School of Psychology, University of Birmingham, Birmingham, UK
Birmingham Early Intervention Service, Birmingham and Solihull Mental Health Trust and School of Psychology, University of Birmingham, Birmingham, UK
School of Psychology, University of Birmingham, Birmingham, UK
Correspondence: Professor Max Birchwood, School of Psychology, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK. E-mail: m.j.birchwood.20{at}bham.ac.uk
Declaration of interest None. Funded by the School of Psychology, University of Birmingham, UK.
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ABSTRACT |
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Aims We examined the hypothesis that individuals who seal over do not have the personal resilience to withstand this major life event.
Method Fifty participants were interviewed during an acute episode of psychosis and reassessed at 3-month and 6-month follow-up. Measures included psychotic symptoms, recovery style, service engagement, parental and adult attachment and self-evaluative beliefs.
Results Sealing-over recovery styles are associated with negative early childhood experience, insecure adult attachment, negative self-evaluative beliefs and insecure identity. Insecure adult attachment was associated with less engagement with services.
Conclusions Sealing over was associated with multiple signs of low personal resilience in adapting to psychosis.
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INTRODUCTION |
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METHOD |
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Fifty individuals with an ICD10 (World Health Organization, 1992) chart diagnosis of schizophrenia or related disorders (F20, F22, F23, F25) were recruited from two urban mental health services. The Structured Clinical Interview for the Positive and Negative Syndrome Scale (SCIPANSS; Kay et al, 1987) was used to assess suitable patients. Participants were excluded if they had a primary diagnosis of substance use disorder, mood disorder or organic mental disorder. Assessments were conducted during acute psychosis and at 3-month and 6-month follow-up.
Instruments
Positive and Negative Syndrome Scale
Severity of psychosis was measured with the SCIPANSS
(Kay et al, 1987).
The 30-item SCIPANSS is a widely used, valid and reliable measure for
assessing symptoms of schizophrenia.
Recovery Style Questionnaire
Recovery style was measured with the Recovery Style Questionnaire (RSQ;
Drayton et al, 1998).
The RSQ is a 39-item self-report measure, designed to reflect categories
consistent with those developed by McGlashan et al
(1977). Four recovery styles
can be classified: integration; mixed picture in which integration
predominates; mixed picture in which sealing over predominates; sealing over.
Higher scores represent sealing over. The RSQ was admini administered at each
of the three stered assessments.
Parental Bonding Instrument
Recalled parenting behaviours were assessed using the revised version of
the Parental Bonding Instrument (PBI;
Parker et al, 1997).
This 25-item self-report questionnaire comprises the Protection Scale (13
items) and the Care Scale (12 items). Participants are asked to indicate, on a
four-point Likert-style scale, the extent to which each item is characteristic
of their mother and father. Low scores on the Care Scale reflect perceived
parental neglect and rejection, whereas high scores reflect perceived parental
warmth and affection. High scores on the Protection Scale indicate perceived
excessive control and intrusive parenting, whereas low scores suggest
perceived parental acceptance of a childs independence and autonomy.
Testretest reliability values have been reported as 0.77 for the
maternal Care Scale, 0.73 for the maternal Protection Scale, 0.58 for the
paternal Care Scale and 0.69 for the paternal Protection Scale in a sample of
patients diagnosed with schizophrenia
(Parker et al, 1982).
Perceived parental abuse (physical) was measured with the five-item Measure of
Parenting Style (MOPS; Parker et
al, 1997). The PBI and MOPS were administered at the 3-month
follow-up point, when the individual had recovered from the acute episode. In
this study, the Cronbach coefficient was 0.97 for maternal care, 0.96
for paternal care, 0.67 for maternal protection, 0.76 for paternal protection,
0.94 for maternal abuse and 0.95 for paternal abuse.
