The ability of adult mental health services to meet clients' attachment needs: The development and...

The ability of adult mental health servicesto meet clients’ attachment needs:The development and implementation of theService Attachment Questionnaire

Isabel Goodwin1*, Guy Holmes2 , Ray Cochrane1 andOliver Mason1

1School of Psychology, University of Birmingham, UK2Shropshire County Primary Care Trust, UK

This study examined the relevance of adult attachment to the relationships betweenmental health services and their clients. The aim of the study was to develop a self-report measure with acceptable levels of reliability and validity and which was groundedin the experiences of service users, to assess the ability of adult mental health servicesto meet clients’ attachment needs.

A combination of qualitative and quantitative methodology was used. The ServiceAttachment Questionnaire (SAQ) was developed via focus groups of service users,followed by a grounded theory analysis of the group data to identify themes andpotential items for inclusion. Two clinical trials were conducted to assess its reliabilityand validity.

The grounded theory analysis produced six key themes forming the basis of the six-subscale, 25-item SAQ. It demonstrated good levels of internal and test–retestreliability. Factor analysis of the subscales revealed a single underlying construct.

The SAQ is a reliable and usable self-report measure, and indicates that attachmentis relevant to the relationships clients have with mental health services. As the measureis the � rst of its kind, further exploration of the measure’s reliability and validity isrecommended.

It is commonlyobserved that the signi�cant increase in interest in adult attachment overrecent years has resulted in a proliferation of theoretical and empirical literature in the�eld. Such research has sought to re�ne and expand upon Bowlby’s original theory ofattachment (Bowlby, 1969, 1973, 1980), which combined concepts from psycho-analysis with those of ethology to produce an explanation of the fundamental affectional

145

Psychology and Psychotherapy: Theory, Research and Practice (2003), 76, 145–161© 2003 The British Psychological Society

www.bps.org.uk

* Requests for reprints should be addressed to Isabel Goodwin, Field House, 1 Myddlewood,Myddle, Shrewsbury,SY4 3RY, UK.

aspects of human relationships (Holmes, 1993). The importance of mental healthservice users being provided with secure attachment relationships by mental healthservices is well documented in the literature: for example, Holmes (1993) identi�escontinuity of care as a key issue in the recoveryprocess, whereby the individual has theopportunity to develop a primaryattachment bond with a principal care-giver; Goodwin(2003) notes that services may be actively harming, rather than helping, people byperpetuating or repeating experiences of insecure, damaging attachments.

It has been argued that mental health care professionals may serve as temporaryattachment �gures for mental health service users by stimulating secure attachment viasensitive and appropriate responses to distress, good professional listening facilitatingemotional containment and consistency of input (Adshead, 1998). In terms of attach-ment to place, it has been suggested that mental health care institutions can representpositive attachment �gures for patients though, equally, may fail to provide a secureattachment (e.g. a secure base, by processes such as discharge followed by long waitinglists for people to re-access help; Adshead, 1998). However, the nature of attachmentrelationships to multiple persons or institutions is complex, for example, in distinguish-ing between attachment to the institution and the actual people the client has met.There are suggestions that a person mayfeel pulled towards institutions which are calm,predictable and resonant with the client’s cultural norms, but these themes have notbeen developed well in the literature, which has been dominated by one-to-oneattachment relationships, such as those between peers.

In the modern National Health Service (NHS) clients often have contact with morethan one person from a service. For example, on an acute ward, even if a patient has akeyworker, they have contact with a wide variety of people and may feel an attachmentto the place rather than (or as well as) an individual worker or group of workers (e.g.‘the nurses on the ward’). Similarly, in community mental health teams and day services,people often see more than one worker, and in Assertive Outreach teams, there is oftenno keyworker—the person sees anymember of the team. On top of this, there is often ahigh staff turnover in mental health settings. Issues of attachment discussed in theliterature, for example in a psychotherapy service, between a person and theirpsychotherapist (as delineated by Holmes 1993, 1994) may therefore not generalizeto all mental health services.

Most empirical studies on attachment have focused on one-to-one relationships andlooked at issues such as style of attachment (see, for example, Hazan & Shaver, 1987)and have utilized interview techniques (e.g. Main, Kaplan & Cassidy’s, 1985 AdultAttachment Interview) or self-report measures (e.g. Trinke & Bartholomew, 1997). Suchmeasures have enjoyed widespread use but do not appropriately measure the complextype of attachments that people might have regarding their involvement with mentalhealth services.

