How might knowing a person’s attachment style inform engagement in CBT for psychosis? Attachment predicts interpersonal beliefs and help-seeking intentions in people with paranoia

The UK National Institute for Health and Care Excellence (NICE) recommends CBT for people with psychosis, yet many do not access therapies promptly, and duration of untreated psychosis predicts poorer outcomes. In addition to systemic service issues, it is likely that insecure attachment, common in people with psychosis, constitutes a key barrier to therapy. If we can articulate attachment patterns in terms of interpersonal beliefs and behaviours, we will be better placed to engage people in CBT. We used a cross-sectional design to examine theoretically predicted relationships between attachment style and (1) beliefs about self and others, (2) underlying assumptions, and (3) help-seeking intentions, across the psychosis continuum – in analogue and clinical samples. We recruited a general population analogue sample with elevated levels of non-clinical paranoia (n=172) and a clinical sample with self-reported psychosis (n=130). All completed standardised measures of attachment, beliefs about self and others, underlying assumptions and help-seeking. Regression analyses showed that insecure attachment predicted higher levels of negative self- and other-beliefs, and problematic underlying assumptions, and reduced help-seeking intentions, with some differences in patterns across analogue and clinical samples. Attachment is associated with CBT treatment targets and can inform psychological formulation and treatment. Our measure of assumptions may have been inappropriate for the clinical group. We conclude with public health, service level, and clinical implications to improve engagement and outcomes in CBT for psychosis. Key learning aims (1) Everyone with psychosis should have access to recommended treatments including CBT, but many do not. Insecure attachment is common in people with established psychosis or elevated levels of non-clinical paranoia, and may be a key barrier to accessing therapy. We show that insecure attachment is associated with (1) beliefs about self and others, (2) underlying assumptions, and (3) help-seeking intentions. Attachment style can inform CBT formulation and intervention, and wider service level and public health campaigns designed to improve engagement and outcomes for people with or vulnerable to psychosis.