Social Work in Mental Health

ISSN: 1533-2985 (Print) 1533-2993 (Online) Journal homepage: https://www.tandfonline.com/loi/wsmh20

Well-being of people diagnosed with schizophrenia

spectrum disorders: the role of attachment style,
parental treatment and couple relationship

Ricky Finzi-Dottan & Michal Segev

To cite this article: Ricky Finzi-Dottan & Michal Segev (2020): Well-being of people diagnosed
with schizophrenia spectrum disorders: the role of attachment style, parental treatment and couple
relationship, Social Work in Mental Health, DOI: 10.1080/15332985.2020.1721040

To link to this article: https://doi.org/10.1080/15332985.2020.1721040

Published online: 28 Jan 2020.

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SOCIAL WORK IN MENTAL HEALTH
https://doi.org/10.1080/15332985.2020.1721040

Well-being of people diagnosed with schizophrenia spectrum

disorders: the role of attachment style, parental treatment and
couple relationship
Ricky Finzi-Dottana,b and Michal Segevb
a
School of Social Work, Sapir Academic College D. N. Hof Ashkelon, Israel; bSchool of Social Work, Bar
Ilan University, Ramat Gan, Israel

ABSTRACT KEYWORDS
This study compares levels and psychosocial predictors of well- Schizophrenia; well-being;
being among 73 persons diagnosed with a schizophrenia spec- attachment styles;
trum disorder (SSD) and 80 matched non-clinical (NC) controls. experiences of parental
bonding; couple relationship
Findings show that the NC group scored higher on well-being,
satisfaction;
experiences of parental care, and couple relationship satisfac- self-differentiation; family
tion; whereas the SSD group scored higher on both avoidant status; gender; parental
and anxious attachment styles, parental overprotection, and acceptance
parental differential treatment (reporting being favored more
than their siblings). Low scores on insecure attachment and
parental care were key predictors of well-being among the NC
group; couple relationship satisfaction mediated the associa-
tion between avoidant attachment and well-being in both
groups. The results warrant interventions that factor in attach-
ment styles when patients diagnosed with SSD begin therapy
that aims to improve their well-being.

Introduction
This study examines the subjective well-being of persons diagnosed with
a schizophrenia spectrum disorder (SSD). Research on the well-being of
persons with serious mental illness is sparse. Although a substantial body
of evidence now demonstrates that high levels of well-being buffer against
pathological symptomatology, including relapse or recurrence of symptoms
(Chakhssi, Kraiss, Sommers-Spijkerman, & Bohlmeijer, 2018; Eack &
Newhill, 2007), research on predictors of well-being among persons diag-
nosed with an SSD is scant. The present study therefore aimed to examine
potential psychosocial predictors, namely personality and family predictors,
for well-being of persons diagnosed with an SSD, while comparing them to
a control, non-clinical, group. Attachment theory offers a theoretical frame-
work for elucidating the developmental pathway through which childhood

CONTACT Ricky Finzi-Dottan rikifnz@biu.013.net.il Sapir Academic College, Israel

This manuscript has not been published elsewhere and that it has not been submitted simultaneously for
publication elsewhere.
The study was approved by the university ethical committee, and all the participants gave their informed
consent
© 2020 Taylor & Francis
2 R. FINZI-DOTTAN AND M. SEGEV