Some aspects of mental health policies and services—such as having stand-aloneteams, a fragmented service structure with a wide variety of ‘expert’ services, peoplebeing allocated to services or teams rather than having a named, consistent key worker,shift-work and high staff turnover—mean that therapist–client attachment issues aremore complex, and it may be more accurate to think of ‘team-’ or ‘institution-’ or‘service-to-client’ attachments. Such relationships may be equally well-considered byreference to work on the ‘need to belong’ (Baumeister & Leary, 1995), which draws onBowlby’s attachment theory but differs from it in that the belongingness hypothesisdoes not regard the need as derived from a particular relationship or focused on aparticular individual. Indeed, Baumeister and Leary (1995) propose that the need to

146 Isabel Goodwin et al.

belong can be directed towards any other human being, and that the loss of relationshipwith one person can to some extent be replaced by another (time allowing). In terms ofmeasurement, Lee and Robbins (1995) have developed two measures of belongingness:the Social Connectedness Scale and the Social Assurance Scale. Although they regardbelongingness as a construct unique from related constructs such as attachment, their�ndings—that social connectedness appears to be related to one’s opinion of self inrelation to other people, while social assurance appears to be related to one’s relianceon other people—might be considered as matching well with frameworks of dimen-sions of adult attachment such as Bartholomew’s four-category model featuring theindividual’s ‘model of self ’ plus ‘model of other’ (Bartholomew, 1993).

There is currently no measure which assesses the abilityof mental health services tomeet the attachment needs of clients. The focus of research studies has been at anindividual level, with few studies or measures designed to consider multiple attachmentrelationships or attachments to something other than individual persons. A notableexception is Smith, Murphy and Coats’ (1999) Social Group Attachment Scale: thisassesses attachment anxiety and avoidance in relation to groups, while consideringthese factors distinct from relationship attachment and from other measures of groupidenti�cation. However, this, as with many attachment measures, is context-speci�c,and thus there is still a need for a measure regarding attachment issues within mentalhealth services.

In addition, the majority (if not all) of the measures currently available in this areahave been developed exclusively by mental health professionals and academics: itemsincluded in assessment measures have been generated by professionals from theirclinical experience and the existing adult attachment literature, often taking previouslydelineated categories and dimensions as a starting point for their framework. Althoughthe clinical experience of researchers developing measures is likely to be extensive, theresultant items and measures developed assume the relevance of attachment theory tothe area in question prior to development of the measure, and items are likely to bearticulated in ways familiar to professionals rather than users.

The current studies were designed to develop a measure to assess the ability of adultmental health services to meet clients’ attachment needs. This includes those aspects ofneeds which the service is best able to meet and those they may be failing to meet, inorder for those needs to be more clearly identi�ed and appropriate addressed to clients’bene�t. The measure (the Service Attachment Questionnaire, SAQ) was developed viathe involvement of current adult mental health service users in focus groups so that itwould encompass aspects of attachment that re�ect what service users �nd helpful andunhelpful regarding services that they receive, and the SAQbe in the language of serviceusers rather than professionals. Asecond study involved preliminary trials of the SAQinorder to assess its reliability and validity.

STUDY 1: DEVELOPMENT OF THE SAQThe aim of this study was to develop a measure assessing clients’ experiences ofattachment relationships provided by mental health services from data generated byfocus groups of mental health service users, and then to substantiate this by comparisonwith the existing literature and measures relating to adult attachment. Ethical approvalfor the study (and for Study 2) was obtained from the local Ethical Review Committee.

The National Service Framework for Mental Health (Department of Health,1999) recommends the active involvement and collaboration of service users and

Ability of mental health services to meet adults’ needs 147

professionals in research and development of services. This plea is repeated by serviceusers themselves (e.g. see Lindow, 2001; Survivors Speak Out, 1984), but despite theserecommendations, there is a dearth of research literature involving service users orshowing sensitivity to these issues. Shields, Morrison and Hart (1988) identify threereasons for seeking the views of service users: �rst, they are a vulnerable group owed amoral obligation to be treated with respect; second, service users can identify cost-effective treatments; and third, in a democratic society, we can ensure the accountabilityof service providers by asking recipients what they think of services.

ParticipantsIn all, 25 potential participants from each of four service areas were contacted by letterrequesting their voluntary involvement in the study, and giving assurances thatparticipation would not affect services they received and that con�dentiality wouldbe maintained. A detachable reply slip was included with instructions for potentialparticipants to return it in a pre-paid envelope.

Of the participants, 10 volunteered for two focus groups; six were ultimately able toattend, resulting in two separate groups of three participants each. Three participantswere male, and three were female. Each group had male and female members, all ofwhom were receiving one or more of the following local NHS adult mental healthservices: inpatient services (acute admission or rehabilitation), community mentalhealth team services, psychological therapy services or day centre services.

ProcedureEach focus group included a facilitator (the �rst author) and a co-facilitator (the secondauthor). Both groups followed the same general format and process, based on thatsuggested by Morgan (1997), and each was scheduled to last 1 hour. Introductions werecarried out, and participants were asked for permission to audiotape the group, towhich each group agreed. On each occasion, the group was then presented with thetask to ‘focus’ on, that is, the generation and discussion of ideas regarding what clientshad found both helpful and unhelpful about the relationships they had with the servicesthat they had received and staff within those services. At the end of each focus group,the facilitators ensured that the participants were feeling comfortable regarding thenature of their discussion.

