington, Matthews, Simpson, Craig, Baird and Blazeby2021). The introduction of psychological approaches in acute care settings constitutes a complex intervention, involving staff knowledge and skill development, embedding behaviour change in routine practice, and addressing significant implementation barriers (cf. Bucci et al., Reference Bucci, Roberts, Danquah and Berry2014; Paterson et al., Reference Paterson, Karatzias, Dickson, Harper, Dougall and Hutton2018). Novel service models and psychological interventions designed for acute services need to consider implementation with key stakeholders as a priority.

We ran a series of four stakeholder Patient and Public Involvement (PPI) consultations to consider an attachment-based approach to acute care using the proposed models. These were attended by people with psychosis, family members and ward staff, and included (1) an open session run with the local NHS Trust lead for service-user involvement, (2) a session with the Trust service-user involvement group,Footnote 2 and (3) two sessions with ward staff likely to be using or supporting the models with wider staff teams – psychologists, psychology assistants and a ward manager. Six people with lived experience of psychosis, two family members, and five ward staff took part in the four PPI sessions.

With participants’ consent, two people kept detailed notes for each PPI session. As usual for PPI meetings, the sessions were not recorded to encourage people to talk openly about their experiences and opinions. The two note keepers compared records immediately following the sessions to produce a final agreed meeting record.

We drew on qualitative methods to identify key points across PPI sessions. The agreed meeting records were analysed in NVivo version 12 using thematic analysis (Braun and Clarke, Reference Braun and Clarke2006). An inductive, open coding approach was used to generate codes, which were then grouped into themes. Codes and themes were revised repeatedly in an iterative process using frequent comparison with meeting records to ensure they reflected the data. Codes and themes were discussed in the research team to aid reflexivity and agree the final themes.

Participants expressed often strong feelings about psychological care on acute wards and reflected on implementation issues for the adapted models. We identified three over-arching themes: (1) need to improve staff–patient interactions on wards; (2) continuity in staff–patient relationships is key to recovery; and (3) advantages and barriers to an attachment-based CBT approach. Table 1 outlines the main areas of discussion, key points made, and implications for practice.

Table 1. Key themes highlighted in PPI sessions

The ward environment was identified by people with psychosis, family members and ward staff as a key barrier to implementation. Suggestions for addressing this focused on means of integrating the models into established ward review systems, practical forms of implementation, and shifting the responsibility for recovery more towards the person with psychosis – a more collaborative approach which may also strengthen staff–patient interactions and continuity of care.

Summary and conclusion

Acute mental health care remains unsafe and untherapeutic across much of the UK (Care Quality Commission, 2017; Care Quality Commission, 2019). Psychological interventions are a key component of plans to address these problems (British Psychological Society, 2021), and a focus on staff–patient relationships as a means of facilitating recovery is likely to be most effective (Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; British Psychological Society, 2021; Bucci et al., Reference Bucci, Roberts, Danquah and Berry2014; Laithwaite and Gumley, Reference Laithwaite and Gumley2007).

Many people with psychosis struggle both with their psychotic experiences, and with attachment-congruent thoughts, feelings and behaviours that exacerbate distress, elicit unhelpful responses from others, and delay recovery. In ward settings, the intra- and interpersonal patterns associated with the activation of the attachment system are intensified as people are typically at their most unwell, and ward environments can be unpredictable and experienced as threatening (Stenhouse, Reference Stenhouse2013; Wood and Pistrang, Reference Wood and Pistrang2004).

Attachment-based CBT models articulate these interpersonal processes simply and identify targets for intervention. However, the challenges of ward environments can jeopardise effective and sustained implementation of psychological approaches (Berry et al., Reference Berry, Haddock, Kellett, Roberts, Drake and Barrowclough2016; Paterson et al., Reference Paterson, Karatzias, Harper, Dougall, Dickson and Hutton2019). For this reason, we strongly recommend engagement with local stakeholders prior to implementation – depending on resources, this might involve formal PPI consultation, review with Trust service user groups, or discussion with ward managers and teams regarding potential benefits and means of addressing local barriers.Footnote 3 Once the ward team is engaged, any change to service provision is more likely to be maintained if woven into established governance systems such as ward reviews, psychology consultation sessions and reflective practice.

It should be noted that we ran PPI consultation sessions with a small number of people linked to just two NHS services. Wider consultation and qualitative research would be a useful next step, and might determine if this approach could be used in other settings, such as forensic and rehabilitation services, where interpersonal cognitive and behavioural processes can contribute to inconsistent provision of care, and so delay people’s recovery.

As psychological therapists, we need to adapt CBT models and skills to work effectively in different contexts. By naming the cognitive, behavioural and affective processes associated with insecure attachment, unhelpful interpersonal patterns can be recognised and reflected upon. All are then in a stronger position to adopt alternative responses in line with the attachment-congruent needs of the person. This is undoubtedly easier said than done, and we hope the formulation models described here will be of use to others seeking to effect similar changes in these settings.