parental bonding and traumas inform vulnerability to schizophrenia (Berry,

Barrowclough, & Wearden, 2007; Read, van Os, Morrison, & Ross, 2005) and
schizotypal disorder (Sheinbaum, Bedoya, Ros-Morente, Kwapil, &
Barrantes-Vidal, 2013; Tilipoulos & Goodall, 2009) while also linking to
coping, rehabilitation processes and well-being (Korver-Nieberg, Berry, &
de Haan, 2014). As a result of their interactions with caregivers during
infancy and childhood, individuals develop mental representations of the
self in relation to significant others, as well as expectations about how others
behave in social relationships. While benevolent representations of parental
bonding constitute attachment security, have potentially protective effects
(Mikulincer & Shaver, 2016), and are linked with life satisfaction, self-efficacy
(Barnes & Mongrain, 2019), and cognitive flexibility (Fathi-Ashtiani &
Sheikholeslami, 2019), insecure attachment is considered to create negative
beliefs about oneself and the social world, leading to vulnerability and viewed
as a psychosocial factor in psychosis (Fisher, Appiah-Kusi, & Grant, 2012).
Well-being refers to an individual’s multi-dimensional state, which includes
physical as well as mental health, knowledge understanding, work freedom,
utility and healthy relationship, and having the capacity to cope with adverse
life events (Diener & Ryan, 2008; Dupuy, 1978; McDowell, 2010). Well-being is
not just the absence of mental disorder but also involves positive feelings and
contentment (emotional well-being), meaningful engagement (psychological
well-being), and contribution to one’s community or society (social well-
being) (Chan, Mak, Chio, & Tong, 2018). Schizophrenia is one of the most
debilitating mental illnesses, characterized by persistent psychopathological
symptoms, and linked to enduring functional disability. Several studies report
that individuals with schizophrenia are lower in subjective well-being than
controls (Stanga, Turrina, Valsecchi, Sacchetti, & Vita, 2019), while their
motivation deficits and depressive symptoms predict reduced happiness and
life satisfaction (Saperia et al., 2018).
While recent studies linked pathological symptoms to well-being (e.g.
Carr, Hardy, & Fornells-Ambrojo, 2018; Chan et al., 2018; Eack & Newhill,
2007), our study seeks to determine psychosocial predictors for the well-
being of persons diagnosed with an SSD. Attachment theory has provided
a salient framework for the impact of relational representations on human
adaptation and well-being throughout life (Mikulincer & Shaver, 2016).
Therefore, and in view of the theory’s main argument whereby an attachment
style forms through parental sensitivity and responsiveness, perceived experi-
ences of parental care or control and differential parental treatment (com-
pared to one’s siblings) were selected as predictors. Discovering such
predictors is of particular importance since literature portrays parents of
adult children with SSDs as objectively and subjectively burdened. In line
with the different pathways by which attachment styles and experiences in
the family of origin affect well-being, marital satisfaction may serve as
 SOCIAL WORK IN MENTAL HEALTH 3

a mechanism explaining the associations between attachment styles and

experiences of parenting and well-being.
Bowlby, 1969–1982 attachment theory is a central theoretical framework
for understanding psychological functioning and emotional regulation. The
attachment system is perceived as an innate psychobiological system that
influences the way people experience stress, and is automatically activated to
seek proximity in times of distress throughout one’s lifespan. The current
conception of the structure relates to two continuous dimensions of attach-
ment insecurity – avoidance and anxiety – which represent individual differ-
ences in attachment system operation (Brennan, Clark, & Shaver, 1998).
People scoring high on avoidance tend to deny the need for close relation-
ships in order to avoid feeling frustrated or hurt, and prefer emotional
distance, relying primarily on themselves. Those high on anxiety are char-
acterized by a strong need for closeness and protection, as well as an acute
fear of rejection and abandonment, thus tending to overly focus on distress,
and relying on emotion-focused coping strategies. People scoring low on
both dimensions are said to display a secure attachment orientation, indicat-
ing that they positively appraise and effectively cope with changes, challenges,
and stress by seeking proximity to others and/or by activating mental repre-
sentations of attachment figures. They are able to regulate distress and
restore emotional balance, thereby reporting better well-being than those
with insecure attachment (Mikulincer & Shaver, 2016).
Research has indicated a connection between attachment styles, experiences
of parental bonding, and schizophrenia (Berry et al., 2007; Korver-Nieber,
Berry, Meijer, & de Haan, 2014). It reveals that an insecure attachment style,
whether anxious or avoidant, is associated with positive and negative symptom
severity (Bucci, Emsley, & Berry, 2017; Carr et al., 2018), suggesting that high
rates of attachment disrupting events experienced in the family may be linked
to, and even partly engender severe mental illness (Chatziioannidis et al.,
2019). Moreover, Trotta et al. (2019) suggest that the interaction between
exposure to childhood adversities and genetic predisposition may play a role
in the dopamine pathway on first-episode psychosis. That being said, secure
attachment and parental care reportedly promote well-being (Love &
Murdock, 2004), and are related to less psychopathology (Collishaw et al.,
2007). Driven by attachment theory’s major assumptions concerning affect-
regulation strategies and the stress-vulnerability model of schizophrenia,
Ponizovsky, Vitenberg, Baumgarten-Katz, and Grinshpoon (2013) reported
that a negative model of the self (anxious-preoccupied and fearful-avoidant
styles) was associated with higher scores of psychotic symptomatology,
whereas the dismissing-avoidant style was only related to anxiety. In another
study, Ponizovsky, Nechamkin, and Rosca (2007) suggested that parental
bonding behavior such as overprotection and control results in the forming
4 R. FINZI-DOTTAN AND M. SEGEV

