BRITISH JOURNAL OF PSYCHIATRY (1998). 172.
64-69
Psychiatric staff as attachment figures
Understanding management problems in psychiatric services in
the light of attachment theory
GWEN ADSHEAD*
Background Attachment theory Attachment theory has been a powerful
argues that psychological development influence on child psychiatry, psychother
apy, and psychotherapy research. Bowlby
and functioning are affected by our earliest
(1988) first postulated that attachment to
attachments to care-givers. Failed or
others has an ethological basis, producing
pathological attachment in childhood may behaviours which are driven by a need for
give rise to repetition of maladaptive relationships, rather than food or sex. This
attachment patterns in adulthood. paper will focus on the implications of
attachment theory for general practice. I
Method Analysisof therapeutic will discuss whether relationships between
general psychiatric patients and mental
relationships in the light of attachment
health care professionals in general psy
theory.
chiatric environments could be charac
terised as 'attachment' relationships. An
Results Relationshipsbetween
understanding of therapeutic relationships
patients and both psychiatric care-givers
within psychiatric services, based on attach
and institutions may resemble attachment ment theory, may offer a new perspective
relationships. on management and behavioural problems
that occur in clinical practice.
Conclusion An attachment
perspective may be useful for
understanding common behavioural ATTACHMENT BEHAVIOUR
ANDTHEORY
disturbances in general psychiatric
settings, and supportthe use of clinical Attachment theory holds that humans are
strategies which focus on containment of essentially social animals who need rela
arousal and the management of anxiety tionships for survival, and whose first
relationships with parental figures have
states.
unique characteristics (Bowlby, 1988). At
tachment behaviour is any form of behav
iour that results in a person attaining or
maintaining proximity to an 'attachment
figure'; usually a care-giver. Such behaviour
is most obvious when people are frightened,
fatigued or sick, and is assuaged by
comforting and care-giving (Bowlby,
1979). It can be seen throughout the life
cycle, especially in emergencies, and its
biological function appears to be the
protection of the developing and vulnerable
organism.
Weiss (1991) suggests that relationships
can only be properly called attachments if
they display specific attachment properties,
including proximity-seeking, elicitation by
•The
Royal College of Psychiatristsand the Britishjournal threat, and the use of attachments as a
of Psychotherapyawarded the author a Psychotherapy secure base. To say that a person is
Prize for an earlier version of this paper. attached to, or has an attachment to
64
another, is to say that they are strongly
disposed to seek proximity to and contact
with that individual, and to do so especially
under certain specified conditions. Both the
quality and the strength of the attachment
are important.
In psychological terms, secure attach
ment relationships allow the developing
individual to construct 'internal working
models', of himself and others, based on the
interaction between himself and the attach
ment figure, which become established as
internal cognitive structures (Main et al,
1985). These structures provide a frame
work for cognitive processing of percep
tions, events and relationships, and the
development of belief systems and cognitive
schemata. Kraemer (1992) proposes a
neurophysiological basis for such cognitive
models.
Bowlby's theory proposes that attach
ment behaviour functions as a kind of
homeostatic mechanism for modulating
anxiety. Increasing anxiety and arousal
increases attachment behaviour; thus, the
goal of attachment behaviour can be seen as
helping the individual to modulate their
anxiety and arousal. Their own chosen
attachment figure is best, but failing this,
any attachment figure will do. A cold,
unhelpful figure is likely to be better than
nothing at all.
PSYCHOLOGICAL EFFECTS
OF INSECURE ATTACHMENT
Most of the early research on attachment in
non-human primates studied the effects of
failed attachment, usually as a result of
early separation. Failed attachment resulted
in disturbances of social behaviour, such as
sexual behaviour and grooming.
In humans, the nature and quality of
attachment has been studied in infants by
looking at infant behaviour in an unfamiliar
situation (Ainsworth et al, 1978). Three
main categories of insecure attachment in
children are described as avoidant, ambiva
lent and disorganised. In adults, security of
attachment style is assessed by linguistic
analysis of memories of parenting, recalled
in a semi-structured interview (Adult Attach
ment Interview (AAI); Main & Goldwyn,
1989). Three insecure attachment styles have
been described: dismissing, preoccupied and
unresolved following trauma or loss.
Could early insecurity of attachment be
a risk factor, predisposing factor or causa
tive agent of later psychiatric disorder?

