Theoretical Paper

A critique on the use of standard

psychopathological classifications in
understanding human distress:
The example of ‘schizoid personality
disorder’
Panagiotis Parpottas

Content and Focus: There is an ongoing debate about how practitioners understand ‘mental disorders’ in
terms of assessment, formulation and treatment. The current diagnostic procedures are defined by rule-based
classifications that largely rely on symptom clusters, such as the Diagnostic and Statistical Manual of mental
disorders (DSM) and the International Classification of Diseases (ICD), and are influenced by the medical
model which supports the concept of nosology. Under this notion, psychological difficulties are seen as
pathological and, therefore, questions are raised about what is ‘normal’ and ‘abnormal’. The aim of this paper
is to make a critique on the use of standard psychopathological classifications in understanding human
distress and the example of so-called schizoid personality disorder will be discussed in non-conventional
psychiatric terms. Additionally, a formulation-driven approach which derives from the basic tenets of
attachment theory will be utilised to understand schizoid personality disorder. Considerations for counselling
psychology practice are also discussed in light of an integrative therapeutic framework, which brings together
concepts from Cognitive Behavioural Therapy (CBT) and psychodynamic therapy.
Conclusions: The current psychopathological classifications provide a descriptive guidance on labelling
symptoms but the limited attention paid on the aetiology of disorders raises important questions. A need for
revision of what constitutes a psychiatric ‘illness’ is apparent and furthermore the inclusion of a formulation-
driven approach in the psychopathological manuals can be invaluable as it can offer a heuristic focus in
understanding human psychological distress.
Keywords: mental disorders; standard psychopathological classifications; schizoid personality disorder;
attachment theory; counselling psychology.

E
XISTING empirical studies related to
human biology and psychology, but also
philosophically-rooted notions such as
the ‘body and mind problem’, imply that
humans are beings with complex and differ-
ent needs. Due to this complexity, humans
have a developmental cognitive tendency to
construct different meanings in their lives by
classifying and naming objects (Towse &
Cowan, 2005). Perhaps without this ability, it
might have been very difficult to cope with
the demands of everyday life and as Golswor-
thy (2004) suggests, we try to produce mean-
ings by categorising things so that our world
becomes more manageable. In line with this,
categorisation applies in the field of psy-
chopathology and underpins the psychiatric
classifications of mental disorders because
understanding and ‘treating’ human distress
is seen as complex and difficult (Fulford et
al., 2006).
It is argued that diagnostic manuals, such
as DSM and ICD, are a necessary frame of ref-
erence in the field of mental health, because
they provide a common language to clini-
cians worldwide in producing clinically

44 Counselling Psychology Review, Vol. 27, No. 1, March 2012

© The British Psychological Society – ISSN 0269-6975
 A critique on the use of standard psychopathological classifications in understanding human distress
meaningful information about peoples’ diffi-
culties, which can then lead to specific inter-
ventions aiming to target symptomatology
(Berganza et al., 2005; Jablensky & Kendell,
2002). Despite the agreement between these
diagnostic systems in identifying symptoms
and classifying mental disorders, it can be
argued that they lack a formulation-driven
approach and also with the publication of
new research they become outdated. In addi-
tion, influenced by the medical model which
supports the concept of nosology, constructs
that derive from the standard psychopatho-
logical manuals may reinforce the view of ‘ill-
ness’. Inflexible use of those atheoretical
classifications, can (mis)label people as
‘mentally ill’ without acknowledging what is
behind the manifestation of their presented
symptoms and difficulties.
In other branches of medicine the
process of classifying, diagnosing and treat-
ing illnesses can be much more straightfor-
ward than in the field of psychiatry (Fulford
et al., 2006). One aspect of the problem here
is the definition of the term mental disorder
and what can be defined as such, especially
when the behaviour is the main instrument
used in diagnosing mental disorders
(Golsworthy, 2004). DSM-IV defines a mental
disorder as:
…a clinically significant behavioral or
psychological syndrome or pattern that occurs
in an individual and that is associated with
present distress (e.g. a painful symptom) or
disability (i.e. impairment in one or more
important areas of functioning) or with a
significantly increased risk of suffering death,
pain, disability, or an important loss of
freedom. (…) Whatever its original cause, it
must currently be considered a manifestation of
a behavioural, psychological, or biological
dysfunction in the individual.