Key practice points

  1. (1) We can adapt CBT models to incorporate anxious and avoidant attachment styles, common to people with psychosis.

  2. (2) We can use these models to identify intra- and interpersonal processes that delay recovery and discharge from acute mental health wards.

  3. (3) Attachment-based CBT formulations may be helpful to guide more effective staff–patient interactions and thereby facilitate recovery in psychosis.

Data availability statement

Not applicable for this Service Model/Form of Delivery paper.

Acknowledgements

We would like to thank all who participated in the consultation groups described here.

Author Contributions

Katherine Newman-Taylor: Conceptualization (equal), Formal analysis (equal), Methodology (equal), Writing – original draft (lead), Writing – review & editing (equal); Sean Harper: Conceptualization (equal), Methodology (equal), Writing – review & editing (equal); Tess Maguire: Conceptualization (equal), Methodology (equal), Writing – review & editing (equal); Katy Sivyer: Conceptualization (equal), Formal analysis (equal), Methodology (equal), Writing – review & editing (equal); Christina Sapachlari: Formal analysis (equal), Writing – review & editing (equal); Katherine Carnelley: Conceptualization (equal), Methodology (equal), Writing – review & editing (equal).

Financial support

This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Conflicts of interest

Katherine Newman-Taylor is an Associate Editor of the Cognitive Behaviour Therapist. She was not involved in the review or editorial process for this paper, on which she is listed as an author. The other authors have no declarations.

Ethical standards

The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS, and the INVOLVE guidelines for PPI.

Footnotes

1 We use the terms ‘in-patient’ and ‘staff–patient interactions’ when discussing acute mental health care on wards specifically, and having sought guidance from people with psychosis in these settings.

2 The Trust involvement group also included other staff, e.g. the governance and assurance lead.

3 We are happy to share a brief PowerPoint presentation for this purpose.

References

Further reading

Berry, K., Haddock, G., Kellett, S., Roberts, C., Drake, R., & Barrowclough, C. (2015). Feasibility of a ward-based psychological intervention to improve staff and patient relationships in psychiatric rehabilitation settings. British Journal of Clinical Psychology, 55, 236252.10.1111/bjc.12082CrossRefGoogle ScholarPubMed
Bucci, S., Roberts, N. H., Danquah, A. N., & Berry, K. (2014). Using attachment theory to inform the design and delivery of mental health services: a systematic review of the literature. Psychology and Psychotherapy: Theory, Research and Practice, 88, 120.10.1111/papt.12029CrossRefGoogle ScholarPubMed
Paterson, C., Karatzias, T., Dickson, A., Harper, S., Dougall, N., & Hutton, P. (2018). Psychological therapy for inpatients receiving acute mental health care: a systematic review and meta-analysis of controlled trials. British Journal of Clinical Psychology, 57, 453472.10.1111/bjc.12182CrossRefGoogle ScholarPubMed
Sood, M., Carnelley, K. B., & Newman-Taylor, K. (2022). How does insecure attachment lead to paranoia? A systematic critical review of cognitive, affective, and behavioral mechanisms. British Journal of Clinical Psychology. https://doi.org/10.1111/bjc.12361 CrossRefGoogle Scholar