Most developmental researchers would
argue for an interactional model of devel
opment. Rutter (1995) suggests that failure
of early attachment may be a risk factor for
later adult psychiatric disorder, by interact
ing with other vulnerability and resilience
factors to increase or decrease the risk of
psychiatric disorder in adulthood. If psy
chiatric disorder were understood as a
failure of the organism to manage neuro-
physiological and psychological homeosta-
sis, then it would be plausible to argue that
probably the majority of those with psy
chiatric disorders will have histories of
failed or pathological attachments, even
though only a minority of those individuals
with failed or pathological attachments will
develop psychiatric disorder.
INSECURE ATTACHMENT
AND PSYCHIATRIC
DIAGNOSES
Most research has been retrospective rather
than prospective, and has studied attach
ment histories in vulnerable subjects. For
example, depression in adulthood is asso
ciated with the loss of an attachment figure
in early life (Brown & Harris, 1978), and
hostility from parents (Parker, 1983). Dis
turbances of attachment have been found in
patients with major psychiatric illnesses,
such as schizophrenia or manic-depressive
illness (Dozier, 1990) and other disorders,
such as pathological bereavement reactions
(Parkes, 1991 ). A recent meta-analysis found
that insecure attachments were over-repre
sented in clinical populations (van Ijzen-
doorn & Bakermans Kranenburg, 1996).
Abuse, attachment and personality
disorder
One particular area of childhood experi
ence which might be relevant to attachment
history is that of abuse and neglect. If
abuse-related insecurity of attachment were
a risk factor for psychiatric disorder, then
one might expect to see an over-representa
tion of abused adults in psychiatric popul
ations. Some studies confirm this (for
review see Mullen et al, 1993). Mullen et
al found that a history of abuse in child
hood significantly increased risk of later
adult psychiatric disorder.
Attachment history is likely to be
relevant to the study and treatment of
personality disorders, where pathological
interpersonal relationships are a key diag
nostic feature. High rates of both sexual
PSYCHIATRIC
and physical abuse by parents have been
found in populations of women diagnosed
as suffering from borderline personality
disorder (BPD; Ogata et al, 1990), and
women who deliberately harm themselves
(Van der Kolk et al, 1991). Patrick et al
(1994) compared security of attachment in
BPD patients with a matched group of
patients with depression, using the AAI.
They found increased rates of insecure
attachment in the BPD group. Repetition
in adulthood of childhood attachment
patterns is most likely to be replicated in
the context of dependency relationships,
such as with their own children (Main et al,
1985); which may be relevant in the
aetiology of child-abusing behaviour, such
as Munchausen's syndrome by proxy.
There may be an interesting connection
between insecurity of attachment, as a
result of childhood trauma, and post-
traumatic stress disorders. In adults, the
psychodynamic effects of external disasters
on the internal world include disturbance of
internal homeostasis, and a massive chal
lenge to neurotic defences against fears of
abandonment (Garland, 1991). Reactions
to extreme threats to security, with con
comitant levels of internal anxiety, are
likely to be modified by cognitive schemata
(cf. internal working models). Adults'
perception of threat, and risk of post-
traumatic stress disorder, may depend on
patterns of attachment and responses to
trauma in early life (Bremner et al, 1993). It
is possible that attachment-based research
could provide an empirical base for Freud's
concept of repetition-compulsion as a
means of mastering trauma.
Therefore, it is reasonable to anticipate
that patients with a history of failed or
insecure attachment are likely to be com
monly present on psychiatric wards. These
are likely to be individuals whose internal
cognitive models make it difficult for them
to manage Stressors, and who may have
developed maladaptive behavioural strate
gies in response to either internal or
external Stressors.
Psychiatric illness and attachment
behaviour
Do relationships between psychiatric pa
tients and mental health care professionals
show the qualities of attachment relation
ships? Illness generally stimulates attach
ment behaviour and proximity-seeking to
health care professionals because it is
anxiety provoking, and because patients
STAFF AS ATTACHMENT FIGURES
are rendered vulnerable by their illness
(Bowlby, 1979). Psychiatric illness is likely
to be a particularly potent stimulator of
attachment behaviour because of the threat
to internal as well as external safety.
The principal functions of any attach
ment figure are to provide a secure base and
to modulate anxiety. In a health care setting,
both functions are achieved by an interac
tional process to which both the individual
and the health care professional contribute.