of insecure attachment styles that affect relationships with others, and is

associated with psychotic symptomatology (Mathews et al., 2016).
Several studies have shown that patients with SSDs viewed their parents as
less caring, highly overprotective, and controlling compared with non-
clinical controls (Favaretto, Torresani, & Zimmermann, 2001; Gomes et al.,
2015). Patients who perceived their parents positively tended to experience
fewer relapses (Parker, Fairley, Greenwood, Jurd, & Silove, 1982; Warner &
Atkinson, 1988). Furthermore, Willinger, Heiden, Meszaros, Formann, and
Aschauer (2002) reported that their study participants had a greater tendency
to describe their mothers as being less caring and more overprotective
toward them compared with the descriptions provided by their healthy
siblings.
Literature describes the burden experienced by family members of
persons with SSDs, especially parents. Two types of burden were
described: objective burden (i.e., negative consequences such as physical
problems, financial difficulties, and household tension), and subjective
burden (i.e. emotional distress over disturbing behaviors) (Provencher &
Mueser, 1997). Such burden probably further increased with the greater
responsibility assigned to caregivers by the reforms in the mental health
system and the rehabilitation of the mentally ill in the community as part
of the deinstitutionalization ideology (Chan, 2011). Parents who are care-
givers have reported having insufficient time for themselves, their other
responsibilities (e.g. family and work), and other family members (Awad
& Voruganti, 2008; Schene, van Wijngaarden, & Koeter, 1998), while
some reported experiencing constant anger (Bademli, Lök, & Kilic,
2017). We assume that this burden could evoke differential treatment of
siblings in the same family, with caregivers being more engaged with the
adult child diagnosed with an SSD. Conversely, the family burden, anger,
and stigma caregivers face may lead SSD patients to think that their
parents prefer their siblings.
Research on the marital life of persons with SSDs is scant, perhaps because
many studies presuppose that patients with an SSD would find it difficult to
maintain a stable partnership as schizophrenia is thought to be associated
with impaired interpersonal functioning. Yet while marital as well as sexual
dissatisfaction are indeed common among persons with SSDs (Aggarwal,
Grover, & Chakrabarti, 2019; Mannion, 1996), new longitudinal studies
now reveal that approximately 20 to 30 percent (a relatively small but none-
theless significant number) of patients have long-term partners, in many
cases, maintaining the same relationship for many years (Jungbauer,
Wittmund, Dietrich, & Angermeyer, 2004; Mannion, 1996). A stable partner-
ship is perceived as a source of support and satisfaction that enhances well-
being (Holt-Lunstad, Birmingham, & Jones, 2008).
 SOCIAL WORK IN MENTAL HEALTH 5

The Present Study

The present study seeks to examine psychosocial predictors for the well-
being of persons with SSDs, and raises the question whether it is lower than
or similar to that of non-clinical persons. In view of the literature, we
hypothesized that persons with SSDs would report lower well-being, higher
insecure attachment, and more parental overprotection. We further aimed to
examine the impact of perceived relationships in family of origin on actual
well-being, and the moderating role played by couple relationship. Thus, only
persons with SSDs who were married or had a steady partner while the study
was conducted were included in it.
In keeping with studies examining the impact of experiences of parental
bonding and differential treatment on attachment (Modestin, Marrer, &
Agarwalla, 2008), as well as on the ties between attachment style and marital
satisfaction (Feeney, 2002), we hypothesized that reports of parental over-
protection, control, and differential treatment, as well as insecure attachment
styles (avoidant or anxious), would be associated with low levels of couple
relationship satisfaction, and, subsequently, with low perceived well-being,
among the SSD group. Life events served as a control variable due to their
important role in well-being (Luhmann, Hofmann, Eid, & Lucas, 2012). In
view of the emphasis placed by literature on well-being as a contributor to
treatment and rehabilitation, understanding the impact of such predictors on
the well-being of persons with SSDs is important.