Revised Adult Attachment Scale (RAAS)
Adult attachment style was measured with the revised version of the Adult
Attachment Scale (RAAS; Collins,
1996); an adaptation of a self-report measure of adult attachment
developed by Collins & Read
(1990). The scale consists of
18 items, 6 on each of three sub-scales: the Close sub-scale refers to the
extent to which an individual is comfortable with closeness and intimacy in
relationships; the Depend sub-scale measures the degree to which an individual
can depend on others; and the Anxiety sub-scale refers to a persons
fear of interpersonal rejection. Ratings are made on a five-point scale (1,
not at all characteristic of me; 5, very characteristic of me). An individual
with a secure attachment style can tolerate closeness/intimacy
and dependence on others and has low anxiety about interpersonal rejection
(Collins, 1996). The RAAS was
administered at the 3-month assessment. The Cronbach coefficient was
0.86 for the Close sub-scale, 0.86 for the Depend sub-scale and 0.97 for the
Anxiety sub-scale.
Evaluative Beliefs Scale
The Evaluative Beliefs Scale (EBS;
Chadwick et al, 1999)
was used to assess self-evaluative beliefs about self and others. Evaluative
beliefs were assessed across three specific dimensions: six items constitute a
self-evaluation sub-scale (SelfSelf); six items constitute evaluations
of other people (SelfOther); and six items constitute a persons
beliefs about how other people evaluate them (OtherSelf). Higher scores
reflect greater negative evaluation. Reliability is reported as excellent
(Chadwick et al,
1999), with for the SelfSelf, OtherSelf and
SelfOther scales reported to be 0.90, 0.92, and 0.86, respectively. In
this study,
for the SelfSelf, OtherSelf and other
SelfOther scales were 0.89, 0.95 and 0.88, respectively. The EBS was
administered at the 3-month assessment.
Service Engagement Scale
Service engagement was measured with the Service Engagement Scale (SES;
Tait et al, 2002).
The SES is a 14-item measure, with higher scores indicating lower engagement.
The SES was completed at the 6-month assessment. The Cronbach coefficient
was 0.81 for availability, 0.76 for collaboration, 0.90 for
help-seeking and 0.82 for treatment adherence.
Self and Other Scale
Secure self was measured with the Self and Other Scale (SOS;
Dagnan et al, 2002).
The SOS is a self-report scale with two sub-scales, the Insecure Self and the
Engulfed Self, each consisting of seven items rated on a five-point scale
ranging from agree strongly to disagree strongly.
The Cronbach coefficient for the Insecure Self sub-scale was reported
as 0.76, and 0.78 for the Engulfed Self sub-scale. In this study,
was
0.92 for the Insecure Self sub-scale and 0.82 for the Engulfed Self sub-scale.
The SOS was administered at the 6-month assessment.
Calgary Depression Scale for Schizophrenia
Depression was measured with the Calgary Depression Scale for Schizophrenia
(CDSS; Addington et al,
1993). The CDSS is a structured interview measure specifically
designed for use in samples of individuals diagnosed with schizophrenia: the
CDSS distinguishes between depression and negative symptoms, and is reported
to be more straightforward to administer than other widely used depression
instruments (Addington et al,
1993).
The CDSS is composed of eight structured questions and one interviewer
observation of the entire interview. The higher the total score, the higher
the level of depression. It has been shown to possess excellent psychometric
properties, including good correlation with other well-established measures of
depression (r=0.790.87), with internal consistency
values of 0.710.79 (Addington et
al, 1993).
Statistical analysis
Statistical analysis was performed with the Statistical Package for the
Social Sciences for Windows, version 10.0.7. The 2 test and
Fishers exact test were used to test categorical variables. One-way
analysis of variance (ANOVA), with planned comparison tests where appropriate,
was used for significance in mean differences between groups. Pearsons
correlation analysis was used to examine relationships between continuous
variables, and a one-sample t-test was used to test mean differences
between two groups.
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RESULTS |
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Self-evaluation and recovery style
Evaluative beliefs
As indicated in Table 1,
there was a significant difference between recovery style groups in
OtherSelf beliefs (F(3,42)= 5.26, P<0.01); the two
sealing-over groups scored significantly higher than the two integration
groups (F(1,42)=15.69, P<0.001), indicating a more
negative view of self.
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Secure self and recovery style
There was a significant overall group effect for the SOS, focusing on the
Insecurity sub-scale (F(3, 39)=6.09, P<0.1,
2=0.32); the planned contrast indicated that the two
sealing-over groups reported significantly higher scores (less secure) than
the two integration groups.
