Attachment Styles, Quality of Life and Service Satisfaction Outcomes in People with Schizophrenia in Israel

Research Article

J Schizophr Res. 2014;1(1): 9.

Attachment Styles, Quality of Life and Service Satisfaction Outcomes in People with Schizophrenia in Israel

Ponizovsky AM1*, Arbitman M2, Baumgarten-Katz I2 and Grinshpoon A2

1Mental Health Services, Ministry of Health, Israel

2Sha'ar Menashe Mental Health Center, Hadera, Israel

*Corresponding author: Ponizovsky AM, Mental Health Services, Ministry of Health, 39 Yirmiyahu St, P.O. Box 1176, Jerusalem, 9446724, Israel

Received: July 09, 2014; Accepted: July 29, 2014; Published: July 31, 2014


Aim: To test the hypothesized associations among satisfaction with psychiatric rehabilitation services, health-related quality of life (HRQoL), psychopathology and attachment styles in inpatients with schizophrenia.

Methods: One hundred-one patients with International Classification on Diseases, Tenth Edition (ICD-10) diagnosis of schizophrenia and duration of rehabilitation program no less than six months were recruited from the rehabilitation wards of the Sha'ar Menashe Mental Health Center, Hadera, Israel. The outcome variablesandattachment styleswere assessed with the standardized questionnaires, and psychopathology severity with the Positive and Negative Syndrome Scale (PANSS). Univariate and multivariate analyses were performed to examine the study hypotheses.

Results: Attachment anxiety, dissatisfaction with rehabilitation services and the severity of general psychopathology predicted poorer HRQoL, accounting for 8.7%, 13.9%, and 5.4%, respectively, of the total variance(R2=.30; Adjusted R2=0.26; F4,100=7.98, p<0.001). In turn, the HRQoL was the only predictor of service satisfaction, accounting for 17% of the variance (R2=.17; Adjusted R2=0.13; F4,101=3.95, p=<0.01).

Conclusion: The results confirmed the hypothesized association between HRQoL and satisfaction with rehabilitation services. Despite this relation, attachment anxiety predicted only poorer HRQoL and more severe general psychopathology, but not service dissatisfaction. The results could contribute to the development of innovative rehabilitation strategies to improve both HRQoL and service satisfaction among inpatients with schizophrenia.

Keywords: Attachment Patterns; Satisfaction with Services; Quality of Life; Psychopathology Severity; Schizophrenia


SMI: Severe Mental Illness; HRQoL: Health-Related Quality of Life; MHC: Mental Health Center; ICD-10: International Classification of Mental and Behavioral Disorders, Tenth Edition; MHCSS-H: Mental Health Client Satisfaction Scale; Q-LES-Q: Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form; RQ: Relational Questionnaire; PANSS: Positive and Negative Syndrome Scale; ANOVA: Analysis Of Variance.


In recent decades, there is increasing interest in the systematic consideration of outcomes other than control of symptoms in the evaluation of long-term treatment effectiveness and rehabilitation for people with severe mental illness (SMI).Among others, satisfaction with health-related quality of life (HRQoL) and satisfaction with services are considered to be valuable outcome measures that contribute to the improvement of both quality of life and quality assurance procedures among clients of mental health centers (MHCs) [1,2]. Because many people with SMI have insecure attachment styles that are considered to be risk factors for development and persistence of psychopathology [3-9], we explored to what extent attachment styles are associated with satisfaction with rehabilitation services, HRQoL and severity of psychopathology among inpatients with schizophrenia.

The two recently published systematic reviews of the literature on attachment and psychosis [10,11] demonstrated clinical relevance of attachment style construct to development, course and treatment of psychosis: insecurely attached people have more severe positive, negative and affective symptoms [4], maladaptive coping strategies [12], showed poorer quality of therapeutic alliance [13] and engagement with services [14-15], and recovery style [16-18]. Clients attending MHCs are in contact with multiple professionals and may therefore develop attachments to psychiatric teams or services in general [19-20]. This tendency may be increased by recent mental health policies which allocate people to teams of staff rather than key workers [15]. Attachment to MHC in turn may influence the appraisal of satisfaction with the received service and be closely associated with users' HRQoL in general. A recent study [21] examined the extent to which individuals' appraisal of satisfaction with the received service was influenced by their own attachment style and found that clients with a more insecure attachment style indicated lower levels of attachment to services, independent of psychotic symptom severity. No analogical study has been conducted in Israel.