Professional carers may be seen as providing
the patient with a temporary attachment
figure. Attachment figures stimulate secure
attachment in dependants by spending time
in 'active reciprocal interaction' (Rutter,
1988); this could be a description of various
ward-based therapeutic activities. Secure
attachment will be facilitated by accuracy,
sensitivity and appropriate responses to
distress; neither too much nor too little.
Good professional listening may provide this
sort of attachment experience.
In childhood, the secure base is used as
a base for what Bowlby called "a series of
excursions", which continue throughout
adulthood. As dependency decreases, the
excursions become longer, so that eventu
ally the dependent individual can exist
without anxiety away from the attachment
figure. Such excursions also provide safety
for creative exploration and hypothesis-
testing. In the same way as mental illness
stimulates attachment behaviour, patients
need a secure base from which to make a
series of excursions back to a level of
optimal function. The asylum function of
a psychiatric institution is a good example
of a secure base, which can provide a basis
for cognitive and affective exploration,
including the chance to make and learn
from mistakes safely.
FEATURES OF ATTACHMENT-
BASED PSYCHIATRIC CARE
Any attachment figure can modulate anxi
ety in a number of ways; by acting as an
affective container, by providing informa
tion, and by providing consistent input. The
affective containment aspect of attachment
may be seen as similar to that maternal
containment function described by Bion
(1962). The primary care-giver helps the
baby to develop a capacity to think and
tolerate anxiety by using her own mental
processes to hold and digest the baby's
internal projections. In this way, the baby's
first cognitive and affective fragments are
ADSHEAD
understood and contained, thus reducing
anxiety. This process also aids the baby in
developing a capacity for abstract thought.
Impairment of thinking is a common
feature of psychiatric illness, whether
caused by psychotic or affective illness, or
by anxiety disorders. It is plausible that, at
an unconscious level, psychiatric staff fulfil
a containing function for their patients.
Care-givers may be internalised cognitively
and affectively to produce a care-giver
'icon' (Kraemer, 1992), which can then be
utilised by the patient to relieve anxiety.
Consciously, containment can be of
fered by empathie listening, which may be
experienced as soothing. Providing infor
mation in a non-threatening way may also
help to reduce anxiety. General information
may be about the ward, the hospital or the
course of any psychiatric illness. Specific
information might be given about how
mental illness affects a specific patient, or
how the patient is experienced by others.
Anxiety is reduced further by the develop
ment of trust, which itself is fostered by
consistency of interaction. Consistency of
staff input allows the patient some degree
of predictability in a new anxiety-provok
ing situation. Listening, information-giving
and consistency offer conscious cognitive
containment of anxiety.
Insecure attachment patterns and
patient responses
Attachments to mental health care profes
sionals and institutions may persist long
after an individual worker has left, or the
institution closed down. Even when psychia
tric care has been less than helpful, patients
may continue to come for appointments and
seek out help. Such attachment may reflect
their neediness; however, it may also be a
manifestation of the replication of insecure
attachment patterns (Main & Goldwyn,
1989). Mental representations of attach
ment may affect the way individuals can
make use of help that is offered. Dismissing
individuals may find it difficult to engage
with treatment. Preoccupied individuals
may get stuck, find it difficult to move on,
or act ambivalently towards offered care.
Unresolved individuals may have difficulty
in thinking about or managing the painful
feelings aroused by treatment. By contrast,
patients with a history of secure attachment
in childhood are more likely to be compliant
with medication, and to disclose more of
their symptoms (Dozier, 1990).
It seems reasonable to conclude that
many aspects of relationships between
psychiatric patients and staff resemble
attachment relationships. The patient, the
mental health professionals and the institu
tion all contribute to these relationships by
an interactive process. This interactive
process is seen in the clinical life of the
unit; the problems that patients pose to
staff, and the way staff respond, both
consciously and unconsciously.
MANAGEMENT PROBLEMS AS
ATTACHMENT BEHAVIOUR
Deliberate self-harm
If attachment bonds develop between psy
chiatric patients and staff, then problems
might be expected at those times when
attachment behaviour is stimulated, such as
separations, or new threats to security. In
general psychiatric units, the two most
common situations are discharge, or loss
of a specific worker - both examples of
separations. Psychiatric patients may be
fearful about leaving the ward to which
they became attached when ill; worsening
of symptoms is commonly seen before
discharge, which may be seen as a form of
protest. The most extreme forms of protest
may be seen in those patients who deliber
ately harm themselves.
