Mental health and mental illness are among the greatest burden of diseases globally (Vigo, Thornicroft, & Atun, Reference Vigo, Thornicroft and Atun2016). The World Health Organization (WHO) has identified relationships as a determinant of mental health and mental illness (WHO, 2004). Multiple empirical studies have identified that experiences in romantic relationships in particular are important to mental health (e.g., Whisman & Baucom, Reference Whisman and Baucom2012). Given this wealth of evidence, there is the need to evaluate the specific pathways through which experiences in romantic relationships and mental health are related. Scholars in the relationship and health sciences have specifically underscored the importance of identifying the interpersonal and intrapersonal mechanisms linking romantic relationships and mental health (Pietromonaco & Collins, Reference Pietromonaco and Collins2017).
Adult attachment provides a powerful theoretical framework to explain the interpersonal pathways linking romantic relationships and mental health (Mikulincer & Shaver, Reference Mikulincer and Shaver2012). Attachment theory is concerned with understanding the functions of a close bond with an attachment figure and how these experiences shape cognition and emotion (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). Research on individual differences in attachment are generally characterised by two continuous and orthogonal dimensions — anxious and avoidant attachment (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). Comparatively, individuals low on dimensions of insecure attachment are considered to possess a predominantly secure attachment orientation (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). Adult attachment orientations provide a taxonomy for reliably capturing and describing how individual differences in cognitive patterns of responding within romantic relationships relate to mental health (e.g., Mikulincer & Shaver, Reference Mikulincer and Shaver2012), thereby indicating adult attachment as an important interpersonal process linked to mental health.
There is also the need to identify important intrapersonal mechanisms helping to explain links between adult attachment and mental health. Research on mindfulness has demonstrated promise, as mindfulness is positively related to mental health and is important to interpersonal processes (Karremans, Schellenkens, & Kappen, Reference Karremans, Schellekens and Kappen2017). Mindfulness represents the capacity to reflect on thoughts, feelings and events free from biased, automatic or habitual tendencies (Kabat-Zinn, Reference Kabat-Zinn1994) and is predictive of improved mental health (e.g., Brown, Ryan, & Creswell, Reference Brown, Ryan and Creswell2007). The tendency to contact the present moment without judgment, characterised by mindfulness, is also believed to facilitate not becoming caught up in the cognitive and emotional biases associated with attachment histories (Ryan, Brown, & Creswell, Reference Ryan, Brown and Creswell2007). In fact, multiple studies have found an inverse association between anxious and avoidant attachment and mindfulness (e.g., Stevenson, Emerson, & Millings, Reference Stevenson, Emerson and Millings2017).
Given the inverse association between adult attachment and trait mindfulness and their inverse links to mental health, it is probable that adult attachment and mindfulness likely work together and in turn relate to mental health. However, there has not yet been a critical evaluation of the research targeting the interplay between adult attachment, mindfulness, and mental health. The current study employed a systematic research synthesis (SRS) to investigate how the interpersonal construct, adult attachment, and the intrapersonal construct, mindfulness, together relate to mental health.
Literature Review
Adult Attachment and Mental Health
Individual differences in attachment stem from repeated experiences with attachment figures who become internal working models of attachment (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). If attachment figures are available and responsive to bids for comfort and support when faced with stress, threats or disappointment, then individuals tend to develop a positive internal working model of attachment (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). When attachment figures are unreliable, unavailable, or rejecting in response to bids for comfort and support when faced with stress, threats or disappointment, individuals tend to develop negative internal models of attachment (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). These differences in internal working models of attachment are reliably captured and represented by two dimensions of attachment insecurity — attachment anxiety and attachment avoidance — where low scores on attachment insecurity represent a relatively secure attachment. In adulthood, dimensions of attachment provide a reliable index for the distinct, relatively stable and automatic cognitive patterns of perceiving and responding to distress (Mikulincer & Shaver, Reference Mikulincer and Shaver2016).