(American Psychiatric Association [APA],
1994; p.xxi).
Some assumptions that derive from the
above definition are that mental disorders
are facts that people struggle with and symp-
toms, whatever the original cause, can be
classified in such terms defining a ‘normal’
Counselling Psychology Review, Vol. 27, No. 1, March 2012
and ‘abnormal’ behaviour or psychological
state. These assumptions can create great
uncertainty to a lay person who can assume
just by reading one of those manuals that
they suffer from a disorder of mind or that
they are psychologically ‘unstable’.
A major limitation of the standard psy-
chopathological classifications is that they
only present with a list of symptoms and clus-
ters, neither providing any understanding,
nor addressing the aetiology of symptoms
and disorders. Even statistically, the categori-
cal system which is used to diagnose mental
disorders proves to be problematic as to what
is normal or abnormal is not discretely clas-
sified (Lopez et al., 2006). Therefore, it can
be argued that the meaning attached on
constructs like psychiatric disorders or men-
tal illness tends to pathologise human expe-
rience. The definition of a mental disorder
becomes more blurred when we talk about
personality disorders as directly, or indi-
rectly, it is implied that there is a ‘faulty’ per-
sonality and a disordered behaviour which
causes problems in interpersonal relation-
ships (Perris, 2000). The rest of the paper
will focus on a discussion around how
schizoid personality disorder (Schizoid PD)
is perceived in DSM-IV terms, and how
attachment theory can be utilised by coun-
selling psychologists to understand a per-
son’s distress who presents with such
difficulties.
The paradigm of Schizoid PD
In plain language, DSM-IV defines a personal-
ity disorder as a steady long-held pattern of
beliefs and behaviours that cause difficulties
in maintaining emotions, thoughts, behav-
iours and interpersonal relationships at a
socially acceptable level. However, ‘Only when
personality traits are inflexible and maladaptive
and cause significant functional impairment or
subjective distress do they constitute a personality
disorder’ (APA, 1994, p.630). But what consti-
tutes the socially acceptable and is that
socially acceptable the same in different coun-
tries and cultures? Why does DSM-IV assume
that personality traits are absolute determi-
45
Panagiotis Parpottas
nants? What methods are valid and reliable to
assess if a personality trait is inflexible or mal-
adaptive? And finally, is a personality disorder
really an illness? These questions have
plagued practitioners for many years and
must be carefully considered before classify-
ing people in such discrete categories.
A person to be diagnosed with Schizoid
PD in DSM-IV terms must meet the following
criteria:
A. A pervasive pattern of detachment from
social relationships and a restricted range of
expression of emotions in interpersonal settings,
beginning by early adulthood and present in a
variety of contexts, as indicated by four (or
more) of the following:
(1) neither desires nor enjoys close relationships,
including being part of a family;
(2) almost always chooses solitary activities;
(3) has little, if any, interest in having sexual
experiences with another person;
(4) takes pleasure in few, if any, activities;
(5) lacks close friends or confidants other than
first degree relatives;
(6) appears indifferent to the praise or criticism
of others;
(7) emotional coldness, detachment, or flattened
affectivity.
B. Does not occur exclusively during the course
of schizophrenia, a mood disorder with psychotic
features, another psychotic disorder, or a
pervasive developmental disorder, and is not
due to the direct physiological effects of a general
medical condition. (APA, 1994, p.641)
My first impression after reading the above
points was that the combination of words
Schizoid and Personality disorder have a nega-
tive connotation. Furthermore, after care-
fully rereading those symptoms, I realised
that they can lead to misleading assumptions
such as: Schizoid PD begins only in early
adulthood, the person has limited or no sex-
ual drives and interests, little or nothing can
give them pleasure and that they seem apa-
thetic in the praise or criticism of others.
Finally, that list of symptoms seems dry as
there is no explanation about their aetiology.
As the main feature of Schizoid PD is with-
drawal from relationships, accompanied by
46 Counselling Psychology Review, Vol. 27, No. 1, March 2012
decreased affect regulatory strategies, attach-
ment theory could possibly provide a
grounded framework in understanding the
nature of these difficulties.