Data analysisThe data generated by the focus groups were subjected to a grounded theory analysiscarried out jointly by the �rst and second authors. The analytic process employed herefollowed that originally developed by Glaser and Strauss (1967) and, more recently,explicitly described by Pidgeon and Henwood (1996). The �rst stage of the process isthat of data collection, completed via the focus groups described above. The initialanalysis involves data storage, which included both audio-tape transcription and thelabelling of data sets. Each piece of text was identi�ed as a separate data strip. In thisstudy, each piece of text which expressed a coherent idea or piece of information whichcould stand alone constituted an individual data strip. This stage is followed by coding,which involved sorting through the data, indexing and describing data strips, anddeveloping codes via the method of constant comparison. This method demands that


each data strip is compared with each one previously examined for differences andsimilarities. In this way, the data strips were gradually sifted into a number of groups,showing similarities within, and differences between, groups. The core analysis featuresre�ning the indexing system , in which categories are developed, de�nitions arewritten, and the system is further re�ned through processes of category linking andcategory splitting. Thus, the groupings were re-examined and adjustments made (i.e.data strips re-allocated) until the similarities within the groups of data and thedifferences between the groups of data achieved a satisfactory level of clarity (in theanalysts’ view). The ultimate stage of the process features the naming of key concepts orthemes, from which items were selected for inclusion in the SAQ. In this analysis,dimensional concepts were developed, as the acknowledged purpose of the datageneration and analysis was to facilitate the development of an assessment measure.

ResultsA total of 146 data strips were identi�ed and examined. Following initial allocation ofdata strips into groups, there was a series of four revisions of the groupings before asatisfactory level of clarity was reached. The concepts (or themes) generated from thedata analysis process were as follows:· Being attended to and listened to: This concerns the importance of being (and

feeling) listened to and taken notice of; how helpful that is, and how unhelpful andhurtful it is to not be listened to. For example, one participant said: ‘You’ve got tobe listened to, heard and taken notice of.’

· Being there—consistency and continuity: This involves the importance of areliable, ongoing relationship with the same person, and the frustration andanger felt when let down, e.g. ‘You hang on for that time with your keyworker,and then they say ‘Oh sorry, I can’t see you now’—it’s so frustrating.’

· Being given enough time—ending and leaving: This relates to the need forsupport for as long as the client feels the need, and the unhelpfulness of time-limited relationships imposed by the service, e.g. ‘I did feel under pressure . . . theywere looking for discharge . . . I needed time.’

· Safe environment: This concerns the need to feel safe and looked after rather thanfeeling suffocated or restricted, e.g. ‘I know they felt I needed to be there to keepme safe, but I felt suffocated there.’

· Relationships which enable helpful talking: This involves the importance ofrelationships which are experienced as accepting and therapeutic, as opposed tothose which are experienced as uncollaborative and judgmental, e.g. ‘It’s just thisfeeling of she’ll accept you for who you are.’

· Human contact and comfort: This concerns the helpfulness of �nding that othersunderstand an individual’s experiences and the harmfulness of the individualfeeling stigmatized and rejected, e.g. ‘To normalize what’s happening to you andthe things you say that have made you think ‘‘I can’t tell anybody that’’.’

The SAQ was then constructed as follows. A total of 24 items were selected from thedata generated by the focus groups, four from within each identi�ed category/theme.The items were all data strips examined in the preceding analysis. Two ‘positive’ itemsplus two ‘negative’ items were selected from each category, for balance. Twenty-fouritems were chosen as being the number that appeared suf�ciently different expressionsof each theme (including those ‘opposites’ of each other). The items within each


thematic subscale were as follows: Subscale 1 (Being attended to): items 1, 7, 13, and 19;Subscale 2 (Being there—consistency and continuity): items 2, 8, 14 and 20; Subscale 3(Being given enough time—ending and leaving): items 3, 9, 15 and 21; Subscale 4 (Safeenvironment): items 4, 10, 16 and 22; Subscale 5 (Relationships which enable helpfultalking): items 5, 11, 17 and 23; Subscale 6 (Human contact and comfort): items 6, 12, 18and 24 (see Appendix.)

The wording of items was retained as far as possible in their verbatim form, as theywere considered to be articulate and accurate re�ections of what clients said, andre�ected adult attachment themes as identi�ed and described in the existing literature.Item responses were in the form of a Likert scale, ranging from Not at all (0) to Always(4). Background information regarding details of the service being received and lengthand extent of current contact was also requested. Self-ratings of how much participantsfelt they had improved as a result of coming into contact with the service (‘I feel worse’[1] to ‘Agreat deal’ [5]) and how helpful the service had been overall (‘Very unhelpful’[1] to ‘Very helpful’ [5]) were also included.

DiscussionThe themes generated from the focus group analysis corresponded to those from theexisting literature and instruments, suggesting that the thematic analysis in this studymay be regarded as re�ecting some of the major themes of attachment theory in adultmental health. However, they use a different language (or style of terminology)—onelikely to be more familiar to the wide range of mental health services users. In addition,they related to attachment issues between people and the services they receive.