Method
Participants
The study group consisted of 73 persons (Mage = 38.71, SD = 11.80; 37% women
and 63% men) diagnosed with an SSD, and assigned a 40% degree of disability
by the National Insurance Institute of Israel (under the Rehabilitation of the
Mentally Ill in the Community Law, 2000). Inclusion criteria were: (1) at least
18 years of age; (2) a DSM-V diagnosis of schizophrenia, persistent delusional
disorder, schizoaffective disorder, other nonorganic psychotic disorders, or
unspecified nonorganic psychosis. Participants were excluded for the following
reasons: (1) having a neurocognitive disorder, (2) having a known history of
intellectual disability, or (3) being diagnosed with drug-induced psychosis. The
non-clinical (NC) control group was comprised of 80 persons from the general
population (Mage = = 29.25, SD = 2.93), living in the same area as the SSD group
(central Israel). All the participants were married or living with a partner for at
least two years at the time the study was conducted.
Three quarters (76.7%) of the SSD group and 95% of the NC control group
participants were born in Israel. Most of the participants reported being secular
(53% of the SSD group, and 73% of the NC controls). A t test indicated that
6 R. FINZI-DOTTAN AND M. SEGEV

group differences were found in age, gender, education, and religiosity. There
were more men than women in the SSD group (n = 43; 63%), and more women
than men in the control group (n = 55; 68.8%). Most of the SSD participants had
a high-school level education, having completed the full 12 years (43%), whereas
77% of the NC controls had academic degrees. It is noteworthy that no differ-
ences were found between the two groups in reported life events (SSD: M = 3.46,
sd = 2.47; NC: M = 2.81, sd = 3.30; t = −1.66).

Instruments
Well-being was assessed by the General Well-Being Scheduler (Dupuy, 1978),
designed to assess how individuals feel about their “inner personal state”
(McDowell, 2010). The scale’s six dimensions include: positive well-being;
self-control; vitality; anxiety; depression; and general health. The 18 items
take the form of questions with six-point answer scales (e.g. “How have you
been feeling in general during the past month?”; “Have you been under or
felt you were under any strain, stress, or pressure?”). Higher scores represent
greater well-being. A total score was calculated and, in our study, Cronbach’s
alpha was 0.91.
Attachment style was assessed by the Experiences in Close Relationships
Scale (Brennan, Clark & Shaver, 1998) consisting of 36 items assessing
attachment anxiety (e.g. “I worry about being abandoned”) and avoidance
(e.g. “I prefer not to show a partner how I feel deep down”) was used to
assess attachment dimensions. Participants rated the extent to which each
item described their feelings in close relationships on a 7-point scale ranging
from 1 (not at all) to 7 (very much). Low scores on both dimensions
characterize the secure attachment style, whereas insecure attachment is
defined by high scores on one or both dimensions. High scores on the
anxiety versus the avoidance dimension have been explained as expressing
different strategies in the attempt to cope with insecurity, either hyperactiva-
tion of the attachment system by increasing proximity (attachment anxiety)
or deactivation of the attachment system through the avoidance of contact
(attachment avoidance). The two scales were conceptualized as independent
(p > .05); Cronbach’s alpha for the anxiety scale and avoidance scale in the
present study were 0.83 and 0.81 respectively. Accordingly, a score for each
of the two subscales was calculated for each participant by averaging their
responses on the relevant 18 items.
Perceived experience of parenting was assessed by the Parental Bonding
Instrument (Parker, Tupling, & Brown, 1979). This is a 25-item measure
designed to assess respondents’ perceptions of their parents’ bonding beha-
vior during the first 16 years of their life. Each item describes a type of
parental behavior, and participants are asked to indicate the degree to which
it describes the parent in question on a 4-point scale. In the present study,
 SOCIAL WORK IN MENTAL HEALTH 7

participants were asked to answer the questions in relation to their fathers.