Attachment theory
From an attachment theory perspective our
interactions with primary caregivers shape
our perceptions about the world, our
responses to others but also the ways we
learn to regulate our emotions. Infants at
times of need, distress and danger tend to
seek proximity from their caregivers in order
to elicit protection and security. If the care-
giver attends to the infant’s needs and secu-
rity is restored then the infant feels
adequately protected and supported. How-
ever, when an attachment figure is unavail-
able, rejecting or inconsistently responsive to
the infant’s needs, the distress increases and
the infant tends to believe that the world is
unreliable and unsafe. The second situation
is called insecure attachment, where the child
to be able to cope with distress may adopt a
secondary attachment strategy which takes
two forms: hyperactivation or deactivation
(Ainsworth et al., 1978). Bowlby (1982) sug-
gested that our experiences are internalised
and stored in memory and finally become
schemas or Internal Working Models of
attachment and affect regulation (IWMs),
which are activated in new situations and
relationships.
Understanding and redefining Schizoid
PD in non-conventional psychiatric
terms from an attachment theory
perspective
Attachment theory is a well-established
theory of close relationships, development
and psychopathology which can enlighten
us, as to whether a person may experience
psychological distress from a relational point
of view (Obegi & Berant, 2009). Unlike DSM,
which in my opinion has never intended to
appreciate the significance of the individ-
ual’s phenomenology, attachment theory val-
ues not only the present, but also the past,
and the developmental context in which a
 A critique on the use of standard psychopathological classifications in understanding human distress
person’s difficulties have developed. Disor-
ders are seen as expressions of an internal
pain coming from difficulties experienced in
interactions with attachment figures (past
and present) and, therefore, symptoms are
signals of that pain, serving a specific func-
tion (Crittenden, 2005). From this stance, a
valid assessment and formulation can lead to
appropriate therapeutic interventions tai-
lored to the individual’s needs. This
approach is highly respected in counselling
psychology, as it can provide an understand-
ing of the person’s phenomenology and
enhance our clinical work, which mainly
focuses in and on the therapeutic relation-
ship. Working with the therapeutic relation-
ship is considered as highly important,
especially for people whose distress is associ-
ated with inflexible longstanding personality
traits and relational difficulties, in other
words people who ‘suffer’ from personality
disorders (Beck et al., 2004; Young et al.,
2003; Wallin, 2007).
Empirical research has revealed that,
insecure attachment and the use of second-
ary attachment strategies by adults, are risk
factors for mental health problems, and that
Schizoid PD is associated with an insecure
attachment and particularly with attachment
avoidance (Dignam et al., 2010; Haggerty et
al., 2009; Lyddon & Sherry, 2001; Sherry et
al., 2007; Shorey & Snyder, 2006). Attach-
ment avoidance is related to an excessive
need for self-reliance and fear of depending
on others, avoidance of emotional closeness
and social withdrawal (Brennan et al., 1998).
People with attachment avoidance make use
of the deactivation strategy, which can pro-
vide a rationale for the Schizoid PD symp-
toms. As Main, Kaplan and Cassidy (1985)
propose, in the co-created nature of the par-
ent-child relationship there is a projection of
‘dismissing rules’ from parents (i.e. the child
should not express any physical or emotional
needs) and an internalisation of those rules
by children. Therefore, facing rejection,
children characterised by attachment avoid-
ance may have learnt to give up on their
proximity-seeking efforts and by using sup-
Counselling Psychology Review, Vol. 27, No. 1, March 2012
pression, avoidance and minimisation of the
pain they try to regulate their emotions
(deactivation strategy).
As Wallin (2007) suggests, the use of the
deactivation strategy lies between the indi-
vidual’s conscious and unconscious IWMs
that shape their inner and interpersonal
experience. The conscious model is about a
good, strong and complete sense of self
while others are seen as untrustworthy. The
unconscious model is about a flawed,
dependent and helpless self while others are
rejecting and punitive. As previously men-
tioned, attachment relationships are power-
ful enough to inform our self-image and our
perceptions of others and the world, hence
from the continuous interactions with our
caregivers and later on from our interactions
with close others, we learn what to expect.