The limitations and weaknesses of focus groups as a research method can be seen as�owing directly from their two de�ning features: the reliance on the researcher’s focusand the group’s interaction (Morgan, 1997). The fact that the researcher directs thegroup makes it less naturalistic than (for example) participant observation and mayresult in uncertainty about the validity of what participants say. In particular, there isconcern that the researcher/group moderator, in maintaining the interview’s focus, willin�uence the group’s interactions (Morgan, 1997). The process of social interaction infocus groups may also affect the development of the discussion and the data subse-quently produced. Speci�c concerns include a potential tendency towards conformity(with some participants withholding things that they might say in private) as well as atendency towards polarization (whereby some participants express more extremeviews in a group that in private; Janis, 1982). It must also be acknowledged that thesample volunteering to participate in a focus group may differ from the broaderpopulation being studied (see, for example, Lebow, 1982).

Anumber of methodological issues merit discussion. The lack of a prior assumptionsabout the role or relevance of attachment theory to clients’ experiences of relationshipswithin adult mental health services gives added credibility to the subsequentlydeveloped SAQ. It may, of course, be argued that the authors were already informedabout attachment theory prior to conducting the grounded theory analysis, and this hadan in�uence on the discussions in the focus groups and in category development. Wewere alert to these concerns, and during the focus groups and the method of constantcomparison, we attempted to put our own perspectives to one side and be aware of, andminimize, these in�uences. For example, the focus group task was not identi�ed interms of attachment theory, and both facilitators did not consciously guide the group to


talk about their experiences in terms of attachment theory. Nevertheless, the fact thatthe people performing the analysis were the same people, both of whom have aninterest in attachment theory, leaves the possibility for this to be an in�uence on thedevelopment of the SAQ.

The limited number of participants in the focus groups calls into question thegeneralizability of the group data. Morgan (1997) suggests that the purposes of theresearch and the constraints of the �eld situation must be taken into account and that,although a rule of thumb speci�es a range of 6–10 participants per group, researchersshould not feel restricted by either this upper or lower boundary. He also suggests thatfocus groups of three participants are perfectly acceptable if the participants are highlyinvolved (Morgan, 1997). In this study, the low numbers in the focus groups were, inpart, a result of people feeling unable to participate due to their current psychologicalstate (a situation which was communicated by several people) and volunteers’ inabilityto attend due to personal time constraints. The quality and quantity of data generated bythe groups in this study, however, suggest a high level of participant involvement. Thenumber of groups conducted mayalso be open to criticism. Morgan (1997) suggests thatthree to �ve groups are likely to be adequate for ‘saturation’—the point at whichadditional data collection no longer generates new understanding (Glaser & Strauss,1967). However, practical and economic considerations (including the willingness andability of service users to engage in a focus group, time, expenses and accommodation)resulted in only two groups being conducted, from which it is not possible to determineif saturation was reached. Future replication may usefully involve a greater number offocus groups. In addition, some form of participant validation could be employed, bytaking the SAQback to focus groups for further discussion, thus maximizing service userinvolvement and completing a triangulation process of the qualitative and quantitativeresearch methods (Hammersley, 1996). In this study, we attempted to achieve this tosome extent by conducting a pilot study (see below).

STUDY 2: VALIDITY AND RELIABILITY OF THE SAQThe aims of the second study were: �rst, to verify the reliability and validity of themeasure via statistical analysis, including Cronbach’s alpha (for internal reliability), test–retest reliability and factor analysis; and second, to obtain further evidence of constructvalidity in the form of positive correlations between participants’ scores on theassessment measure and self-ratings of (1) how much they felt they had improved asa result of coming into contact with the service and (2) how helpful they felt the servicehad been.

Participants

Trial 1 (test)Atotal of 600 potential participants were sent the SAQ(150 to each of the four serviceareas). Of these, 154 completed and returned the measure as requested—a responserate of 26%. Of the 154 participants, 34 (22%) were receiving adult inpatient services; 43(28%) were receiving CMHT services; 45 (29%) were receiving psychological therapyservices; and 32 (21%) were receiving Day Centre services. Contact details provided byparticipants were categorized and coded per annum from January 1, 1991 to January 1,2001. ‘First contact’ dates up to and including the year 1990 were coded as 1/1/1990.Approximately 82.5%of participants (N 127) had been in contact with the service


they were currently receiving for over one year. Data were missing for 18 (11.5%)participants. Twenty-three participants (15%) had attended up to 10 appointments; 25(16%) had attended 11–30 appointments; 26 (17%) had attended 31–50 appointments;and 61 (40%) had attended 50 appointments. Data were missing for 19 (12%)participants.