The PBI consists of two subscales: care and overprotection. Ideal parenting is
represented by a low score on overprotection, and a high score on care. Low
scores on the care scale reflect parental neglect and rejection, whereas high
scores on the overprotection scale indicate excessive control and intrusive
parenting (Parker, 1990). In the present study, high correlations were found
between maternal and paternal care and overprotection (r = .47 and r = .51
respectively), thus parenting experiences with the two parents were calculated
into one score, and Cronbach’s alpha was 0.95 for care and 0.92 for
overprotection.
Perceived parental differential treatment was assessed using the rivalry
scales of the Adult Sibling Relationship Questionnaire (Stocker, Lanthier, &
Furman, 1997). The scales consisted of items on maternal and paternal
favoring/disfavoring of siblings (e.g. “Do you think your father/mother favors
either yourself or your sibling/s?”; “Do you think your mother is closer to
you or to your sibling/s?”; “Do you think your father/mother supports you or
your sibling/s more?”; 12 items). High scores in this variable reflect parents
preferring the respondent, while low scores mean that parents favor the
respondent’s siblings over the respondents themselves. Finzi-Dottan and
Cohen (2011) found high correlations between paternal and maternal favor-
itism (r = .57). Therefore, a single score was calculated for both parents, and
Cronbach’s alpha was 0.93.
Satisfaction from couple relationship was assessed by the Relationship
Assessment Scale (Hendrick, 1988) designed to measure relationship satisfac-
tion. This scale consists of 7 items rated on a 7-point Likert scale (e.g. “In
general, how satisfied are you with your relationship?”). The RAS is uni-
dimensional, with higher scores representing greater relationship satisfaction.
In our study, Cronbach’s alpha was 0.90.
Life events were assessed by Solomon’s Life Events Index (Solomon, 1995).
Participants were presented with a list of 13 stressful life events such as war,
abuse, divorce, and car accidents, and were asked to indicate whether or not
either they or someone in their family had directly experienced them. The total
score was calculated as the number of events the participant had experienced;
the higher the score, the more personal or family events were reported.

Procedure
The study was approved by the ethics committee of the researchers’ university,
as well as the Mental Health Department of the Israeli Ministry of Health. SSD
participants were recruited from three community mental health centers in
Israel. Potential study participants were referred to the researchers by clinical
staff in these centers, based on patients’ chart diagnosis, and ability to give
voluntary informed consent. The clinical staff informed potential participants
8 R. FINZI-DOTTAN AND M. SEGEV

of the study and its purpose, assuring them that their responses would be
anonymous and used only for research, and asking their permission to provide
us with their contact information. This process enabled those participants who
preferred not to participate to decline (only 4 persons with SSDs refused to
participate). The questionnaires were administrated personally by the second
author, a mental health clinician experienced in working with mentally ill
patients. Informed consent was obtained from all participants. A total of
89 persons with SSDs answered the questionnaires; however, 16 questionnaires
were only partially filled and therefore excluded from the data analysis.

Data analysis
Group differences were examined via univariate analyzes of variance
(ANCOVA). In view of its well-known impact on well-being (Pitkänen
et al., 2012), and in light of the differences found between the two groups
in this respect, education level served as a covariant. Pearson correlations
were calculated for all participants, as well as separately for each group, and
Z Fisher was performed to examine the significance of the differences in
these correlations. In keeping with the research model, a series of 5-step
hierarchical linear regression analyses was conducted to examine the inde-
pendent variables’ contribution to well-being.

Results
Comparison of predictor and outcome variables in the two groups
A series of one-way analyses of variance (ANCOVA) was conducted to examine
group differences in both the outcome (well-being) and predictor (attachment
styles, perceived experience of parenting, perceived parental differential treat-
ment, and satisfaction from couple relationship); education level served as
a covariant. A comparison of the said variables between the two groups,
including means, standard deviations, test statistics, and their significance levels
are presented in Table 1. The analyses revealed that the groups differ in all study
variables: the NC group scored higher on well-being, parental care, and couple
relationship satisfaction; whereas the SSD group scored higher on both avoi-
dant and anxious attachment, parental overprotection, and parental differential
treatment (reporting being favored more than their siblings).

Correlations between predictors and outcomes among both groups

The correlations between predictors and outcomes in both groups are pre-
sented in Table 2. Well-being was found to be negatively associated with
avoidant and anxious attachment, perceived parental overprotection, and
 SOCIAL WORK IN MENTAL HEALTH 9

Table 1. Comparison of predictor and outcome variables between SSD and NC groups.
SSD NC
N = 73 N = 80
Variables M sd M sd F Cohen’s D
Well-being 66.52 23.02 81.92 17.02 9.87** 0.76
Avoidant attachment 3.97 1.56 3.13 1.12 12.32** 0.61
Anxious attachment 3.80 1.54 3.09 0.94 16.14*** 0.40
Parental care 2.91 0.93 3.33 0.64 18.59*** 0.52
Parental overprotection 2.32 0.94 1.71 0.49 9.23** 0.81
Parental differential treatment 19.1 7.66 17.73 4.79 16.13*** 0.20
Couple relationship satisfaction 4.82 1.74 5.40 1.29 8.19** 0.37
**p < .01; ***p < .001.

Table 2. Correlations between study variables.