Consequently, individuals with attachment
avoidance may use the deactivation strategy
as they may believe that others are no good
to trust or will reject their needs, just like
their primary caregivers.
Reframing the DSM-IV’s criteria for
Schizoid PD into a more tentative presenta-
tion derived from attachment theory, could
mean, that individuals who present with such
difficulties may tend to keep relationships at
a distance, choosing to be more self-reliant
as they feel discomfort with intimacy and
interdependence. They may have a desire
for some degree of contact but as they fear
rejection or emotional ‘traumatisation’ they
may be reluctant to pursue steady or long-
term romantic, sexual and other relation-
ships preferring short-term relationships,
and by keeping others ‘at arms length’ they
‘survive’ from the emotional closeness of
those relationships. Finally as they may have
learnt to devalue emotions in times of pain,
they may experience some difficulties in reg-
ulating and demonstrating some of their
emotions giving the impression to others,
who are different from them, of a distant,
detached and unemotional person.
Attachment theory describes personality
functioning in a nonpathological way and
provides a coherent aetiology of the distress
47
Panagiotis Parpottas
of people who are diagnosed by Schizoid PD
in DSM-IV terms. In addition, attachment
research with its recent developments, sug-
gests that the IWMs are best captured in
dimensional rather categorical terms to avoid
misleading categorisation (Fraley & Waller,
1998). According to this, the different ways of
relating and regulating difficult emotions
(deactivation or hyperactivation) represent a
logical adaptive functioning, for example, all
of us have the need sometime not to express
feelings and even suppress them or even
withdraw from relationships for a little while,
which can be seen in the ‘adaptive’ side of a
continuum. However, if these characteristics
tend to be excessive and cause persistent dif-
ficulties to a person, they may lead to psycho-
logical distress which lies somewhere at the
other end of the continuum.
Attachment theory strongly suggests that
our attachment experiences inform rather
than define our future relationships and as
we form more than one relationship, our
IWMs may differ from one relationship to
another (Shaver & Mikulincer, 2009). As we
have multiple social roles in our lives, our
interactions with different people shape the
choice of particular actions, thoughts and
behaviours. This is hopeful and positive as it
is understood that a schizoid person may
have good interactions and relationships
with some people at some level. All these are
in accordance with McRay’s and Costa’s
(2003) definition of personality traits which
are seen as only dispositions and not
absolute determinants, confirming that the
traditional categorical classification systems
wrongly assume that personality disorders
are stable and absolute facts of human
nature. A categorised system like DSM takes
a more medicalised approach, and inflexible
use of such manual might lead to a danger of
pathologising human experience. Not giving
the proper attention to understanding why
people behave as they do, psychopatho-
logical classifications can never capture the
complexity and uniqueness of human expe-
rience (Ivey & Ivey, 1998). Counselling psy-
chology is a branch of scientific and applied
48 Counselling Psychology Review, Vol. 27, No. 1, March 2012
psychology that resists dogma and takes such
issues seriously by formulating that psycho-
logical distress is a product of interacting sys-
tems (Boucher, 2010).
Implications for practice
This section aims to highlight issues in work-
ing with clients who present with Schizoid
PD and an integrative therapeutic frame-
work, which combines interventions from
CBT and psychodynamic therapy, will be dis-
cussed. My intension is not to create an inte-
grative model of therapy in working with
Schizoid PD, but to enrich counselling psy-
chologists’ work by bringing together attach-
ment theory and two therapeutic
approaches which were found to be differ-
ently effective when working with clients
higher in attachment avoidance (Daniel,
2006; Eagle & Wotlitzky, 2009; Fonagy et al.,
1996; Lawson, 2010; Mcbride et al., 2006;
Muller, 2009; Tasca et al., 2011). Arguably,
when interventions from CBT and psychody-
namic therapy are blended together, they
pay considerable attention in understanding
and working with the conscious and uncon-
scious beliefs, representations and defences
of a client who presents with Schizoid PD.
Therefore, my view of this integration is one
where the attachment-informed therapist,
creatively and interchangeably uses interven-
tions derived from CBT and psychodynamic
therapy in their work, and being attuned and
empathic, tailors these interventions to the
client’s actual needs.