Trial 2 (re-test)In all, 100 participants from Trial (1) volunteered to also participate in Trial 2. Of these,54 completed and returned the measure as requested, a response rate of 54%. Of the 54participants completing the measure for the second time: 6 (11%) were receiving adultinpatient services; 16 (30%) were receiving community mental health team services; 20(37%) were receiving psychological therapy services; and 12 (22%) were receiving daycentre services. With the exception of the reduced number of participants receivinginpatient services, some of whom may have been discharged, the distribution is similarto that in Trial 1. For length of contact with service, the distribution was very similar tothat in Trial 1. Data were missing for 2 (4%) participants. Nine participants (17%) hadattended up to 10 appointments; 11 (20%) had attended 11–30 appointments; 12 (22%)had attended 31–50 appointments; and 19 935%) had attended 50 appointments. Datawere missing for 3 (6%) participants. This is, again, a similar distribution to the data inTrial 1.

The criterion for inclusion was that participants must be receiving one or moreof the following local NHS mental health services: adult inpatient services (acuteadmission or rehabilitation), community mental health team services, psychologicaltherapy services or day centre services. Potential participants were excluded if theywere not receiving one of those four mental health services, or if the majority ofresponses contained within the completed measure appeared incoherent or incon-sistent with the instructions provided (e.g. if a participant responded to theinstruction to use the scale of 1–4 by entering ticks rather than numbers in responseto items on the measure).

Procedure

Pilot studyApilot study (N 11) was conducted, asking questions such as: ‘Did the measure makesense?’ and ‘Were the instructions clear?’ One respondent suggested an additional itemthat they felt was not covered suf�cientlyby the existing items, which was subsequentlyadded to the subscale ‘Being given enough time—ending and leaving’, bringing the totalnumber of items to 25.

Trial 1 (test)Participants received the following: a personally addressed letter providing an outline ofthe nature and purpose of the study and a request for completion and return ofthe assessment measure; a copy of the SAQ; a pre-paid return envelope; and a blankname/address label, which participants were asked to complete and return with themeasure if they were willing to participate in Trial 2 in 1 month’s time.


Trial 2 (re-test)Participants were sent a covering letter similar to that in Trial 1, but relating to theircontinued participation, one month after receipt of their �rst completed measure. Theywere requested to complete the SAQ again and return it in the pre-paid envelopeprovided.

Implied consent to participate was accepted in this part of the study by virtue ofvoluntary completion and return of the SAQ. It was anticipated that consent was‘informed’ as far as possible by virtue of the detailed covering letter accompanyingthe SAQ, wherein participants were explicitly advised that this was a research projectand that they were free to refuse to participate with no consequence for theirtreatment. However, there are issues in relation to accepting implied rather thanexplicit written consent which must be acknowledged. Baldwin (2001) states thatthe person should be able to understand all the necessary information given and thenform a reasonable conclusion, before giving their unequivocal consent plus theirauthorization (the latter usually being a written, signed statement testifying to theirconsent). Anonymous participation, involving no direct contact between researcherand participants, such as in this part of the study, where there is no writtenstatement testifying consent does lead to less clarity regarding the status ofparticipants’ consent.

Data analysisData were analysed using STATISTICA (for the PC). The coding of positive items was 1(Not at all ) through to 4 (Always); the coding of negative items was the reverse: 4 (Notat all ) through to 1 (Always). The rating of improvement was coded 1 (I feel worse)through to 5 (A great deal ), as was the rating of helpfulness of the service (1 Veryunhelpful through to 5 Very helpful ).

Results

Scale means and standard deviationsTable 1 presents the range of item means and standard deviations within eachsubscale. Item means are consistently just above 3.0, indicating that all the subscalesare susceptible to a tendency towards a ceiling effect. However, there is reasonableitem variability.

Correlational patternsThe mean inter-item correlations (Pearson’s product-moment coef�cients) within eachscale (see Table 1) indicate that the items designated for each subscale display generalcongruency without redundancy.

Reliability and validity

Internal and test–retest reliabilityAlpha coef�cients of internal reliability for each subscale and for the total scale areshown in Table 1. All six subscales reached acceptable levels of internal consistency



Tab

le1.

Des

crip

tive

and

relia

bilit

yst

atis

tics

for

subs

cale

san

dto

tals

cale

Subs

ale

Num

ber

ofite

ms

insc

ale

Mea

nof

scal

eite

ms

(SD

)M

ean

inte

r-ite

mco

rrel

atio

n

Inte

rnal

relia

bilit

y(C

ronb

ach’

sal

pha)

(N15

4)

Test

–ret

est

relia

bilit

y(P

ears

on)

(N54

)

Scal

e1:

Bein

gat

tend

edto

and

liste

ned

to(L

IST

ENIN

G)

43.

32(0

.85)

0.41

0.73

0.77

Scal

e2:

Bein

gth

ere—

cons

iste

ncy

and

cont

inui

ty(C

ON

SIST

ENC

Y)

43.

18(0

.96)

0.31

0.62

0.81

Scal

e3:

Bein

ggi

ven

enou

ghtim

e—en

ding

and

leav

ing

(EN

DIN

G)

53.