1 2 3 4 5 6
Well-being - −.36** −.49** .44** −.37** −.14
(1)
Avoidant attachment −.36
(2)
Anxious attachment −.49** .05
(3)
Parental care .44** −.36** −.20
(4)
Parental overprotection −.37** −.13 .10 −.46**
(5)
parental differential treatment −.14 .05 .05 −.33** .15
(6)
couple relationship satisfaction .25** −.29* −.07 .14 −.06 .02
(7)
*p < .01; **p < .01.

parental differential treatment; and positively linked to parental care and

couple relationship satisfaction. Correlations were also calculated separately
for each group, and Z Fisher analyses only revealed significant differences in
two sets of correlations: between parental overprotection and parental differ-
ential treatment (z = −1.89, p < .05), found to be stronger in the SSD group
(p = .21 compared to p = .12 in the NC group); and, in the other direction,
parental overprotection was associated with higher parental differential treat-
ment in the SSD group, contrary to the NC group. While differences in
correlations between the two groups were examined too, these were found to
be non-significant.

Examination of model: prediction of well-being by predictors and

moderator
In this section we examine the proposed model, whereby couple relationship
satisfaction moderates the links between anxious and avoidant attachment,
parental care and overprotection, and parental differential treatment, on the
10 R. FINZI-DOTTAN AND M. SEGEV

one hand (the predictors), and well-being on the other. To do so, a series of
5-step hierarchical linear regression analyses was conducted (Table 3).
Although differences between the groups were found with regard to religi-
osity, the correlations with well-being were nevertheless non-significant
(r = −.10 for the SSD group, and r = −.10 for the NC group). We therefore
refrained from introducing this variable into the regression analysis. During
the first step, the participants’ age, gender, and education were introduced as
control variables. Gender was effect-coded to compare women (1) with men
(−1). During the second step, the two groups were introduced and effect-
coded to compare SSD (1) with NC control (−1). During the third step, the
predictors anxious and avoidant attachment were introduced. During the

Table 3. Standardized (β) regression coefficients predicting well-being.

Variables B Std. Err. β ΔR2
Step 1 .18**
Age −.08 .20 −.03
Gender −6.85 3.91 −.15
Education level 12.05 2.67 .42***
Step 2 .12**
Age −.11 .21 −.02
Gender −6.02 3.80 −.13
Education level 9.03 3.04 .32**
Groupsa −11.35 3.45 −.34***
Step 3 .18***
Age −.12 .20 −.05
Gender −5.01 3.71 −.11
Education level 9.02 3.62 .22*
Groups −11.15 3.50 −.23*
Anxious attachment −6.61 1.42 −.38***
Avoidant attachment –4.22 1.35 −.26**
Step 4 .07*
Age −.13 .20 −.06
Gender −59 3.66 −.11
Education level 5.31 3.48 .20
Groups −6.14 3.11 .14
Anxious attachment −4.44 1.06 −.29**
Avoidant attachment –3.18 1.12 −.26*
Parental care 8.12 2.50 .29**
Parental overprotection .84 2.61 .02
Parental differential treatment −.01 .27 .00
Step 5 .01
Age −.14 .20 −.06
Gender −5.10 3.36 −.11
Education level 5.27 3.18 .18
Groups 2.39 5.21 .11
Anxious attachment −5.91 1.37 −27**
Avoidant attachment –1.78 1.41 −.16
Parental care 8.38 2.48 .30***
Parental overprotection .48 2.59 .01
Parental differential treatment −.01 .27 .00
Couple relationship satisfaction 2.04 1.12 .13
*p < .05, **p < .01, ***p < .001.
a
Group = SSD vs. NC participants.
 SOCIAL WORK IN MENTAL HEALTH 11

fourth step, the predictor experiences with parents was introduced. During
the fifth step, the moderator – couple relationship satisfaction – was intro-
duced. We then introduced the interaction between the predictors and
moderator with the groups, but it proved non-significant. As can be seen
from the regression analysis performed in the fifth step, when couple rela-
tionship satisfaction entered the regression equation, the contribution of
avoidant attachment decreased and became non-significant (see Table 3).
We therefore performed the bootstrapping test in SPSS PROCESS macro
function (PROCESS v3.0; Hayes, 2013), and it revealed that couple relation-
ship satisfaction in fact mediated the association between avoidant attach-
ment and well-being (b = −5.97, p < .001). Figure 1 shows avoidant
attachment being linked to a low level of couple relationship satisfaction
which, in turn, was linked to low well-being. Thus, this mediation goes
beyond the direct link between avoidant attachment and well-being, applying
to both groups, and not to the SSD group specifically.