Insecure attachment orientations are characterised by implicit and automatic maladaptive strategies to manage distress. Anxious attachment is characterised by hyperactivation strategies to manage distress that involve increased sensitivity and interpretation of negative thoughts, emotions and perceived threats in the environment (Gardner & Zimmer-Gembeck, Reference Gardner and Zimmer-Gembeck2018). Avoidant attachment is characterised by deactivation strategies to manage distress, which involve attempts to suppress or distance aversive thoughts, emotions and perceived threats in the environment (Andriopoulos & Kafetsios, Reference Andriopoulos and Kafetsios2015). The hyperactive and deactivating cognitive strategies to manage distress, characterised by anxious and avoidant attachment, resemble the negative cognitive biases predictive of problems in mental health (Mikulincer & Shaver, Reference Mikulincer and Shaver2012).
Negative biases in attention and interpretation of information are common processes characterised by insecure attachment orientations and problems in mental health. Cognitive biases toward negative emotions, heightened sensitivity to threats in the environment, and a tendency to suppress or avoid negative stimuli increase risk for emotional disorders (Mathews & MacLeod, Reference Mathews and MacLeod2005). This is important to note, as the hyperactivation and deactivation strategies characterised by anxious and avoidant attachment are akin to these risks for emotional disorders (Mikulincer & Shaver, Reference Mikulincer and Shaver2012). In support of these conceptual links between insecure attachment orientations and emotional disorders are decades of empirical studies that have found insecure attachment orientations predict psychological distress, depression and anxiety (e.g., Mikulincer & Shaver, Reference Mikulincer and Shaver2012, Reference Mikulincer and Shaver2016). Taken together, adult attachment provides a theoretical framework supported by empirical evidence that explains the specific processes through which romantic relationships and mental health are linked.
Mindfulness and Mental Health
Mindfulness as a Western positive psychological construct has been described as a process of ‘paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally’ (Kabat-Zinn, Reference Kabat-Zinn1994, p. 4). It is important to note because a detailed overview of mindfulness is beyond the scope of this article; the principles central to the Western concept of mindfulness and the relation between mindfulness and mental health are described below (for comprehensive reviews, see Baer Reference Baer2003; Brown et al., Reference Brown, Ryan and Creswell2007).
Individual differences in mindfulness are defined as state- and trait-like qualities, which can be cultivated through mindfulness meditation (Bergomi, Tschacher, & Kupper, Reference Bergomi, Tschacher and Kupper2013). Whereas state-like qualities are considered momentary conditions, trait-like qualities are considered stable characteristics (Odum & Baumann, Reference Odum, Baumann, Madden and Bickel2010). Mindfulness as a state is characterised by intentional self-regulation, acceptance, curiosity, and open attention to immediate internal and external stimuli (Bishop et al., Reference Bishop, Lau, Shapiro, Carlson, Anderson, Carmody and Devins2004; Lau et al., Reference Lau, Bishop, Segal, Buis, Anderson, Carlson and Devins2006). Mindfulness as a trait-like quality (i.e., trait or dispositional mindfulness) is the degree to which individuals naturally tend to be mindful in daily life (Bishop et al., Reference Bishop, Lau, Shapiro, Carlson, Anderson, Carmody and Devins2004; Brown & Ryan, Reference Brown and Ryan2003). State and trait mindfulness can be enhanced through mindfulness meditation (Baer, Reference Baer2003). Mindfulness meditation focuses on increasing moment-to-moment awareness and acceptance of thoughts, feelings or sensations in a non-judgmental manner (Baer, Reference Baer2003). Thus, mindfulness may be conceptualised as an intrapersonal process with variations within (i.e., state mindfulness) and between (i.e., trait mindfulness) individuals, and can be cultivated through intentional practice (i.e., mindfulness meditation).