08(0

.99)

0.35

0.72

0.61

Scal

e4:

Safe

envi

ronm

ent

(SA

FET

Y)

43.

25(0

.92)

0.39

0.70

0.69

Scal

e5:

Rel

atio

nshi

psw

hich

enab

lehe

lpfu

ltal

king

(TA

LKIN

G)

43.

18(0

.92)

0.37

0.70

0.78

Scal

e6:

Hum

anco

ntac

tan

dco

mfo

rt(C

OM

FORT

)4

3.35

(0.8

5)0.

310.

620.

80

Tota

lsca

le25

3.22

0.34

0.93

0.84

(>0.60): Four subscales produced highly acceptable levels of reliability, while twosubscales, Consistency and Comfort, produced alpha coef�cients of borderlineacceptability. The total scale showed a high level of internal reliability.

The Pearson product moment correlation coef�cients indicate that all the subscalesand the total scale have a very reasonable temporal stability over a time period of onemonth (0.61–0.84; see Table 1). The lowest coef�cient relates to ending and leaving,which may be reasonably expected to show some alteration during the course oftherapy or other service involvement.

Factorial validityAprincipal-components analysis of the individual subscales was conducted to assess forthe presence of underlying constructs. Table 2 shows that all six subscales loaded ontoone main factor, accounting for approximately 72%of the variance. This suggests thatthe subscales are largely unidimensional and lends support to a single underlyingconstruct.

Technically, this data set of 25 items with 154 participants may also be entered into afactor analysis. For both statistical and pragmatic reasons, it would clearly have beendesirable to replicate at least some of the scales. However, the results did not suggest asimple structure that proved possible to interpret.

Construct validity (correlations)Preliminary construct validation was undertaken by predicting positive correlationsbetween participants’ scores on the assessment measure and self-ratings of (1) howmuch they felt they had improved as a result of coming into contact with the service,and (2) how helpful they felt the service had been to them. Table 3 presents thecorrelations between each subscale (plus the total scale) and these two ratings, labelledas ‘IMPROVED’ and ‘HELPFUL’, respectively.

All correlations in Table 3 are highly signi�cant p < .001 , indicating that allsubscales are positively correlated with both how much participants feel they haveimproved and how helpful they feel the service has been.


Table 2. Factor loadings resulting from principal-components analysis of subscales

Factor loadings (unrotated)Subscale Factor 1

Listening .89Consistency .86Ending .74Safety .86Talking .87Comfort .85Explained variance 4.34Proportion of total .72

Further exploration of the data: Differences between service areasThere were some differences between subscale means across the four different serviceareas (see Table 4), with consistently lower scores for the inpatient population. Themean total scale score for inpatients was also lower for inpatient services than for theother three service areas—community mental health team, psychological therapy andday centre services. Aone-way ANOVAindicated that these differences were signi�cantfor all of the subscales and for the total scale (see Table 4). A subsequent post hoccomparison (Newman–Keuls test) indicated a signi�cant difference between inpatientservices and each of the three other service areas but no signi�cant difference in themeans of those three areas (Table 5). This �nding suggests that participants receivinginpatient services perceive that their attachment needs are less well met by this servicethan do participants receiving other services. Table 4 also shows lower scores forinpatients as regards the degree of improvement and how helpful they felt services hadbeen, but this difference was not signi�cant.

DiscussionAlthough the reliability analysis suggests that the measure is—as a whole—highlyinternally reliable, and remains reasonably reliable over a retest period of 1 month, thefactor analysis conducted suggests the presence of onlyone major underlying construct.This stands in contrast to a number of researchers in the �eld who have concluded thattwo underlying ‘higher order’ factors, identi�ed as Avoidance and Anxiety, are detect-able in self-report attachment measures. Brennan, Clark and Shaver (1998) conducted afactor analysis of all self-report attachment measures, which they combined into a singlequestionnaire of 323 items, and their �ndings con�rmed the presence of these twofactors. It is possible that such extensive studies are required to delineate ‘higher order’factors that smaller, more context-speci�c measures—such as that developed here—areunable to detect. Alternatively, attachment to services may genuinely possess a singledimension (or factor) of key importance.

As a self-report instrument, the SAQenjoys the same advantages as other self-reportmeasures (for example, they are relatively easy to administer and score, and they


Table 3. Correlations between scale and ratings of improvement and service helpfulness

Pearson product-momentcorrelation ( p-value)N 150 (Casewise

deletion of missing data)

Subscale Improved Helpful

Listening 0.56 (.00) 0.53 (.00)Consistency 0.48 (.00) 0.49 (.00)Ending 0.40 (.00) 0.28 (.001)Safety 0.49 (.00) 0.50 (.00)Talking 0.46 (.00) 0.50 (.00)Comfort 0.46 (.00) 0.40 (.00)Total scale 0.55 (.00) 0.52 (.00)

directly assess views that adults have about contemporary attachment �gures). Equallyapplicable are the disadvantages. The inability to include open-ended questionsappeared to frustrate a number of participants, who wrote additional explanatorynotes next to items or added general comments. The most common comment related tothe dif�culty participants found in trying to respond about one speci�c service area, asmany service users are engaged in more than one service at the same time or movebetween different service areas depending on their needs. (This also may havecontributed to the ceiling effect found here, as participants were asked to respondabout the service they were receiving that they considered ‘most important’, which islikely to have also been that which provided secure attachment relationships and whichthey found most helpful.) The inability to explore contradictory responses is anotherdisadvantage of self-report measures and one also experienced in this study. Finally, the