It is generally accepted, that clients’
attachment dimensions can affect their
approach to therapy, the process and also
the outcome of therapy (for a review see in
Daniel, 2006). Accordingly, schizoid clients
who present as self-reliant and detached,
they may approach the therapist in a distant
way, often being reluctant to express any
emotions and believing that the therapist
will be unavailable, rejecting or intrusive.
Working in and on the therapeutic relation-
ship can be very reparative for them because
the core of their distress is relational. There-
fore, counselling psychologists informed by
 A critique on the use of standard psychopathological classifications in understanding human distress
attachment theory, will initially aim to con-
struct a relationship which fosters a ‘secure
base’ (Bowlby, 1988) within such emerging
relational patterns will be understood and
reworked. But to achieve this, there is a need
for adaptation, sensitivity, responsiveness,
flexibility and integration, all which are com-
ponents of a secure and sensitive caregiving
from the part of the therapist (Fitch &
Pistole, 2010; Parpottas, 2011).
From an attachment theory perspective,
the goal of therapy with clients higher in
attachment avoidance is to gradually expose
them to emotional expression and new
attachment experiences (Mallinckrodt et al.,
2009). The same may apply to schizoid
clients, who are characterised by a down-reg-
ulation emotional strategy and detachment
in relationships. This is because emotions
can be very frightening, especially in the
beginning of therapy, and threats associated
with closeness and dependence on the ther-
apist may be evoked by the frame of therapy.
For instance, it was found that clients with
higher attachment avoidance may prema-
turely terminate their therapy if they self-
disclose emotions too early in therapy (Tasca
et al., 2009).
One way of approaching schizoid clients
in the early stage of therapy, is to stay on a
cognitive level when exploring past relation-
ships and distressing experiences. This way,
the focus is on logic which is congruent with
the avoidant client’s strategy ‘valuing cogni-
tion over emotion’ (McBride & Atkinson,
2009). By integrating some CBT techniques
around negative cognitions and beliefs while
working with the transference, can be
proven less threatening for schizoid clients.
For example, interventions such as guided
discovery and testing negative automatic
thoughts (Sanders & Wills, 2005), can be
used in such way to understand the client’s
beliefs and assumptions about what may hap-
pen if they let themselves feel close to others
and their therapist and what that may mean
for them. Slade (2008) suggests that in this
way therapists work ‘in style’ with clients
higher in attachment avoidance, meaning
Counselling Psychology Review, Vol. 27, No. 1, March 2012
that they work at a more cognitive level
which these clients can respond well.
As therapy continues, clients can be pre-
pared for deeper work and the key here, as
Wallin (2007) suggests, is to follow the affect.
Therapists can then work ‘out of style’
(Slade, 2008), meaning that they work in
more affective ways in order to respond to
schizoid clients’ underlying emotional needs
by challenging their deactivation strategy
and attachment avoidance. We must be
reminded at this point, that the use of Roger-
ian conditions (Rogers, 1957) are essential
throughout the process, especially attune-
ment and empathic understanding, as in this
way clients can learn more adaptive strate-
gies for affect regulation.
While therapy gradually exposes schizoid
clients to their unintegrated emotional expe-
rience, which can become the most chal-
lenging task of therapy, they may use again
their deactivation strategy and related
defences to protect themselves. Here by inte-
grating psychodynamically driven interven-
tions in our work with cognitions, we aim to
go beyond the surface of the client’s beliefs
into understanding the representational
aspects of their difficulties. For example,
from what we already know from exploring
the client’s negative automatic thoughts, we
may choose to focus on interpreting the con-
flict and anxiety behind those beliefs and by
using empathic confrontation to challenge
the client’s defences. Unfolding the underly-
ing conflict, the therapist helps the client to
make the connections between thoughts,
behaviours and suppressed emotions which
govern their emotional responses in rela-
tionships, all showing the ‘royal road’ in
understanding the client’s unconscious and
maladaptive IWMs.
Our therapeutic work becomes more
experiential when the therapeutic relation-
ship is utilised to point out the client’s
avoidant attachment strategies in the here-
and-now and by linking them with the there-
and-then, the so-called corrective emotional
experience (Bowlby, 1988) can take place.
