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Understanding Adult Attachment in Family Relationships: Research, Assessment and Intervention
by Antonia Bifulco and Geraldine Thomas

Attachment theory has become a key focus of both research and practice in understanding and treating psychological and social risk for marital and relationship problems, parenting and clinical disorders. In particular, adult attachment style is a key explanatory factor for understanding problems in human relationships. This practical book introduces and explains an easily accessible assessment tool for adult attachment style, the Attachment Style Interview (ASI). Based on extensive research study, it then discusses appropriate interventions and case assessments that can be made to help families in need. Simpler than the Adult Attachment Interview, which requires expert administration, the ASI is an invaluable and evidence-based resource and is particularly useful for multiagency practitioners working with children and families, including those in adoption and fostering, child Safeguarding, ‘Looked After’ and therapeutic services. Presenting clear and concise descriptions of the measure and summaries of the attachment models developed, it provides discussions of its relevance for different practice contexts. This text uses a range of worked case studies to illustrate its principles and applications. It details attachment issues in different relationship domains to cover areas of risk and resilience relevant for practice such as:

• Adult depression and anxiety and stress models
• Partner difficulties including domestic violence
• Childhood neglect and abuse as a source of attachment problems
• Parenting and intergenerational transmission of risk
• Resilience factors Interventions, service application and use in family therapy.

Expected publishing date: Autumn 2012.

Research abstracts / published papers

The ASI is continuously being used in research to investigate further its relationship to childhood experience, parenting, and mental health in different age groups by the Lifespan Research Group, based at Kingston University London. More information about their research and consultancy can be found on their website: www.lifespanresearch.org.uk

The following abstracts summarise some key published papers. These papers are available on request. The email address is LifespanTraining@kingston.ac.uk

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Adult Attachment Style I: Its relationship to clinical depression
A Bifulco et al. Social Psychiatry & Psychiatric Epidemiology; 37: 50-59 (2002)

Adult Attachment Style II: Its relationship to psychosocial depressive vulnerability
A Bifulco et al. Social Psychiatry & Psychiatric Epidemiology; 37: 60-67 (2002)

Maternal attachment style and depression associated with childbirth: Preliminary results from a European/US cross-cultural study
A Bifulco et al, British Journal of Psychiatry 184 (supplement 46) s31-37. (2004)

Teenage pregnancy, attachment style, and depression: a comparison of teenage and adult pregnant women in a Portuguese series
B. Figueiredo, A. Bifulco, A. Pacheco, R. Costa & R. Magarinho Attachment and Human Development, 8 (2). pp. 123-138, (2006)

The Vulnerable Attachment Style Questionnaire (VASQ): An interview-derived measure of attachment styles that predict depressive disorder
A Bifulco et al, Psychological Medicine, 33:1099-1110, (2003)

Adult attachment style as a mediator between childhood neglect/abuse and adult depression and anxiety
A Bifulco et al. Social Psychiatry & Psychiatric Epidemiology 41(10):796-805, (2006)

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Background
Although there is an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment, which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al., 2002) .

Method
222 high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into 'Angry-dismissive' and 'Withdrawn'. The degree to which attitudes and behaviour within such styles were dysfunctional ('non-standard') was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder.

Results
The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the 'non-standard' levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder.

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Background
A range of studies show adult attachment style is associated with depressive- vulnerability factors such as low self-esteem, poor support and childhood adversity. However, there is wide inconsistency shown in the type of insecure style most highly associated. Few studies have examined attachment style in relation to clinical depression together with a range of such factors in epidemiological series. The present study uses an interview measure of adult attachment, which differentiates type of attachment style and degree of insecurity of attachment, to see (a) if it adds to other vulnerability in predicting depression and (b) to see if there is specificity of style to type of vulnerability.

Method
222 high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. The Attachment Style Interview for Adoption / Fostering (ASI-AF) differentiated five styles (Enmeshed, Fearful, Angry-dismissive, Withdrawn and Standard) as well as the degree to which attitudes and behaviour within such styles were dysfunctional ('Non-standard'). Attachment style was examined in relation to low self-esteem, support and childhood experience of neglect or abuse, and all of these examined in relation to clinical depression in a 12-month period.

Results
The presence of any 'insecure' style was significantly related to poor support, low self-esteem, and childhood adversity. Some specificity of type of style and type of vulnerability was observed. Logistic regression showed that non-standard Enmeshed, Fearful and Angry-dismissive styles, poor support and childhood neglect/abuse provided the best model for clinical depression.

Conclusion
Insecure attachment in the form of Markedly Enmeshed, Markedly Fearful, or Markedly Angry-dismissive styles were shown to be associated with other depressive-vulnerability factors involving close relationships, self-esteem and childhood adversity and added to these in modelling depression.

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Background
Whilst insecure attachment style has been shown to relate to major depression in women, its relationship to depression associated with childbirth is largely unknown. A new UK-designed measure (Attachment Style Interview for Adoption/Fostering: ASI) utilised across European and US centres allowed for an assessment of its wider utility as a risk marker for maternal disorder.

