Theoretical support for the potential role of attachment style in the internalisation of stigma comes from a number of perspectives. These include evidence on the role of attachment style in determining responses to feelings of distress and threat generally as well as evidence on relationships between stigma relevant concepts and attachment style in wider groups of people prone to stigma. There is also limited support from research in the context of adult mental health where internalised stigma and attachment have been measured. Support for the investigation of the potential role of attachment style in the internalisation of stigma may also be drawn from developing thinking in stigma research.
An attachment perspective suggests that a person’s security of attachment may determine how they respond to perceived or experienced stigma (Mikulincer & Shaver 2012). Research suggests that, in comparison to people with insecure attachment, people with secure attachment styles have greater resources to call on in the face of emotional distress or perceived threat, including more ready access to positive memories to help alleviate distress (Mikulincer, Shaver & Pereg 2003). Conversely people who are less securely attached have an increased tendency to exaggerate appraisals of threats (Mikulincer et al. 2000), difficulties in the suppression of negative thoughts and feelings (Mikulincer, Dolev & Shaver 2004) and a greater tendency for rumination (Mikulincer, Shaver & Pereg 2003). It is conceivable that these same predispositions could play some role in determining how people with experience of mental health problems respond to perceived or experienced stigma, which can be understood as a form of social threat and a source of considerable distress. Further, it is also possible that attachment style may play some role in determining whether people with experience of mental health problems internalise or reject stigma.
Support for the proposition that people with secure attachment styles may have more internal resources to call upon for self-validation in the face of other’s negative attitudes and behaviours can be gleaned from research on other groups who are prone to societal stigma (Zakalik & Wei 2006; Elizur & Mintzer 2003). Relevant observations include a reduced
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likelihood for internalising shame amongst lesbians with secure attachment styles (Wells & Hansen 2003), a mediating effect for perceived discrimination in the relationship between insecure attachment styles and depression in gay men (Zakalik & Wei 2006) and an increased endorsement of stigma and negative stigma-related self-image amongst people living with HIV who have an anxious attachment style (Riggs, Vosvick & Stallings 2007). It should be noted that all of these studies were observational so it is not possible to draw conclusions on causal relationships. The small number of studies which have looked at relationships between internalised stigma and attachment style in the context of adult mental health have also shown higher levels of internalised stigma to be associated with insecure attachment styles (Restek- Petrović et al. 2015; Cheng, McDermott & Lopez 2015). Again, these findings were observational and as yet untested longitudinally, so caution is required in their interpretation.
Given gaps in understanding about the underlying processes involved in the internalisation of mental health stigma (Livingston & Boyd 2010) some researchers have called for new research approaches (Sibitz et al. 2011b; Margetić et al. 2010; Livingston & Boyd 2010) and these offer further support for the consideration of attachments style as potentially contributory. Social cognitive theorists focus on the social-relational context in which stigma exists and have largely neglected to consider the role of more fixed individual level contributors in determining responses to stigma. For example, Margetić and colleagues (2010) have proposed that personality may be implicated in determining the internalisation of stigma. A case may also be made for attachment style being an individual level determinant which potentially determines the internalisation of stigma.
Figure 1.2 demonstrates how social cognitive models of internal stigma focus on the conditions in which stigma exists, individual’s responses to those conditions and the consequences of those responses. Internal working models, governing the interpretation and processing of attachment relevant experiences and access to memories of perceived threat (Mikulincer, Shaver & Pereg 2003), might be hypothesised as influencing responses to
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conditions in which stigma exists and also in playing a role in determining its consequences and outcomes.
Figure 1.2 An attachment informed model of the internalisation of stigma
A second shift in stigma research has been toward an increased focus on better understanding the availability of ‘buffers’ against the toxic effects of stigma (Rüsch et al. 2006; Thoits 2011). It is proposed that focusing more strongly on buffers and coping strategies might usefully inform the development of interventions to build stigma resistance (Campellone et al. 2014). Specific support for the potential role of attachment in stigma resistance may be gleaned from two perspectives. Wider research suggests attachment style plays an important role in determining coping style in psychosis (Gumley et al. 2014) and this may suggest a similar role in relation to coping with the effects of public stigma. Secondly access to social support has been shown to be a positive buffer against stigma (Livingston & Boyd 2010; Lysaker et al. 2007), so it is noteworthy that the extent to which people can access this social support is in part contingent upon attachment style (Graves et al. 1998). Attachment theory is
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concerned with our mental representation of self in relation to others (Bowlby 1969), so our access to, and interpretation of, social relationships and the support they can provide are important.