References

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: a psychological study of the strange situation. Lawrence Erlbaum.Google Scholar
Arriaga, X. B., Kumashiro, M., Simpson, J. A., & Overall, N. C. (2017). Revising working models across time: relationship situations that enhance attachment security. Personality and Social Psychology Review, 22, 7196. https://doi.org/10.1177/1088868317705257 CrossRefGoogle ScholarPubMed
Berry, K., Barrowclough, C., & Wearden, A. (2007). A review of the role of adult attachment style in psychosis: unexplored issues and questions for further research. Clinical Psychology Review, 27, 458475. https://doi.org/10.1016/j.cpr.2006.09.006 CrossRefGoogle ScholarPubMed
Berry, K., Ford, S., Jellicoe-Jones, L., & Haddock, G. (2013). PTSD symptoms associated with the experiences of psychosis and hospitalisation: a review of the literature. Clinical Psychology Review, 33, 526538.CrossRefGoogle ScholarPubMed
Berry, K., Ford, S., Jellicoe-Jones, L., & Haddock, G. (2015). Trauma in relation to psychosis and hospital experiences: the role of past trauma and attachment. Psychology and Psychotherapy: Theory, Research and Practice, 88, 227239.10.1111/papt.12035CrossRefGoogle ScholarPubMed
Berry, K., Haddock, G., Kellett, S., Roberts, C., Drake, R., & Barrowclough, C. (2016). Feasibility of a ward-based psychological intervention to improve staff and patient relationships in psychiatric rehabilitation settings. British Journal of Clinical Psychology, 55, 236252. https://doi.org/10.1111/bjc.12082 CrossRefGoogle ScholarPubMed
Boniwell, N., Etheridge, L., Bagshaw, R., Sullivan, J., & Watt, A. (2015). Mental health nurses’ perceptions of attachment style as a construct in a medium secure hospital: a thematic analysis. The Journal of Mental Health Training, Education and Practice, 10, 218233.10.1108/JMHTEP-01-2015-0002CrossRefGoogle Scholar
Bowlby, J. (1969). Attachment and Loss: Vol. 1. Attachment. Basic Books.Google Scholar
Bowlby, J. (1973). Attachment and Loss: Vol. 2. Separation, Anxiety, and Anger. Basic Books.Google Scholar
Bowlby, J. (1988). A Secure Base. Basic Books.Google Scholar
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77101. https://doi.org/10.1191/1478088706qp063oa CrossRefGoogle Scholar
British Psychological Society (2021). Psychological services within the acute adult mental health care: Pathway guidelines for service providers, policy makers and decision makers. British Psychological Society.Google Scholar
Bucci, S., Roberts, N. H., Danquah, A. N., & Berry, K. (2014). Using attachment theory to inform the design and delivery of mental health services: a systematic review of the literature. Psychology and Psychotherapy: Theory, Research and Practice, 88, 120.10.1111/papt.12029CrossRefGoogle ScholarPubMed
Care Quality Commission (2017). The state of care in mental health services 2014 to 2017: Findings from CQC’s programme of comprehensive inspections of specialist mental health services. Available at: https://www.cqc.org.uk/sites/default/files/20170720_stateofmh_report.pdf Google Scholar
Care Quality Commission (2019). Letter to mental health providers from Dr Paul Lelliott. Available at: https://carequalitycomm.medium.com/letter-to-mental-health-providers-from-dr-paul-lelliott-211cd8846bb1 Google Scholar
Crossley, N., & Sweeney, B. (2020). Patient and service-level factors affecting length of inpatient stay in acute mental health service: a retrospective case cohort study. BMC Psychiatry, 20, 19. https://doi.org/10.1186/s12888-020-02846-z CrossRefGoogle ScholarPubMed
Cutler, N. A., Sim, J., Halcomb, E., Moxham, L., & Stephens, M. (2020). Nurses’ influence on consumers’ experience of safety in acute mental health units: a qualitative study. Journal of Clinical Nursing, 29, 43794386.CrossRefGoogle ScholarPubMed
Department of Health (1999). The National Service Framework for Mental Health: modern standards and service models. Department of Health.Google Scholar
Dozier, M. (1990). Attachment organisation and treatment use for adults with serious psychopathological disorders. Development and Psychotherapy, 2, 4760. https://doi.org/10.1017/S0954579400000584 Google Scholar
Fraley, R. C., & Dugan, K. A. (2021). The consistency of attachment security across time and relationships. In Thompson, R. A., Simpson, J. A., & Berlin, L. J., Attachment: The Fundamental Questions (pp. 147153). Guilford Press.Google Scholar
Gumley, A. I., Schwannauer, M., Macbeth, A., Fisher, R., Clark, S., Rattrie, L., … & Birchwood, M. (2014a). Insight, duration of untreated psychosis and attachment in first-episode psychosis: prospective study of psychiatric recovery over 12-month follow-up. British Journal of Psychiatry, 205, 6067. https://doi.org/10.1192/bjp.bp.113.126722 CrossRefGoogle ScholarPubMed
Gumley, A. I., Taylor, H. E. F., Schwannaeur, M., & MacBeth, A. (2014b). A systematic review of attachment and psychosis: measurement, construct validity and outcomes. Acta Psychiatrica Scandinavica, 129, 257274. https://doi.org/10.1111/acps.12172 CrossRefGoogle ScholarPubMed
Kobak, R. R., & Sceery, A. (1988). Attachment in late adolescence: working models, affect regulation, and representations of self and others. Child Development, 59, 135146.10.2307/1130395CrossRefGoogle ScholarPubMed