Table 4. Means and levels of signi�cance for subscales, total scales and perceptions of improvement andhelpfulness, for each service area

Communitymental Psychological

In-patient health term therapies Day centre

X SD X SD X SD X SD F p

SubscalesListening 11.71 2.53 13.19 2.53 14.06 2.38 13.96 1.97 7.49 .0001Consistency 10.71 2.95 12.65 2.44 13.93 2.09 13.18 1.97 12.42 .0000Ending 14.21 3.57 15.30 3.74 15.36 3.26 17.03 2.55 3.81 .0114Safety 11.88 2.93 12.93 2.66 13.46 2.54 13.70 2.39 3.25 .0233Talking 11.68 2.77 12.53 2.75 13.73 2.52 12.56 2.31 4.20 .0069Comfort 12.33 2.42 13.53 2.24 14.06 1.97 13.53 2.56 3.77 .0119

Total 72.81 14.79 80.13 13.99 84.54 12.72 83.83 10.90 5.71 .0010Improved 3.73 1.05 3.97 1.04 3.82 1.13 4.19 0.85 1.23 nsHelpful 3.85 1.25 4.35 0.81 4.26 0.86 4.19 0.99 1.82 ns

Table 5. Post hoc comparison (Newman–Keuls test) for differences between total scale scores for allservice areas

Newman–Keuls test; total scaleProbabilities for post hoc tests

Critical ranges; p .05 (Step 1 6.08; Step 2 7.33; Step 3 8.06)

Community mental PsychologicalService In-patient health team therapies Day centre

In-patient – .0183 .0009 .0011Community mental health team .0183 – .3306 .2339Psychological therapies .0009 .3306 – .8185Day centre .0011 .2339 .8185 –

problem of socially desirable responses is also likely to have affected results: Althoughparticipants were informed that their responses would remain anonymous and wouldnot be seen by the service, they were included in the study only if they were currentlyreceiving a local adult mental health service. This may have contributed to the higherthan expected mean scores; patients are frequently reluctant to be critical of services—especially hospitals—in questionnaires, although sensitive interviewing can illicit amore rounded set of opinions (e.g. Goodwin, Holmes, Newnes & Waltho, 1999). It mayhave been that the two questions to assess validity (regarding helpfulness andimprovement) were not suf�ciently sensitive to illicit participants’ feelings aboutservices (and highlight signi�cantly lower scores on these scales, which matchedtheir signi�cantly lower SAQ scores). Future research needs to correlate SAQ scoreswith a wider range of measures.

Concerns about the possible effects of �lling in the SAQ, despite assurances ofanonymity in the accompanying letter, may explain the relatively low response rate inTrial 1 and the subsequent effect of attrition in Trial 2. This appears to be a dif�cultyfrequently encountered in this area, where a clinical population is being researched. Infact, the response rates obtained here compare favourably with those achieved in othersimilar research (cf. West & Sheldon-Keller, 1992), though a higher response rate wouldhave meant that we could have more con�dence regarding generalizability of the dataand about the validity of the SAQ and its subscales.

GENERAL DISCUSSIONThe current study sought, �rst, to develop a measure which assesses the ability of adultmental health services to meet the attachment needs of clients. This was achieved via aqualitative process involving adult mental health service users, followed by a groundedtheory analysis, resulting in the identi�cation of a 25-item measure consisting of sixsubscales—the SAQ. The subscale themes identi�ed here correspond well to dimen-sions identi�ed within existing literature and instruments in the �eld. For example,‘Being there—consistency and continuity’ corresponds with Holmes’ (1994) ‘securebase’, which emphasizes the ‘importance of the reliability, predictability and consis-tency’ (p. 72) of the therapist to which the client can turn when distressed, and alsowith West and Sheldon-Keller’s (1994) ‘availability’, in which a unique relationship isprovided with another individual ‘who is perceived as available and responsive and whois turned to for emotional and instrumental support’ (p. 101). Afurther example is thetheme of ‘human contact’ and comfort’ identi�ed in this study, which links closely withHolmes’ (1994) ‘attunement’—focused and empathic listening—as well as with Westand Sheldon-Keller’s (1994) ‘use’ of the attachment �gure, where a person may turn tothe other for comfort and reassurance. Second, it was anticipated that the measurewould meet accepted standards of statistical reliability and validity. Tests of internalreliability and test–retest reliability indicated that this aim had been met. A factoranalysis indicated the presence of one valid underlying construct. Third, furtherevidence of construct validitywas sought via positive correlations between participants’scores on the assessment measure and self-ratings of both how much participants feltthey had improved as a result of coming into contact with the service and how helpfulthey felt the service had been. This aim was also supported by the results.