Miss A. was a 33-year-old woman with a long
history of contact with psychiatric services. As a
child, she had been raised by a mother with bi
polar disorder, and an alcoholic father who was
extremely physically abusive to all the children.
She had spent much of her early life in different
care settings. She was described by one psychia
trist as"the angriest person I have ever seen". Miss
A. regularly sought extra unscheduled time with
staff in the out-patient clinic, and refusal of her
request would result in overdoses and self-harm.
Deliberate self-harming behaviours often
occur following interaction with another
person, usually one to whom the self-
mutilator is attached and who may be
threatening to leave. Such actions may be
seen as pathological attachment behav
iours, which are both an attempt to
dissuade the care-giver from leaving, and
a means of reducing arousal.
Disturbed behaviour may be a reaction
to the loss of a specific attachment figure,
such as a key nurse, even if feelings of
attachment are not consciously recognised.
Mental state deterioration has been ob
served in in-patients who have temporarily
lost their consultant (Persaud & Meux,
1994).
Anger and violence
Distress and anxiety may also manifest as
anger, which, together with anxiety, is a
common manifestation of failed or insecure
attachment (Bowlby, 1984). Anger may be
expressed in order to dissuade the care-
giver from leaving, as a protection of a
relationship which is valuable to the angry
person. A particular finding of interest is
that anger may specifically be expressed
towards care-givers (Main & George,
1985), suggesting that there is something
about perceived failures of care-giving that
may elicit anger.
Miss A. had made a therapeutic attachment to a
member of the clinical team. They worked to
gether, meeting regularly, for over two years.
The team member wished to withdraw, and gave
notice to Miss A. of her planned departure. Miss
A. grabbed a pair of scissors, forcing the team
member to shut the door and barricade it. Miss
A. stood for some time outside the door,
gouging out the wood with the scissors, and
being verbally abusive. Eventually she had to
be removed by security.
Understanding violence to health care
professionals as attachment behaviour
Where mental health care professionals are
seen as attachment figures, threats to re
lationships with them may produce anger and
violence. Assaults on staff, or self-harming
behaviour are associated with the diagnosis
in individuals of some types of personality
disorder. Personality disorder may be
manifested as failure to make attachments,
including engaging with psychiatric services.
Attacks may be made on offered care, either
indirectly by sabotaging treatment plans, or
directly by assaults on staff. This can lead to
rejection by staff and the termination of care.
It is recognised that such patients are
unpopular with mental health care profes
sionals; as unpopular as they probably were
with their original parents. Some of their
maladaptive behaviours can be seen as
traumatic re-enactments of earlier rejection
and abuse (Van der Kolk, 1989).
Such behaviours may also represent an
unconscious struggle for mastery of over
whelming affects, in the same way as
attachment behaviour in infancy uncon
sciously reduces anxiety. Traumatic re-
enactment functions as a projective mea
sure, so that the victim remains a victim,
and all their aggression is projected onto
their aggressor. Identification with the
aggressor offers another means of soothing
and managing aggressive impulses. Projec
tive identification, as a cognitive and

affective strategy, is most likely to be used
by those individuals who lacked an attach
ment figure who could contain and soothe
their arousal. It is not surprising to find this
primitive defence against anxiety in use on
psychiatric wards. By this mechanism, care-
givers may then be perceived as persecutory
and aggressive. The reality of this percep
tion for the patient should not be under
estimated in terms of dangerousness;
violence to staff may be understood by
patients as an attempt to defend themselves
against anxiety-inducing objects.
RESPONSES OF
PROFESSIONALS: CLINICAL
PRACTICE AND
COUNTERTRANSFERENCE
Common psychiatric problems can be
understood in attachment terms; there are
many aspects of good professional practice in
mental health which encourage attachment
bonds to develop. In addition, professional
carers themselves may have attachment
histories which affect the relationships they
form with patients. Attachment psycho-
pathology in the staff may be just as
problematic, and harder to detect.
It is known that many health care
professionals have experience of illness in
their own families. This may be a positive
feature. However, negative family experi
ences of illness have been shown to be
related to later occupational stress in health
care professionals (Vaillant et al, 1972;
Firth Cozens, 1992).
Adults deprived of care in childhood
may seek to provide it for others in their
professional lives (Vaillant et al, 1972).