Figure 1. The mediation analysis. *p < .05, **p < .01, ***p < .001.
12 R. FINZI-DOTTAN AND M. SEGEV

Discussion
Taking into account the self-report design of the study, the findings provide
partial support for the study hypotheses by showing that the NC group
scored higher on well-being, experiences of parental care and couple relation-
ship satisfaction, whereas the SSD group scored higher on both avoidant and
anxious attachment, parental overprotection, and parental differential treat-
ment (reporting being favored more than their siblings). No differences in
correlations were found between the groups, besides those between parental
overprotection and parental differential treatment, whereby parental over-
protection was associated with higher parental differential treatment in the
SSD group, but not in the NC group. The regression analysis yielded that
predictors for well-being were being in the NC group, low levels of anxious
and avoidant attachment, and parental care. The moderation hypothesis was
not confirmed; however, the results indicate that couple relationship satisfac-
tion mediates the association between avoidant attachment style and well-
being. Notably, this moderation was found among both groups, and was not
specific to SSD participants.
The results regarding lower levels of well-being among SSD participants
compared to the controls are supported by literature, as noted in the intro-
duction. Eack and Newhill (2007) indicated in their meta-analysis that
positive and negative symptoms impacted the well-being of persons with
schizophrenia receiving treatment in the community more than inpatients,
because these symptoms pose substantial threats to social adjustment and
functioning, stifling well-being. Chan et al. (2018) reported that the negative
symptoms of psychosis (blunted affect and emotional withdrawal, devoid
motivation, anhedonia) were the main cause of diminished well-being.
Another threat to well-being is the internalized stigma whereby low self-
esteem may be an obstacle to recovery (Morgades-Bamba, Fuster-
Ruizdeapodaca, & Melero, 2019).
Our results indicate that the high scores on insecure attachment (anxious
or avoidant) in the SSD group are supported by several past studies (Korver-
Nieber et al., 2014; Ponizovsky et al., 2007), reporting the link between
insecure attachment and psychotic symptomatology and well-being. Korver-
Nieber, Berry, Meijer, de Haan, and Ponizovsky (2015) reported that anxious
attachment was associated with both psychotic and affective symptoms of
schizophrenia, and suggested that the characterizations of anxious attach-
ment (sensitivity to interpersonal threat, poor self-esteem, and a tendency to
be overwhelmed by negative affect) may increase vulnerability to the devel-
opment of both affective and psychotic symptoms. Avoidant attachment was
related to emotional withdrawal and passive social withdrawal. The contribu-
tion of anxious and avoidant attachment to well-being lends support to
Korver-Nieber et al.’s results. However it is unclear whether insecure
 SOCIAL WORK IN MENTAL HEALTH 13

attachment is related to sensitivity to psychotic symptomatology (Berry at al.,

2007), or personality characterization formed in childhood (Bowlby,
1969–1982) and affecting the interpersonal relations of persons with SSDs,
as well as their compliance with treatment (Tyrrell, Dozier, Teague, & Fallot,
1999). In a related vein, Chatziioannidis et al. (2019) and Sheinbaum et al.
(2015) linked reflections of hostile parenting with anxious attachment,
reporting that anxious attachment mediates the association between reflec-
tions of parental treatment and schizophrenia. Moreover, it is possible that
genetic factors moderate the association between childhood adversity and
psychosis, potentially by influencing how an individual reacts biologically
and/or psychologically following exposure to adversity, in such a way as to
set them off on the path to psychosis (Trotta et al., 2019).
The SSD participants in our study reported less parental care than the
controls. In addition, out of the two family variables (parental treatment and
couple relationships), only parental care contributed to well-being. Similar
findings were reported by Warner and Atkinson (1988), whereby patients who
perceived their parents negatively experienced severe courses of schizophrenia,
whereas those who perceived their parents positively, and reported making
frequent contact with them, tended to experience a milder course of illness.
Perhaps caring for SSD patients in the community places a substantial burden
and ongoing stress on the long-term relationship between caregiver (parents)
and patient (Chan, 2010), expressed in negative affects such as anger (Bademli
et al., 2017), that may have “colored” SSD participants’ perceptions of their
parental treatment, and affected their subjective well-being.
The higher scores on overprotective and controlling parenting reported by
the SSD group may be linked to parents’ high expressed emotions (EE;
critical comments, hostility, and emotional overinvolvement). The caregivers’
overprotection may be considered as their effort to prevent relapses and
hospitalization (Kavanagh, 1992) in view of the lack of insight into the illness
and noncompliance with treatment that may exacerbate psychotic symptoms
(Chan, 2010). If this is true, we can understand SSD participants’ reports of
parental differential treatment; in other words, their parents were more
involved with them than with their siblings, contrary to the reports of NC
controls. Furthermore, parental overprotection was associated with higher
parental differential treatment in the SSD group, but not in the NC group.
Although couple relationship satisfaction correlated positively with well-
being, the SSD participants reported lower scores than the NC controls. This
difference may be explained by the SSD group’s higher scores in insecure
attachment, which affects interpersonal relations. Anxious attachment
reflects negative perception of the self, a strong desire for closeness and
intimacy, a need for protection, elevated fears of abandonment or rejection,
and profound worries about the availability of significant others, manifested
in insistent attempts to attain proximity, support and love through clinging
14 R. FINZI-DOTTAN AND M. SEGEV

