Augmenting cognitive behavioural therapy for psychosis through the integration of attachment theory.

Abstract

Psychosis describes clinical diagnoses (such as schizophrenia) and psychotic-type experiences (such as paranoia). Cognitive behavioural therapy (CBT) is a first-line recommended treatment for psychosis, though outcomes remain modest. Given that psychosis encompasses several diagnoses and experiences, observed in both clinical and non-clinical groups, researchers and clinicians have begun to adopt symptom-specific approaches that focus on individual experiences and target particular maintenance processes. The present thesis focuses on paranoia, a common experience in psychosis and the general population that describes distressing interpersonal threat beliefs. Attachment theory provides a framework to conceptualise the development and maintenance of paranoia since there is robust evidence that insecure attachment styles are positively associated with paranoia (and psychosis more broadly). However, the mechanisms involved in the attachment–paranoia association are poorly understood; investigating these is likely to have significant clinical implications, as the mechanisms may constitute key targets in CBT to improve clinical and recovery outcomes. In this thesis, I draw on attachment theory to inform CBT for psychosis, specifically by investigating CBT-relevant mechanisms in the attachment–paranoia association. I begin by systematically and critically synthesising the existing literature that examines key cognitive, affective, and interpersonal behavioural mechanisms in the attachment–paranoia association (Manuscript 1). I establish that key mechanisms include negative self/other beliefs, cognitive fusion, emotion regulation, and help-seeking, but that the literature to date is largely limited due to underpowered and unrepresentative samples, lack of control of confounding variables, and reliance on cross-sectional and correlational designs, precluding claims about causation and direction of effects. Based on these gaps and limitations, I present three empirical experimental studies (one ongoing). In the first two studies, I recruit adults with high levels of non-clinical paranoia and investigate whether candidate cognitive mechanisms (negative self/other beliefs and cognitive fusion; Manuscript 2) and emotion regulation strategies (e.g., rumination and suppression; Manuscript 3) mediate the association between attachment and paranoia. In Study 4, I aim to replicate the effects from the non-clinical studies in a clinical group with psychosis. In all studies, I utilise attachment imagery priming to examine the causal effects of attachment style on paranoia, key mechanisms, and other variables of interest. Together, these experiments provide robust causal evidence for the impact of attachment on paranoia and the cognitive and affective mechanisms involved in this relationship. This evidence can be used to inform CBT for psychosis to reduce paranoia and improve recovery outcomes.

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Identifiers

ORCID for Monica Sood: orcid.org/0000-0003-3242-7925

ORCID for Katherine Newman-Taylor: orcid.org/0000-0003-1579-7959

ORCID for Katherine Carnelley: orcid.org/0000-0003-4064-8576

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