One manifestation of insecure attachment
in children described by Bowlby is a style of
relating called compulsive care-giving,
whereby the child attends to the needs of
others, and disregards their own. Bowlby
suggested that children forced into this role
develop a false adulthood, similar to the
notion of false self proposed by Winnicott
(1965).
It is possible that compulsive care-
giving is a psychological style which may
be found in a proportion of all health care
professionals. This style may not be patho
logical per se; however, it is known that
sick health care professionals are often
reluctant to admit any difficulties, or seek
help. Suppression of dependency needs
leads to difficulties in acknowledging the
demanding nature of the work. This can
PSYCHIATRIC
lead to denial of feelings generally, and
specifically denial of the psychological
needs of both patients and staff. Feelings
of distress remain hidden and suppressed,
leading to the use of pathological defences
such as substance misuse to reduce anxiety,
or to staff burn-out.
Maladaptive caring
Under stress, carers may develop maladap-
tive interpersonal strategies with patients;
usually in the form of over-involvement
with the patient's distress, or a tendency to
dismiss it. Over-involved carers may need
their patients to remain in a cared-for role,
and find it difficult to allow patients to
improve and regain independence. Over-
involvement can result in boundary viol
ations of various degrees; this is a common
problem with those patients with abusive
histories. Dismissal of distress can lead to
rejection of patients, and intolerance of
distress and dependence. The pejorative use
of the term 'attention-seeking' also gives an
idea of the wish to reject neediness experi
enced by some health care professionals.
Failure to address dependency needs
can lead to anger (Bowlby, 1984), which
fuels a wish to reject patients seen as
'troublesome'. Projections of anger and fear
by patients are likely to resonate with the
care-giver's own unconscious aggression.
Care-givers may feel overwhelmed with
feelings of fear and aggression, which are
experienced as both alien and real. These
strong countertransferential feelings may
then be acted out, either overtly unprofes-
sionally, or more commonly by covert use
of professional structures, such as ward
rounds or rigid enforcement of contracts
(Main, 1977).
Mental health care professionals who
have themselves survived frank abuse in
childhood may act out more pathologically
in the caring role. Such adults may become
abusive themselves, identifying with the
aggressor in the same way as was described
for patients above. This may manifest itself
as abuse of patients, either physical or
sexual. Various public inquiries have shown
that this can happen at either an individual
or institutional level. A milder manifestation
of such experiences may be inappropriate
relationships with patients, transgressing
professional boundaries. This is perhaps
even more likely with patients who have
been abused in childhood. Boundary viol
ations and sexual exploitations of such
patients by health care professionals is now
STAFF AS ATTACHMENT FIGURES
recognised as a significant therapeutic
problem (Gabbard, 1989).
THE INSTITUTION AS AN
ATTACHMENT FIGURE
Mental health care institutions can be a
positive attachment figure for patients,
especially those who did not experience
secure attachment in childhood. However,
mental health care institutions may also fail
to provide a secure base. Psychiatric in
stitutions may be frightening in terms of
architecture, atmosphere or ward popul
ation. The institutional environment may
stimulate abnormal attachment behaviour,
rather than reduce it. Attention-seeking
behaviour may be related to a need for
alleviation of anxiety and arousal, which is
understandable from both an etnologica!
perspective, and in terms of a patient's
personal experience.
Institutional settings which infantilise
and disempower patients will encourage
regression and an expectation of 'special'
care in the patients. If such expectations are
both frustrated and criticised, then this
increases confusion and anxiety in an
already vulnerable patient. Ward regimes
often encourage both dependence and
independence simultaneously; so that an
individual is 'ill' and in need of care, until
they misbehave in some way and 'must take
responsibility for themselves'.
Institutions may be ambivalent about
the services they provide, encouraging staff
to develop different types of treatment or
support, then failing to provide structures
to make them possible. This ambivalence
presumably reflects that of the staff and the
general public, especially in relation to
difficult or violent patients. Lack of support
for staff, both managerial and financial,
may reduce institutional capacity to re
spond sensitively and appropriately to
patients' needs. Inconsistency of staff, both
in personal terms and in terms of staffing
levels, also increases anxiety, while decreas
ing the capacity to contain it.