Another important aspect of therapy, as
49
Panagiotis Parpottas
known from psychoanalysis, whatever these
clients are reluctant to feel, it will often be
evoked in their therapists. Therefore, our
countertransference is an important ‘tool’
throughout the process of therapy as it can
guide us to the client’s unintegrated experi-
ence. Putting into words unspoken emotions
and unconscious fantasies, and making the
connections with the client’s current nega-
tive beliefs and avoidant behaviours, is
critical for the client in becoming more
reflective and integrated.
Slade (2008) suggests that moving
between ‘in style’ (working with cognitions)
and ‘out of style’ (working with affect)
responses where necessary and appropriate,
promotes flexibility and integration which
are important components of a successful
therapy. This is how I believe integrating
CBT and psychodynamic interventions and
utilising the therapeutic relationship and the
therapist’s use of self in our work, we can
create a space which fosters a secure base
and a safe heaven for the client. Ultimately,
this can enable schizoid clients to explore
their internal worlds and become more flex-
ible in processing new information, at a cog-
nitive, emotional and experiential level, in
order to understand, challenge and rework
their old IWMs.
Although attachment theory is not an
independent psychotherapeutic approach, it
is a theory about relationships which can
inform our formulation of the client’s dis-
tress, and our interventions, by placing the
therapeutic relationship at the heart of
therapy. However, some caution must be
stressed on the use of ideas that derive from
the basic tenets of attachment theory and
from this integrative therapeutic framework.
As each person is different and their distress
differs in nature and degree, our formula-
tion must always be a tentative working
hypothesis, based on their specific experi-
ences and difficulties, and our interventions
must follow accordingly. In other words, per-
sonal experience comes first and theory and
the technical aspects of therapy follow in
50 Counselling Psychology Review, Vol. 27, No. 1, March 2012
order to minimise the danger of losing the
individual’s experience in a pool of theoreti-
cal ideas. Therefore, the previous implica-
tions for practice must be seen as tentative
ideas and suggestions and not a ‘treatment
plan’ that suits every client.
Conclusion
For many years the stigma of being ‘crazy’ was
attached to any difficulty related to mental
health and perhaps the standard psy-
chopathological classifications still give this
impression. Although the current diagnostic
systems have been developed for classification
purposes, they just label ‘clinical phenom-
ena’, specific attitudes and behaviours (Ivey &
Ivey, 1998). The present paper took a differ-
ent perspective in understanding psychologi-
cal distress, utilising attachment theory to
formulate hypotheses about the symptomatol-
ogy of Schizoid PD in non-conventional psy-
chiatric terms, which is relevant to the
philosophy and ethos of counselling psychol-
ogy. Important inferences that derive from
this paper are that whatever a mental disorder
is, it does not reflect facts about individuals.
The lack of clarity on why some people expe-
rience a specific disorder leaves the tradi-
tional diagnostic classifications incomplete.
After all, mental illness is only a construct that
people have developed to understand such
phenomena (Golsworthy, 2004). A need for
revision is apparent in the standard psy-
chopathological manuals and the inclusion of
a formulation-driven approach is essential as
it can bring together a systematic organisation
of symptoms and a comprehensive under-
standing of their aetiology.
About the Author
Panagiotis Parpottas has recently completed
his PsychD in Psychotherapeutic & Coun-
selling Psychology at the University of Surrey.
Correspondence
Panagiotis Parpottas
Email: counsellingpsy@gmail.com
 A critique on the use of standard psychopathological classifications in understanding human distress
References
Ainsworth, M.S., Blehar, M.C., Waters, E. & Wall, S.
(1978). Patterns of attachment: A psychological study
of the Strange Situation. Hillsdale, NJ: Erlbaum.
American Psychiatric Association (1994). Diagnostic
and Statistical Manual of Mental Disorders (4th ed.).
Washington, DC: Author.
Beck, A.T., Freeman, A., Davis, D.D. & Associates.
(2004). Cognitive therapy for personality Disorders.
London: Guilford Press.
Berganza, C.E., Mezzich, J.E. & Banzato, C. (2005).