Aims
To establish the reliability of the ASI across European/US centres, its stability over a 9-month period, and to test associations of insecure attachment with characteristics of the social context and with DSM-IV major or minor depression.

Method
The ASI was used by nine centres antenatally on 204 women, of whom 174 were followed-up 6 months postnatally. Inter-rater reliability was tested on 35 cases and the ASI was repeated at 6-months postnatally on a subset of 96 of the 174 women. Affective disorder throughout pregnancy and to 6 months postnatally was assessed by means of the SCID.

Results
Satisfactory inter-rater reliability was achieved with relatively high stability rates at follow-up. Rates of insecure attachment for the total group were similar to previously published London rates despite significant variability across study centres. Insecure attachment related to lower social class position and more negative social context. It also related to DSM-IV major or minor depression both antenatally and postnatally. A specific association of Avoidant style (Angry-dismissive or Withdrawn) and antenatal disorder and Anxious style (Enmeshed or Fearful) and postnatal disorder was found.

Conclusion
The ASI can be used reliably in European and US centres as a measure for risk associated with childbirth. Its use will allow for theoretically underpinned preventative action for disorders associated with childbirth.

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Abstract
The aim of this Portuguese study is to compare the experience of pregnancy in teenage years and later adulthood and to examine insecure attachment style as a risk factor for depression during pregnancy. The Attachment Style Interview (ASI; Bifulco, Moran, Ball, & Bernazzani, 2002) and the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987) were administered to 66 pregnant adolescents and 64 adult women. Pregnant teenagers were found to be nearly three times more likely to have an insecure attachment style of Enmeshed, Angry-Dismissive, or Fearful style than adults, all at high levels of impairment (54% vs.19%, p5.02). Logistic regression showed, when all risk factors were entered, highly Enmeshed style and poor partner support provided the best model for depression with age at pregnancy no longer adding. Insecure attachment style should be addressed in prevention and intervention strategies with teenage mothers.

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Background
The Vulnerable Attachment Style Questionnaire (VASQ) was developed to provide a brief self-report tool to mirror an existing investigator-based interview (Attachment Style Interview - ASI). Both aimed to identify individuals with attachment relationship styles that are predictive of depressive disorder. This paper describes the development and scoring of the VASQ and its relationship to poor support and major depression.

Method
Items for the VASQ reflected behaviours, emotions, and attitudes relating to attachment relationship style, drawn directly from the ASI. The VASQ was validated against the ASI for 262 community-based subjects. Test-retest was determined on 38 subjects.

Results
Factor analysis derived 2 factors, labelled 'insecurity' and proximity-seeking'. After eliminating redundant items a scoring system was derived using median scores. The VASQ insecurity dimension had highest mean scores for those with interview-based Angry-dismissive and Fearful styles and was significantly correlated with degree of interview-based insecurity. The proximity-seeking VASQ scores had highest mean for those with Enmeshed interview attachment style and was uncorrelated with ASI insecurity. VASQ scores were highly correlated with a well known self-report measure of insecure attachment (Relationship Questionnaire) and test-retest reliability of the VASQ was satisfactory. The total VASQ score and the insecurity subscale proved highly related to poor support and to depressive disorder. This was not the case for the proximity-seeking dimension.

Conclusion
The VASQ is a brief self-report measure which distinguishes individuals with attachment styles vulnerable for depressive disorder. The use of the measure for screening in research and clinical contexts are discussed.

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Background
There has been little prospective investigation of the relationship between adult attachment style and clinical levels of anxiety and major depression. This paper seeks to address this, as well as examining the potentially mediating role of adult insecure attachment styles in the relationship between childhood adverse experience and adult disorder.

Method
154 high-risk community women studied in 1990-1995 were followed up in 1995-1999 to test the role of insecure attachment style in predicting new episodes of anxiety and/or major depressive disorder. The Childhood Experience of Care and Abuse (CECA) and the Attachment Style Interview (ASI) were administered at first interview and the Structured Clinical Interview for DSM-1V (SCID) administered at first and follow-up interview. Major depression and clinical level anxiety disorder (GAD, Social Phobia or Panic and /or Agoraphobia) were assessed at first contact and for the intervening follow-up period.

Results
55% (85/154) of the women had at least one case level disorder in the follow-up period. Only markedly or moderately (but not mildly) insecure attachment styles predicted both major depression and case anxiety in follow-up. Some specificity was determined with Fearful style significantly associated both with depression and Social Phobia, and Angry-Dismissive style only with GAD. Attachment style was unrelated to Panic Disorder and/or Agoraphobia. In addition, Fearful and Angry-dismissive styles were shown to partially mediate the relationship between childhood adversity and depression or anxiety.

Conclusion
In order to correctly interpret lifespan models of adult psychiatric disorder, it is necessary to test for mediating factors. Attachment theory provides a framework for determining how dysfunctional interpersonal style arising from early childhood perpetuates vulnerability to affective disorders. This has implications for intervention and treatment to break cycles of risk.

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