Recovery style and interpersonal attachment
Parental attachment
Preliminary correlation analysis at the 3-month assessment of the
relationship between the PBI and level of depression was undertaken to
determine the potential confounding effect of depression on perceived parental
bonding (i.e. to examine the possibility that negative mood might be a source
of bias in reported memories of perceived parenting). Correlations between the
Care, Protection and Abuse sub-scales and concurrent level of depression were
unrelated for mothers (r=0.10, P=0.54; r=0.02,
P=0.88; r=0.11, P=0.50) and for fathers
(r=-0.08, P=0.66; r=0.03, P=0.86;
r=-0.14, P=0.42). Similarly, there were no significant
correlations between any PBI and PANSS scales during follow-up, with the
exception of a correlation between PANSS general psychopathology and maternal
overprotection (r=0.39, P=0.007), between PANSS total
psychopathology and maternal abuse (r=0.34, P=0.03) and
between low paternal care and PANSS positive symptoms (r=-0.35,
P=0.025).
The means, ANOVA results and significance levels between the four recovery
style groups on the PBI scales are presented in
Table 1. There was a
significant overall difference for both the Care and Abuse sub-scale scores
for mothers (F(3,42)=4.81, P<0.01, 2=0.62;
F(3,37)=6.07, P<0.01,
2=0.33). Each of
the sealing-over groups rated mothers (F(1,42)=13.41,
P<0.001) and fathers (F(1,37)=38.19, P<0.001)
as significantly less caring and more abusive (F(1,42)=8.39,
P<0.01; F(1,37)=17.78, P<0.001, mothers and
fathers, respectively) than did each of the two integration groups. There were
no significant differences between the four groups in either maternal
protection (F(3,42)=2.12, P=0.11) or paternal protection
(F(3,37)= 1.06, P=0.38). These results were unaffected when
controlling for PANSS scales.
Adult attachment
Table 1 indicates that the
four recovery style groups differed significantly on the RAAS Close
(F(3,42)=3.92, P<0.01, 2=0.22), Depend
(F(3,42)=5.04, P<0.01,
2=0.26) and
(rejection) Anxiety sub-scales (F(3,42)=5.42, P<0.01,
2=0.28). Planned comparisons revealed that the two
sealing-over groups scored lower on the Close (F(1,42)=7.43,
P<0.01) and Depend (F(1,42)=13.51, P<0.001)
sub-scales but higher on the Anxiety sub-scale (F(1,42)=12.20,
P<0.001) than the integration groups.
There were no correlations between the RAAS and the PANSS, with the exception of a correlation of r=0.31 (P=0.03) between RAAS Anxiety and PANSS positive. The four recovery style groups continued to differ significantly on RAAS Anxiety when PANSS positive was controlled (F(3,42)=7.1, P<0.001).
Relationship between childhood and adult attachment
Attachment theory argues that attachments in childhood provide the
cognitive schema that guide adult relationships; the attachment style and
mental models of self and others develop early and tend to endure over time
(Bowlby, 1973). This study
therefore examined the relationship between the PBI and RAAS (see
Table 2).
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Strong and significant correlations were observed between the RAAS Depend and Close sub-scales and the Care sub-scale of the PBI for mothers and fathers. In contrast, the RAAS Depend and Close sub-scales were inversely related to the PBI Abuse sub-scale, again for both parents. Rejection anxiety in adult relationships (RAAS Anxiety) was significantly correlated with PBI abuse and (lack of) care in both parents. The (over) protection scale did not feature as a significant dimension linking early and adult attachment.
Current adult attachment and service engagement
A one-sample t-test conducted on the SES total scores revealed
that the RAAS insecurely attached group had significantly higher
SES mean scores (mean 23.72, s.d.=10.74) than the securely
attached group (mean 10.07, s.d.=10.20): t=3.64,
P<0.001, 2=0.31. These results reveal that having
an insecure attachment style is associated with a greater likelihood of
dis-engaging from mental health services staff.
Recovery style and psychological adjustment
Recovery style and depression
Contrary to expectations, the ANOVA results revealed no significant
between-group differences in the level of depression at the 6-month follow-up
(F(3,38)=1.14, P>0.05, 2=0.08).