and controlling behaviors as means for regulating suffering and distress

(Mikulincer & Shaver, 2016). Attachment avoidance reflects the deactivation
of the attachment system, manifest in discomfort with closeness and inti-
macy, inclination for emotional distance, reluctance for self-disclosure, and
a strong need for self-reliance (Mikulincer & Shaver, 2016). The features of
avoidant attachment also explain their association with couple relationship
satisfaction, as well as the mediating role of the latter between avoidant
attachment and well-being. We can conclude, therefore, that insecure attach-
ment not only harms well-being, but that high scores on avoidant attachment
hinder couple relationship satisfaction.

Limitations
The study contains some methodological limitations. First, the sample is
small because recruiting persons with SSDs who are either married or in
a steady relationship is extremely difficult. Second, several differences were
found between the SSD and control groups, and an effort had to be made to
control for them in the various analyses. Third, the study was only carried
out at one point in time, providing a mere “snapshot” of the well-being of
SSD patients living in the community. Two further limitations pertain to the
instruments used in the study: (1) All the instruments were self-report
questionnaires, which are subject to response bias; (2) All the questionnaires
were completed in the same order. To avoid the possibility that earlier
questions affect the responses to later ones, changing the order of the
questions given to different study participants is preferable. Yet another
limitation pertains to the cross-sectional nature of the study: the small size
of our sample and the specificity of our participants (SSD patients who are in
steady relationships) may restrict the generalization of our results.

Clinical and policy implications

These limitations notwithstanding, this research allows for a better and deeper
understanding of the potential contribution of past and present family relations
(in terms of attachment style, parental treatment, and couple relationship satisfac-
tion) to the subjective well-being of persons with SSDs living in the community.
First, professionals working with SSD patients in the community should not only
address their illness and its repercussions, but support them to enhance their well-
being too. The well-being of people suffering from an SSD throughout their lives is
directly associated with a need for help, including secure relationships with
professionals, reflecting the need to be heard and seen, the need for independent-
living support, as well as a stable social network (Gunnmo & Fatouros Bergman,
2011). Attachment theory has considerable potential relevance for clinical work
with individuals diagnosed with SSDs, adding to our understanding of how
 SOCIAL WORK IN MENTAL HEALTH 15

interpersonal styles may impede engagement with services and therapies (Berry
et al., 2007). Gumley, Taylor, Schwannauer, and Macbeth (2014) systematic review
of attachment and schizophrenia-related disorders found that individuals with
SSDs who had a secure attachment had better engagement and greater treatment
adherence, whereas insecure attachment was found to be related to disengagement
with treatment services, and avoidant attachment was related to help-seeking
difficulties, poorer use of treatment, longer hospital admissions and lower-rated
therapeutic alliance (Tyrrell et al., 1999).
Since elevating well-being has the potential of being a buffer against
pathological symptomatology, including relapse or recurrence of symptoms
(Chakhssi et al., 2018; Eack & Newhill, 2007), individual, family and couple
interventions are recommended. Individual interventions may focus on ele-
vating low self-esteem that stems from internalized stigma possibly serving as
an obstacle to recovery (Carter, Read, Pyle, & Morrison, 2019). Family
interventions may aim to lower the high expressed emotion (NG, Yeung, &
Gao, 2019). Since a stable partnership is perceived as a source of support and
satisfaction that enhances well-being (Holt-Lunstad et al., 2008), couple
interventions aimed at the containing and supporting of difficulties, espe-
cially during relapses, are warranted.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.

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