Advances in psychiatric diagnosis and classifica-
tion. In G.N. Christodoulou (Ed.), Advances in
psychiatry. Vol. II (pp.21–29). Athens: HPA.
Boucher, T.A. (2010). Cognitive-behavioural contri-
butions to pluralistic practice. In M. Milton
(Ed.), Therapy and beyond. Counselling psychology
contributions to therapeutic and social issues
(pp.156–169). West Sussex: Wiley-Blackwell.
Bowlby, J. (1982). Attachment and Loss, Vol. 1: Attach-
ment (2nd ed.). New York: Basic Books.
Bowlby, J. (1988). A secure base: Clinical applications of
attachment theory. London: Routledge.
Crittenden, P.M. (2005). Attachment theory, psy-
chopathology and psychotherapy: The dynamic-
maturational approach. Psychotherapia, 30,
171–182.
Daniel, S.I.F. (2006). Adult attachment patterns and
individual psychotherapy: A review. Clinical
Psychology Review, 26(8), 968–984.
Dignam, P., Parry, P. & Berk, M. (2010). Detached
from attachment: Neurobiology and phenome-
nology have a human face. Acta Neuropsychiatrica,
22, 202–206.
Eagle, M. & Wotlitzki, D. (2009). Adult psycho-
therapy from the perspective of attachment
theory and psychoanalysis. In J.H. Obegi &
E. Berant (Eds.), Attachment theory and research in
clinical work with adults (pp.351–378). New York:
Guilford Press.
Fitch, J.C. & Pistole, M.C. (2010). Development and
use of CCQ. Unpublished manuscript, Purdue
University.
Fraley, R.C. & Waller, N.G. (1998). Adult attachment
patterns: A test of the typological model. In J.A.
Simpson & W.S. Rholes (Eds.), Attachment theory
and close relationships (pp.77–114). New York:
Guilford Press.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy,
R., Mattoon, G. et al. (1996). The relation of
attachment status, psychiatric classification, and
response to psychotherapy. Journal of Consulting
and Clinical Psychology, 64, 22–31.
Fulford, K.W.M., Thornton, T. & Graham, G. (2006).
Oxford textbook of philosophy and psychiatry. Oxford:
Oxford University Press.
Counselling Psychology Review, Vol. 27, No. 1, March 2012
Golsworthy, R. (2004). Counselling psychology and
psychiatric classification: Clash or co-existence?
Counselling Psychology Review, 19(3), 23–28.
Haggerty, D., Hilsenroth, M.J. & Vala-Steward, R.
(2009). Attachment and interpersonal distress:
Examining the relationship between attachment
styles and interpersonal problems in a clinical
population. Journal of Clinical Psychology and
Psychotherapy, 16, 1–9.
Ivey, A.E. & Ivey, M.B. (1998). Reframing DSM-IV:
Positive strategies from developmental coun-
selling and therapy. Journal of Counselling and
Development, 76, 334–350.
Jablensky A. & Kendell, R.E. (2002). Criteria for
assessing a classification in psychiatry. In M. Maj
et al. (Eds.), Psychiatric diagnosis and classification
(pp.1–24). London: John Wiley & Sons Ltd.
Lawson, D.M. (2010). Comparing cognitive behav-
ioural therapy and integrated cognitive behav-
ioural therapy/psychodynamic therapy in group
treatment for partner violent men. Psychotherapy,
Theory, Research, Practice, Training, 47(1), 122–133.
Lopez, S.J., Edwards, L.M., Pedrotti, J.T., Prosser,
E.C., LaRue, S., Spalitto, S.V. & Ulven, J.C.
(2006). Beyond the DSM-IV: Assumptions, alter-
natives and alterations. Journal of Counselling &
Development, 84, 259–267.
Lyddon, W.J. & Sherry, A. (2001). Developmental
personality styles: An attachment theory.
Conceptualisation of personality disorders.
Journal of Counselling and Development, 79,
405–414.
Main, M., Kaplan, N. & Cassidy, J. (1985). Security in
infancy, childhood and adulthood: A move to the
level of representation. Monographs of the Society
for Research in Child Development, 50(1-2), 66–104.