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DISCUSSION |
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Methodological issues
The reliance in this study on retrospective accounts of early childhood
experience, and the potential recall bias that may have resulted from
depressed mood, raises a question about the reliability of these data.
However, statistical analysis indicated little or no bias due to an effect of
mood on reported memories of perceived parenting; Duggan et al
(1998) reported that depressed
patients retrospective reports of parental relationships, as measured
by the PBI, were corroborated by their siblings. Although bias cannot be ruled
out, these considerations, and the similarity with other findings in the
literature, do support their validity: attachment theory argues that
attachments in childhood and adolescence provide the cognitive schema that
come into play in adult relationships, so we would expect correlations between
early (PBI) and adult (RAAS) attachment measures, which was precisely what was
observed. From a methodological point of view, however, the predicted link
between self-ratings of childhood and adult relationships argues against
retrospective bias in the case of the PBI and supports one of the central
propositions of attachment theory, that individuals are accessing schema that
endure and are common to both. It should be emphasised, however, that the link
between parental attachment and adult functioning in this group does not imply
that the arrow of causality runs from parent to child; contemporary child
development theory accepts that there may be behavioural anomalies in the
child (e.g. arising from a developing psychosis) that some parents may find
difficult adapting to, and that these transactions culminate in
attachment difficulty (Duggan et
al, 1998).
The use of inner-city settings in recruiting participants raises the question that the results may not generalise; for example, there may be a higher rate of parental neglect linked to deprivation in this setting. However, it should be noted that the participants were, in seven out of ten instances, within 5 years of first onset of psychosis and the experimental sampling method identified patients in acute crisis, including those who relapsed several times. We believe the sample, therefore, to be representative of the trajectories of psychosis in general (Harrison et al, 2001), but we cannot discount the possibility that the level of perceived parental difficulty is inflated.
The single correlation between anxiety about rejection in relationships and PANSS positive symptoms (r=0.31) raises the possibility that this mistrust is partly influenced by psychosis. This did not affect the observed difference between recovery groups, although mistrust in relationships is often observed as a premorbid characteristic and may lie on a continuum with persecutory thinking.
Recovery style and early childhood experience
This study found that participants with sealing-over recovery styles
reported lower levels of parental care during early childhood than those who
tended to use integration recovery styles, with no differences in parental
protection. These findings are consistent with previous research in which the
lack of care dimension appears to be more important to psychological
functioning than the protection dimension of the PBI
(Mackinnon et al,
1993; Drayton et al,
1998). The results of the present study add further support to the
view that anomalies of early childhood experience may have an effect on coping
with adversity in adulthood (e.g. Bowlby,
1969; Richman & Flaherty,
1987).
Previous evidence suggests that other early developmental experiences, such as physically abusive parenting, are important influences on emotional distress in adulthood; for example, Parker et al (1997) reported a link between abusive parenting and an adult diagnosis of depression. The present study adds to this evidence in finding that individuals with sealing-over recovery styles reported higher levels of reported abuse in childhood from both parents compared with individuals with integration recovery styles. However, the level of depression in the present study was unrelated to perceived parenting behaviour. The perception of parenting behaviour was evaluated after controlling for the effect of mood, indicating that the PBI scores were independent of the concurrent level of depression. Thus, as indicated above, reported parental behaviour was not the result of response bias related to depression, a finding consistent with previous research (Gerlsma et al, 1994).
Recovery style and adult attachment
Compared with integration recovery styles, sealing-over recovery styles
were associated with participants reports of more anxiety about
interpersonal rejection, as well as with lower levels of comfort with
closeness and dependence in relationships. Furthermore, insecurely attached
participants were more prone to low engagement with services than were
participants who had more secure attachment styles. This finding, that
insecure attachment was related to an avoidant style of coping (i.e. sealing
over), which in turn predicted less engagement with services, is in line with
attachment theory and previous research showing the vulnerability of
insecurely attached persons in coping with stressful life experiences
(Bowlby, 1969;
Mikulincer, 1998). Again, this
is in keeping with previous research showing that insecurely attached persons
tend towards interpersonal distance
(Klohnen & Bera, 1998) and
negative, mistrusting beliefs about other people
(Collins & Read, 1990;
Mikulincer, 1998). It seems
likely that mental health professionals are also viewed in this way by
patients who seal over and have insecure attachment styles, which in turn
contribute to lower engagement with services
(Adshead, 1998;
Tait et al, 2003). In
other words, low engagement with psychiatric services and case managers may,
in part, reflect attachment concerns. An alternative explanation is that low
engagement with psychiatric services is a rational response to maladaptive
care strategies adopted by mental health care professionals
(Adshead, 1998), or where
services are inappropriate or insensitively delivered to clients
(Tait et al, 2002).
