Attachment theory-based approaches to treatment and problem behaviour in a medium secure hospital: Effects of staff gender on ratings

Purpose: The aim is to determine whether staff ratings of service user attachment style are associated with service user misconduct during inpatient treatment in a medium secure mental health unit; also, to gauge whether staff can evaluate attachment style reliably. Design/methodology/approach: Retrospective case note analysis on 55 inpatient treatment episodes were supplemented with staff ratings of service user attachment style. Records of untoward incidents were centrally retrieved. Kappa statistics were used to analyse levels of staff agreement regarding service user attachment style. Findings: Attachment style was associated with hostile episodes, treatment non-compliance and service user aggression. Post hoc analysis on a subset of data yielded poor overall agreement in ratings of attachment style (Kappa=0.2). Further analysis revealed a sex-based asymmetry with high consistency in ratings of female service users (Kappa=0.79) and very low inter-rater reliability for male service users (Kappa=-0.05). It is important to note that the staff included in the interrater reliability analysis were female. Research limitations/implications: The sample was small, the observation period was short and staff conducting the ratings had no special training in the rating tool. Practical implications: Attachment style per se played a significant part in the success and/or failure of service user treatment (when measured by misconduct). However, the validity of staffs' ratings of attachment style may interact systematically with the sex of staff and service users. These findings have important implications for the application of the concept of attachment in clinical settings. Social implications: Mental health professionals place central importance on the establishment of therapeutic relationships between clinicians and service users. Service user attachment style is assumed to play a role in mediating the success, or failure, of relationships with clinicians. Originality/value: This study makes a novel contribution to the application of attachment theory to secure mental health care, it also demonstrates that gender is an important factor in staff appraisals of service users' approach to treatment.