In this study we will focus on inpatient rehabilitation services for several reasons. First, these services provide a number of interventions to teach users social skills necessary for further daily living in the community and improving quality of their lives. The sense of attachment security facilitates engagement in exploration [22], whereas attachment insecurity impairs acquiring of the skills. Second, users of these services are separated from primary attachment figures for extended time periods and that alone may cause feeling of insecurity and activating their attachment needs. Under such conditions, only mental health personnel may play a role of attachment figures for rehabilitation service users [15,20,23]. Third, MHC users' attachment styles would affect their satisfaction with services and quality of their lives, if the severity of psychopathological symptoms could be controlled for [24].

Satisfaction with services is a subjective condition that results from the comparison between clients' expectations about health care provision and their actual experiences [25,26]. From the service perspective, satisfaction with service can be seen as a result of the ability of the service to provide a standard of care above a certain quality threshold, and the perception of each patient that the care received has been tailored to the patient's own problems [27]. By assessing client satisfaction, clinicians and health managers can learn the client's opinion regarding the services received, and also obtain a quality indicator of the centers' functioning [28]. Assessment of patients' satisfaction with MHCs has been recommended for improving the quality of services [29].

Clinical trials across many areas of medicine characteristically include HRQoL as an important outcome variable [30-33]. Several researchers have recommended that HRQoL be part of any outcome evaluation of treatment of patients with SMI [24,34,35]. A considerable body of studies [24,36,37] had shown that HRQoL in schizophrenia is substantially impaired, independent of stage of the illness, with positive, negative and depressive symptoms and side-effects of medication as well as dissatisfaction with social relationships as the major determinants of this impairment. Although several studies regarding HRQoL as the outcome variable in assessing effectiveness of treatment among people with SMI have been performed during the last decade in Israel [30-40], a survey addressing satisfaction with services along with HRQoL is lacking. Such information is needed to improve both quality assurance procedures and HRQoL of the MHCs' users.

The attachment theory proposes that attachment is the base upon which emotional health, social relationships, and one's worldview are built [22,41]. The ability to trust and form reciprocal relationships with the primary caregiver during the first two years of a child's life will affect the emotional health, security, and safety of the child, as well as the child's development and future interpersonal relationships [42]. Although there are different ways of conceptualizing adult attachment [43], based on the notion that attachment style can be determined by a person's model of self (positive or negative) and of others (positive or negative), Bartholomew and Horowitz [44] proposed a four-category attachment style model and this is the model used in this study. Specifically, individuals with a "secure" attachment style (self and other are both positive) are characterized by a sense of self-worth and a trust that others will be available and supportive in times of stress and adversity; they are comfortable seeking and expecting support from others. Individuals with a "preoccupied" attachment style (negative self, positive other) are preoccupied by attachment needs and depend on others for personal validation, acceptance, and approval. Those with "fearful" attachment (self and other both negative) regard others as uncaring and unavailable and themselves as unlovable. "Dismissing" individuals (positive self, negative other) remove themselves from others, regarding themselves as self-sufficient and invulnerable to abandonment by others.

Most investigators who use self-report measures of adult attachment style [43-45] agree that two primary dimensions are involved-attachment anxiety and attachment avoidance-and that “these two dimensions represent different ways of regulating the distress and insecurities resulting from a failure to find external or internal sources of comfort and support” [46]. The anxiety dimensionassesses the degree to which individuals worry about being rejected, abandoned, or unloved by significant others and reflects underlying negative self-model and positive other-model [44]. The avoidance dimensionevaluates the degree to which individuals limit intimacy and interdependence with others and reflects underlying positive self-model and negative other-model [44]. In adult attachment research, there is growing consensus that individual differences are best measured in terms of the attachment anxiety and avoidance dimensions that underlie the four attachment prototypes [46,47].

The present study aimed: 1) to evaluate satisfaction with inpatient psychiatric rehabilitation services and HRQoL outcomes among people with schizophrenia at a conventional state-funded MHC in Israel, and 2) to examine the relations between attachment styles and both outcomes, controlling for potentially confounding effects of psychopathology severity. We hypothesized that 1) satisfaction with services is positively related to life satisfaction; and 2) insecure attachment stylesare negatively related to satisfaction with services and quality of life, whereas positively to the current psychopathology.

Materials and Methods


The setting for this study was the state-funded Sha'ar Menashe Mental Health Center that is the greatest psychiatric institution in both Israel and Middle East. The center has 420 beds distributed as follows: 130 acute, 90 chronic, 35 geriatric, 40 rehabilitation and 125 maximum high security beds. The hospital serves a catchment area with a mixed Arab-Jewish, lower and middle-income population of 830,000.