Other institutional factors operate at a
wider level to stimulate abnormal attach
ment behaviour in patients. Therapeutic
approaches which take a very particular
kind of 'scientific' approach may be seen as
defences against the emotional experience
of being mentally ill (Main, 1977). An
emphasis on pharmacological treatments of
distress, when combined with a subtle (or
not so subtle) denigration of empathie
«7
ADSHEAD
listening skills, means that staff are ill-
equipped to modulate patient anxiety, or
contain regressed behaviour. Involuntary
detention may be experienced by patients
as controlling and abusive, no matter how
justified the detention on ethical and
clinical grounds. This is particularly so for
those patients who were 'detained' in care
as children, after abuse by parents.
IMPLICATIONS FOR
TREATMENT
Psychiatric care providers may not be able
to alter radically the nature of patients'
psychopathology. However, there are ways
in which psychiatric environments, both
physical and interpersonal, could be more
containing of patient anxiety and arousal,
and provide a safe base for patients to move
to recovery and beyond.
The first step is to provide a secure
base. This can be understood as the ward,
the out-patient clinic or the buildings
themselves. A secure base can offer affec
tive containment and anxiety modulation
by a multi-modal management strategy,
which includes long-term psychological
support, the appropriate use of the Mental
Health Act, and appropriate medication.
The aim of a clinical attachment-focused
strategy would be to allow the patient to
develop new skills in modulating their own
anxiety, and examine maladaptive attach
ment patterns, in their own lives and on the
ward. Such an approach also allows staff to
understand disturbed behaviour as mani
festations of severe anxiety and arousal in
disabled individuals; and may also allow
them to reflect on the aspects of their own
attachments which contributed to their
choice of a career in professional caring.
Attachment theory and research suggest
that attachment behaviour can change in
response to interpersonal experience (Fo-
nagy et al, 1996). Work with non-human
primates suggests that the behaviour of
socially isolated monkeys may be improved
after contact with 'therapist' monkeys.
Vulnerable children may be protected by
contact with one consistent parenting figure,
and the presence of a confiding relationship
is a protection against depression (Brown &
Harris, 1978). Personality disorders may be
responsive to treatment approaches that take
account of attachment needs, behaviours
and bonds (Linchan, 1992).
Understanding disturbed ward beha
viour in the light of attachment theory
68
may help in the management of such
behaviour. A proactive emphasis on anxiety
and arousal reduction, combined with care
ful planning of separations and losses on
wards, might help to reduce tension and
violence; at least as much as the provision
of courses for staff in control and restraint.
Secure attachment fostering
change
Miss A. was offered fixed appointments with the
team psychiatrist, and open, but limited 'drop-in'
time with a nurse who knew her well. Close ad
herence to boundaries, combined with a flexible
capacity to respond at times of distress, and ap
propriate use of medication, helped contain Miss
A.'s distress, and lead to a reduction in violence to
others, and to herself. When the team psy
chiatrist left the team after three years, Miss A.
was warned well in advance. At their last meet
ing, she was able to thank him for the help she
had received, and express grief that he was going.
The positive effects of a professional carer
'being with', rather than 'doing to' patients
is well known. This is likely to be particu
larly true for those with histories of failed
attachment. Confiding in someone, telling
one's story and being listened to are potent
modulators of anxiety. The traumatic stress
literature has shown the value of narrative
in reducing fear in all forms of psychother
apy, cognitive and dynamic. Cultural iden
tities are built and sustained in tales, stories
and myths. It can be therapeutic just to
listen to stories of deprivation and distress;
there is a danger that current psychiatric
practice offers little or no space for
recounting painful experiences. Attachment
theory suggests that long-term listening
may be important for those patients who
have distressing stories to tell.
CONCLUSION
Attachment theory continues to develop,
both empirically and clinically. It has
demonstrated its value; first, as a theory
which combines ethology, neurobiology
and individual psychology; and second, as
a means of examining empirically hypoth
eses based on psychodynamic clinical work.
Psychodynamic approaches to general psy
chiatric practice, based on attachment
theory, allow for the recognition of both
the patient's and the professional's subjec
tivity, and an understanding of the impor
tance of that subjectivity for therapeutic
relationships. Violence and other negative
staff-patient interactions need to be under
stood in the light of patient's previous
attachments, and replication of those at
tachments with staff. Attachment theory
offers possibilities for research into under
standing staff-patient relationships in gen
eral psychiatric hospitals. It also offers a
way of thinking about change.
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