Indeed, researchers have suggested that the formation of a trusting
relationship between mental health care professionals and service users is a
task for both parties (Tait et
al, 2002).
Contrary to the hypothesis, and the findings of Drayton et al (1998), the results indicate that participants with sealing-over recovery styles do not hold higher levels of negative evaluative beliefs about the self or about others, and are not more depressed, compared with those who use integration recovery styles. However, those who used sealing-over recovery styles also reported higher ratings on the OtherSelf sub-scale of the EBS, indicating a vulnerability to believe that others view them in a negative way. This is in line with findings that individuals who seal over also tend to have insecure attachment styles that are represented by concerns about ongoing interpersonal relationships. Although speculative, one possible explanation is consistent with attachment theory (Bowlby, 1969): individuals with sealing-over recovery styles who also have insecure attachment styles may be more likely to misinterpret others behaviour towards them as rejecting or critical and therefore are more likely to believe that others view them in a negative manner; or alternatively, it is possible that they are more sensitive to actual rejecting behaviour from others and are realistic in their appraisal of others views about themselves.
Recovery style and view of self
The results show that individuals who seal over have difficulties with
feelings of insecurity and interpersonal rejection; however, they were no more
likely than people who integrate to feel a need to protect the self from being
controlled by others. This supports the view that a functional sense of self
or identity is an important resilience factor in recovery from psychosis, and
in facilitating coping efforts (Davidson
& Strauss, 1992); conversely, individuals are unlikely to
engage in approach types of coping if they have failed to develop an active
and robust identity that goes beyond the confines of the illness
(Davidson & Strauss,
1992).
Therapeutic implications
The majority of the sample was aged under 30 years and was within 5 years
of onset of psychosis. This is a period of high risk of relapse
(Robinson et al,
1999) where the blueprint for long-term trajectories
is laid down (Harrison et al,
2001). Drug non-compliance is common in this phase and linked to a
cycle of relapse (Robinson et al,
1999); without effective service engagement at this stage, our
most effective treatments will not have an opportunity to deliver the benefits
they promise (Birchwood, 2003).
This and our linked study (Tait et
al, 2003) together suggest that service engagement is not
solely a matter of insight or resolution of psychotic symptoms, but of
personal adaptation to the potentially traumatic nature of the diagnosis and
its treatment. This analysis proposes two therapeutic avenues.
The first concerns the design of services and the interpersonal behaviour of case managers. Individuals who seal over may be more likely to engage with a service that is on tap, but not on top: in other words, one that engages in a low-key, informal way, that keeps the patient in control of the relationship and focuses attention to the broader needs and aspirations of the individual, in a normalising context. Demanding and cajoling compliance with treatment, insensitive use of psycho-education and stigmatising the individual (e.g. by admission to wards with more chronic patients) would be likely to stoke avoidance and disengagement in this group. Because engagement is a two-way process, additional research to understand the complex effects of the interpersonal relationship between the client and the mental health care professional appears to be of urgent policy importance.
Second, therapeutic attention needs to focus on raising self-esteem through non-intrusive activity; the case managerclient relationship may be seen as a test bed to develop trust in others. Case managers would need to have low expressed emotion in their interpersonal behaviour and to recognise that they may be key figures in restoring the individuals psychosocial development trajectory (Birchwood, 2003). The style of intervention envisaged is the low-key, motivational approach employed in compliance therapy (Kemp et al, 1996).
In conclusion, this study has shown that a sealing-over recovery style is associated with multiple indicators of low personal resilience in adapting to psychosis. Whether sealing over is adaptive in reducing distress during recovery should be explored.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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