One hundred-one patients from rehabilitation and partly chronic wards were recruited for this study during 2012 according to the followinginclusion criteria: 1) ICD-10 diagnosis of schizophrenia [48]; 2) duration of treatment no less than six months, and 3) sufficient comprehension skills to provide written informed consent for participation in the study. Patients with comorbid serious medical illnesses and organic brain syndromes were not enrolled.The rationale of the selection criteria was to create a homogeneous cohort of typical users of inpatient rehabilitation services. After explanation of the study aims and procedure all participants provided written informed consent for participating in the study as approved by the Institutional Review Boards for HumanStudies.


The main outcome variables were measured with the Mental ealth Client Satisfaction Scale [49,50], adapted for use with inpatient rehabilitation services, and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form [51]. The predictor variables were measured with the Relational Questionnaire [44] and the Positive and Negative Syndrome Scale [52].

Mental health client satisfaction scale

The MHCSS-H is a validated Hebrew version of the Charleston Psychiatric Satisfaction Scale [50]. This is self-report multidimensional questionnaire is designed to measure satisfaction with mental health services. Sixteen items describe five service domains (Availability/ Accessibility, Quality of care, Explanation/Participation, Staff's attitude, and Facilities conditions) of satisfaction, including two anchor items (“Overall quality of the care provided” and “Would you recommend this clinic to a friend or relative?”). Responses are rated on a 5-point Likert scale ranging from 1 (“very dissatisfied”) to 5 (“very satisfied”). For this sample, internal consistency of the MHCSS-H was excellent (Cronbach's alpha = 0.94) [50].

Quality of life enjoyment and satisfaction questionnaire

The Q-LES-Q is a self-report form composed of 16 items, each rated on a 5-point scale that indicates the degree of enjoyment or satisfaction experienced over the past week. A total score of 1 to 15 items is computed. The items evaluated each subject's satisfaction with: their physical health; social relations; ability to function in daily life; ability to get around physically; mood; family relations; sexual drive and interest; ability to work on hobbies, work, leisure time activities; economic status; household activities; living/housing situation; medication and overall sense of well-being. To avoid augmenting scores, global item 16, ‘life satisfaction and contentment over the last week', was not included in the total score. The Q-LES-Q was validated in Hebrew elsewhere [24]; for the present sample, Cronbach's alpha was 0.91.

Relational questionnaire

The RQ is used to assess adult attachment styles: they are described by 4 brief statements and participants are asked to endorse the statement that is most self-descriptive (they are described in the Introduction section). In addition to the categorical forcedchoice approach we also applied the dimensional approach, asking participants to indicate how much each description corresponded to their general relationship style. Responses were rated on a 7-point Likert-type scale ranging from 1 (“Not at all like me”) to 7 (“Very much like me”). Completing the forced-choice section first serves to counterbalance and minimize order effects when participants rank the degree to which each prototype characterizes them.The attachment anxiety dimension was calculated as (fearful plus preoccupied scores) minus (secure plus dismissing scores) and the attachment avoidance dimension was computed as (fearful plus dismissing scores) minus (secure plus preoccupied scores) [53]. The validity of this attachment classification has been demonstrated by its empirical relationships to self-concept and interpersonal functioning [44] and to psychological wellbeing and social functioning [54].

To ensure completion of the self-reported questionnaires, the researcher (MA) did read the items to the participants. In the end of the session, the researcher used the PANSS for assessing the severity of positive, negative and general psychopathological symptoms. Its 30 symptom items are scored from absent (1) to extreme problem (7).The Cronbach's a for the present sample was 0.70 for the positive scale, 0.92 for the negative scale, and 0.87 for both general psychopathology scale and PANSS as a total.

Statistical analyses

Pearson product moment correlations were calculated to test the relationships among all measures. To test our hypotheses, firstly, univariate analyses comparing intergroup measurements were performed using ANOVA with Tukey HSD post-hoc single comparisons. Then multiple regression analyses on linear models were performed to predict service satisfaction and quality of life outcomes from insecure attachment dimensions (anxiety and avoidance), controlling for the severity of positive, negative and general symptomatology. For all analyses, the level of statistical significance was established at p < .05. Statistical analyses were performed with SPSS version 17 for Windows (SPSS Inc., Chicago, IL) (Table 1).