In contrast to the development of the majority of adult attachment assessmentmeasures, this study utilized a combination of qualitative and quantitative researchmethods. It has been argued that such methodological eclecticism cancels out the


respective weaknesses of each method (Hammersley, 1996). In addition, the form ofeclecticism adopted here—facilitation (whereby the grounded theory analysis of focusgroup data served to generate items for the measure that were likely to be relevant andintelligible to the intended audience prior to quantitative data collection and analysis)—uses the different techniques to their best advantage.

An example of how this measure can be utilized is provided by the �nding that themean totals on the SAQ for participants receiving in-patient services were signi�cantlylower than for participants receiving other services. Inpatient services, where patientsare on ‘acute’ wards, have contact with a wide number of workers on different shifts andattend weekly ward rounds where discharge is discussed, may not be conducive toevoking secure attachments. The literature indicates that insecure attachments can havea deleterious effect on people’s mental health and chances of recovery, and the SAQcanbe used to assess attachment to services. One problem, however, with utilizing themeasure in its current form is that the scores on the scales for our samples wereuniversally in the high range. In our sample, over 50%of participants had had over 30appointments, and over 82%had received the service for which they �lled in the SAQforover one year; it may be that as a group, they have had relatively secure attachment tothe services, and this explains the high mean scores on the SAQ. However, it is alsopossible that the SAQ is not very sensitive at the lower end of the range. Furtherresearch, for example, with people who are unhappy with services (e.g. people whohave made complaints, people who drop out of services) is needed to check out thispossibility. We are putting the SAQ into the public domain in the hope that furtherresearch will be done to verify its reliability and validity, including its sensitivity topoorer attachment experiences, and whether good as well as poor attachmentexperiences relate to various measures of improvement or deterioration in people’smental health.

Future study may also explore issues such as gender differences in service-relatedattachment needs and relationships, which the current study did not seek to examine,but which have been reported in some adult (peer) attachment measure studies.

The mental health service in this study was located in a large rural inland county inEngland, though it is likely to share similarities with other mental health services aroundthe country. Future research might involve replication or implementation of the SAQinother geographical locations and across other types of service areas (e.g. assertiveoutreach or older adult services) and provide further evidence of the measure’sreliability and validity. We are currently involved in negotiations to trial the SAQ in achild and family service and a community alcohol service in different areas, as well as inan adult learning disability service more locally.

In conclusion, the SAQ is a way of measuring the ability of modern mental healthservices to meet clients’ attachment needs. Developed using a combination of qualita-tive and quantitative methodology, the SAQ displays a high level of internal reliabilityand test–retest reliability, suggesting that it is a coherent and usable scale. Furtherresearch is necessary to determine any required re�nements to the measure.

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Received 17 July 2001; revised version received 9 January 2003

Appendix: Service Attachment QuestionnaireBelow is a list of 25 statements about mental health services and the experiences peoplemight have whilst receiving them. Please read each item and then respond to each oneby indicating how close the statement is to your ow n ex perience and feelin gs aboutthe service you are curren tly in contact w ith . Write the number in the spaceprovided using the following rating scale:

1Not at all

2Sometimes

3Quite often

4Always

___ 1. I have somebody who listens attentively to me.___ 2. I have regular time with the same person that knows me and my problems.___ 3. I feel under pressure to get better and be discharged.___ 4. I have a feeling of being looked after.___ 5. I have the feeling that I’ll be accepted for who I am, whatever I say.___ 6. I’m helped to realize that it’s not just me—other people have similar problems.___ 7. I don’t feel listened to, or taken notice of.___ 8. I get frustrated because I have to wait too long to see my keyworker/therapist.___ 9. I feel con�dent that support will be provided when I am discharged.___ 10. I feel suffocated by the service rather than feeling safe.___ 11. I can’t relate to/get on with certain people in the service.___ 12. It feels like there’s a ‘them and us’ attitude from the staff.___ 13. I feel that people in the service understand my needs and problems.___ 14. I know that the same person is there for me consistently.___ 15. I worry that I won’t be better within the allocated time and will need longer.___ 16. I feel safe within the service.___ 17. I don’t feel judged, just accepted.___ 18. I feel patronized and stigmatized by the service.___ 19. I don’t feel that people really want to listen to what my problems are.___ 20. I worry that I’ll be discharged without any follow-up from my keyworker/

therapist.___ 21. I feel con�dent that if I need more time and help, over longer, that it will be

given.___ 22. I feel frustrated at my lack of freedom within the service.___ 23. I feel I have a partnership with my keyworker/therapist and that we work

together.___ 24. I have the feeling my keyworker/therapist is really interested in me and wants

to help.___ 25. I am made to feel that I am a burden to the service and outstaying my welcome.


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