Korver-Nieberg, N., Berry, K., Meijer, C., de Haan, L., Ponizovsky, A. M. (2015). Associations between attachment and psychopathology dimensions in a large sample of patients with psychosis. Psychiatry Research, 228, 8388. https://doi.org/10.1016/j.psychres.2015.04.018 CrossRefGoogle Scholar
Laithwaite, H., & Gumley, A. (2007). Sense of self, adaptation and recovery in patients with psychosis in a forensic NHS setting. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 14, 302316.CrossRefGoogle Scholar
Lay, B., Lauber, C., & Rössler, W. (2006). Prediction of in-patient use in first-admitted patients with psychosis. European Psychiatry, 21, 401409. https://doi.org/10.1016/j.eurpsy.2005.12.004 CrossRefGoogle ScholarPubMed
Loft, N. O., & Lavender, T. (2016). Exploring compulsory admission experiences of adults with psychosis in the UK using Grounded Theory. Journal of Mental Health, 25, 297302.10.3109/09638237.2015.1101415CrossRefGoogle ScholarPubMed
Mikulincer, M., & Shaver, P. R. (2016). Attachment processes and emotion regulation. In Mikulincer, M. & Shaver, P. R., Attachment in Adulthood: Structure, Dynamics, and Change (2nd edn) (pp. 187225). New York: Guilford Press.Google Scholar
NHS England (2019). NHS Mental Health Implementation Plan 2019/20–2023/24. NHS England.Google Scholar
Paterson, C., Karatzias, T., Dickson, A., Harper, S., Dougall, N., & Hutton, P. (2018). Psychological therapy for inpatients receiving acute mental health care: a systematic review and meta-analysis of controlled trials. British Journal of Clinical Psychology, 57, 453472.Google ScholarPubMed
Paterson, C., Karatzias, T., Harper, S., Dougall, N., Dickson, A., & Hutton, P. (2019). A feasibility study of a cross-diagnostic, CBT-based psychological intervention for acute mental health inpatients: results, challenges, and methodological implications. British Journal of Clinical Psychology, 58, 211230.10.1111/bjc.12209CrossRefGoogle ScholarPubMed
Ponizovsky, A. M., Nechamkin, Y., & Rosca, P. (2007). Attachment patterns are associated with symptomology and course of schizophrenia in male inpatients. American Journal of Orthopsychiatry, 77, 324331. https://doi.org/10.1037/0002-9432.77.2.324 CrossRefGoogle Scholar
Ride, J., Kasteridis, P., Gutacker, N., Aragon Aragon, M. J., & Jacobs, R. (2020). Healthcare costs for people with serious mental illness in England: an analysis of costs across primary care, hospital care, and specialist mental healthcare. Applied Health Economics and Health Policy, 18, 177188.10.1007/s40258-019-00530-2CrossRefGoogle ScholarPubMed
Royal College of Psychiatrists (2016). Old problems, new solutions: Improving acute psychiatric care for adults in England. Royal College of Psychiatrists.Google Scholar
Royal College of Psychiatry (2016). Old problems, New Solutions: Improving acute psychiatric care for adults in England. https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/policy/policy-old-problems-new-solutions-caapc-report-england.pdf?sfvrsn=7563102e_2 Google Scholar
Safran, J. (1990a). Towards a refinement of cognitive therapy in light of interpersonal theory: I. Theory. Clinical Psychology Review, 10, 87105.10.1016/0272-7358(90)90108-MCrossRefGoogle Scholar
Safran, J. (1990b). Towards a refinement of cognitive therapy in light of interpersonal theory: II. Practice. Clinical Psychology Review, 10, 107121.10.1016/0272-7358(90)90109-NCrossRefGoogle Scholar
Safran, J., & Segal, Z. V. (1996). Interpersonal process in cognitive therapy. Jason Aronson Incorporated.Google Scholar
Skivington, K., Matthews, L., Simpson, S. A., Craig, P., Baird, J., Blazeby, J. M. et al. (2021). Framework for the development and evaluation of complex interventions: gap analysis, workshop and consultation-informed update. Health Technology Assessment, 25. https://doi.org/10.3310/hta25570 Google Scholar
Stenhouse, R. C. (2013). ‘Safe enough in here?’: patients’ expectations and experiences of feeling safe in an acute psychiatric inpatient ward. Journal of Clinical Nursing, 22, 31093119.CrossRefGoogle Scholar
Tait, L., Birchwood, M., & Trower, P. (2004). Adapting to the challenge of psychosis: personal resilience and the use of sealing-over (avoidant) coping strategies. British Journal of Psychiatry, 185, 410415. https://doi.org/10.1192/bjp.185.5.410 CrossRefGoogle Scholar
Wickham, S., Sitko, K., & Bentall, R. P. (2015). Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self-esteem. Psychological Medicine, 45, 14951507. https://doi.org/10.1017/S0033291714002633 CrossRefGoogle ScholarPubMed
Wood, D., & Pistrang, N. (2004). A safe place? Service users’ experiences of an acute mental health ward. Journal of Community & Applied Social Psychology, 14, 1628.CrossRefGoogle Scholar
Wyder, M., Ehrlich, C., Crompton, D., McArthur, L., Delaforce, C., Dziopa, F., … & Powell, E. (2017). Nurses experiences of delivering care in acute inpatient mental health settings: a narrative synthesis of the literature. International Journal of Mental Health Nursing, 26, 527540.CrossRefGoogle ScholarPubMed
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Figure 1. Attachment-based CBT formulation models

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Table 1. Key themes highlighted in PPI sessions

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