), and is also an associate clinical teacher at the University of Warwick. His interests include the contribution of attachment theory to personality development and the help-seeking literature, and the assessment of attachment in adolescence and adulthood. This is the second of two articles by Kenneth Ma discussing attachment theory in general adult psychiatry. The first article (Ma, 2006), which should be read in conjunction with the current one, gave an overview of attachment theory, and outlined some of the latest research into the relationship between attachment and different psychiatric disorders.
Case vignette 1Mr G. is a 39-year-old man who has had episodes of schizophrenia since the age of 17. He lives on his own. Since his diagnosis, he has been hospitalised six times because of uncontrolled auditory hallucinations and delusions of persecution; the most recent hospitalisation occurred 2 years ago. For the past 7 years, his keyworker has been Mr S., a community psychiatric nurse with whom Mr G. has formed a trusting relationship. Owing to staff shortage, Mr G. is reviewed medically by the senior house officer (SHO) on the team rather than the consultant; this means that he has to meet a new doctor every 6 months. At Mr G.'s latest outpatient psychiatric appointment, the SHO (who was meeting the patient for the first time) suggested that Mr G.'s antipsychotic medication be increased, as it was reported that his auditory hallucinations were becoming more prominent. Mr G. at first denied the increase in positive symptoms and objected strenuously to the proposed medication change. However, in consultation with Mr S., who attended the appointment with him, he admitted to a deterioration in his mental state and accepted the increase in medication.
Staff as attachment figuresThe idea that patients can come to regard mental health professionals as attachment figures (even if for a limited time period) has been argued cogently by a number of authors (Bowlby, 1988;Dozier et al, 1994;Adshead, 1998;Goodwin, 2003;Wilkinson, 2003), although this has not always been backed up by empirical research. Psychiatric staff who function as caregivers may play an important role in providing both a secure base for patients whose attachment needs are activated during periods of distress and corrective experiences that disconfirm patients' insecure 'internal working models' of attachment relationships (see Ma, 2006), thus enabling more secure ways of interacting with others. The case vignette of Mr G. with which I opened this article illustrates the secure base function that can be fulfilled by individual keyworkers. During his illness, Mr G. has met a series of different doctors at different stages of their training. His attachment system is activated during an appointment with another new doctor, which makes it difficult for him to accept medical advice from this relative stranger. However, the presence of Mr S., with whom he has developed a secure attachment over the years, enabled Mr G. to accept the change in medication. Thi...