Mallinckrodt, B., Daly, K. & Wang C-C. D.C. (2009).
An attachment approach to adult psychotherapy.
In J.H. Obegi & E. Berant (Eds.), Attachment
theory and research in clinical work with adults
(pp.234–268). New York: Guilford Press.
McBride, C., Atkinson, L., Quilty, L.C. & Bagby, R.M.
(2006). Attachment as moderator of treatment
outcome in major depression: A randomised
control trial of interpersonal psychotherapy
versus cognitive behaviour therapy. Journal of
Consulting and Clinical Psychology, 74, 1041–1054.
McBride, C. & Atkinson, L. (2009). Attachment
theory and cognitive behavioural therapy. In J.H.
Obegi & E. Berant (Eds.), Attachment theory and
research in clinical work with adults (pp.434–458).
New York: Guilford Press.
McRay, C.C., & Costa, P.T. (2003). Personality in adult-
hood. A five-factor theory perspective. New York:
Guilford Press.
51
Panagiotis Parpottas
Muller, R.T. (2009). Trauma and dismissing (avoid-
ant) attachment: Intervention, strategies in indi-
vidual psychotherapy. Psychotherapy, Theory,
Research, Practice, Training, 46(1), 68–81.
Obegi, J.H. & Berant, E. (2009). Attachment theory and
research in clinical work with adults. New York:
Guilford Press.
Parpottas, P. (2011). Effects of therapists’ attachment and
caregiving on the working alliance. Doctoral thesis,
University of Surrey.
Perris, C. (2000). Personality-related disorders of
interpersonal behaviour: A developmental-
constructivist cognitive psychotherapy approach
to treatment based on attachment theory. Clinical
Psychology and Psychotherapy, 7, 97–117.
Rogers, C. (1957). The necessary and sufficient
conditions of therapeutic personality change.
Journal of Consulting Psychology, 21(2), 95–103.
Sanders, D. & Wills, F. (2005). Cognitive therapy:
An introduction. London: Sage.
Shaver, P.R. & Mikulincer, M. (2009). An overview of
adult attachment theory. In J.H. Obegi & E.
Berant (Eds.), Attachment theory and research in
clinical work with adults (pp.17-45). New York:
Guilford Press.
Sherry, A., Lyddon, W.J. & Henson, R.K. (2007).
Adult attachment styles and developmental
personality styles: An empirical study. Journal of
Counselling and Development, 85, 337–348.
Shorey, H.S. & Snyder, C.R. (2006). The role of adult
attachment styles in psychopathology and
psychotherapy outcomes. Review of General
Psychology, 10(1), 1–20.
52 Counselling Psychology Review, Vol. 27, No. 1, March 2012
Slade, A. (2008). The implications of attachment
theory and research for adult psychotherapy.
In J. Cassidy & P.R. Shaver (Eds.), Handbook of
attachment. Theory, research and clinical applications
(pp.762–783). New York: Guilford Press.
Tasca, G.A., Szadkowski, L., Illing, V., Trinneer, A.,
Grenon, R., Demidenko, N. et al. (2009). Adult
attachment, depression, and eating disorder
symptoms: The mediating role of affect regula-
tion strategies. Personality and Individual Differ-
ences, 47, 662–667.
Tasca, G.A., Ritchie, K. & Balfour, L. (2011). Implica-
tions of attachment theory and research for the
assessment and treatment of eating disorders.
Psychotherapy, 48(3), 249–259.
Towse, J. & Cowan, N. (2005). Working memory and
its relevance for cognitive development. In W.
Schneider, R. Schumanh-Hengsteler & B. Sodian
(Eds.), Young children’s cognitive development
(pp.9–38). London: LEA.
Young, J.E., Klosko, J.S. & Weishaar, M.E. (2003).
Schema therapy. A practitioner’s guide. London:
Guilford Press.
Wallin, D. (2007). Attachment in psychotherapy.
New York: Guilford Press.
Westen, D., Nakash, O., Thomas, C. & Bradley, R.
(2006). Clinical assessment of attachment
patterns and personality disorder in adolescents
and adults. Journal of Consulting and Clinical
Psychology, 74(6), 1065–1085.
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