Mindfulness (i.e., state, trait, or mindfulness meditation) is counter to the compulsive, automatic behaviour, intense focus and rumination characterised by maladaptive affective processes (Brown et al., Reference Brown, Ryan and Creswell2007). Specifically, an attentional bias toward and difficulty disengaging from avoidance, and suppression of negative thoughts and emotions increases a vulnerability to emotional disorders (Mathews & MacLeod, Reference Mathews and MacLeod2005). Mindfulness, on the other hand, provides an alternative mode of processing negative thoughts and emotions. This is because higher mindfulness is characterised by increased awareness but lower attachment and judgment of negative thoughts and emotions that protects against problems in mental health (Brown et al., Reference Brown, Ryan and Creswell2007). In line with these ideas are multiple empirical studies that demonstrate how mindfulness is inversely related to anxiety, depression, psychological distress, poor psychological adjustment and stress (e.g., Brown et al., Reference Brown, Ryan and Creswell2007). Mindfulness thus presents as an important intrapersonal process linked to mental health.
Insecure Attachment Orientations and Mindfulness
Multiple investigators have called attention to the relationship between attachment and mindfulness (e.g., Ryan et al., Reference Ryan, Brown and Creswell2007; Shaver, Lavy, Saron, & Mikulincer, Reference Shaver, Lavy, Saron and Mikulincer2007). One primary way in which scholars underscore this relationship is through noting the similarities between central ideas in theoretical and empirical research on attachment and mindfulness. Specifically, the sense of safety and attunement characteristic of secure attachment mirrors the openness and awareness of mindfulness (Ryan et al., Reference Ryan, Brown and Creswell2007; Shaver et al., Reference Shaver, Lavy, Saron and Mikulincer2007), whereas the sensitivity to rejection, rumination, suppression and avoidance of distressful thoughts and events characterised by insecure attachment orientations opposes the open, direct and accepting observation of thoughts and experiences free from judgment supported by mindfulness (Ryan et al., Reference Ryan, Brown and Creswell2007; Shaver et al., Reference Shaver, Lavy, Saron and Mikulincer2007). Hence, mindfulness likely allows the processing of information counter to the negative and avoidant cognitive biases characterised by insecure attachment orientations and predictive of poor mental health.
Stress response appears to be a second area by which adult attachment and mindfulness are related and likely affect mental health. Stress response is important because social evaluative stress is reliably found to be negatively associated with mental health (Dickerson & Kemey, Reference Dickerson and Kemeny2004). This is significant given the divergent links adult attachment and mindfulness have with stress response. For instance, within the context of experiences in close relationships, an intense search and avoidance of potential threats and safety characterised by insecure attachment is associated with poor stress response (Pietromonaco & Collins, Reference Pietromonaco and Collins2017). Mindfulness, on the other hand, is characterised by non-reactivity and improved stress response (Brown et al., Reference Brown, Weinstein and Creswell2012). Thus, an intentional and non-reactive stance likely plays an important role in the tendency to search for or avoid potential threats to manage stress. Therefore, stress response may be an important component by which adult attachment and mindfulness relate and affect mental health.
Multiple scholars and empirical studies point to emotions as a third important way by which attachment and mindfulness are linked and presumably relate to mental health. Empirical data has illustrated the association between insecure attachment and mindfulness as shared by emotion regulation strategies (Stevenson et al., Reference Stevenson, Emerson and Millings2017). Emotion regulation strategies, such as attempts to limit, exaggerate or alter emotions have been demonstrated to underlie attachment and mindfulness (Stevenson, Millings, & Emerson, Reference Stevenson, Millings and Emerson2019). An experimental study found anxious attachment negatively predicted mindfulness but only through emotion regulation (Melen, Pepping, & O'Donovan, Reference Melen, Pepping and O'Donovan2017). These studies highlight the relationship between insecure attachment and mindfulness with particularly important implications related to affect.
The Current Review
Multiple studies have provided empirical support for the conceptual links between adult attachment and mindfulness (e.g., Stevenson et al., Reference Stevenson, Emerson and Millings2017). The current study builds upon this information by exploring how this relationship may have an impact on mental health. The present study aims to inform research and clinical practice by targeting the interplay between attachment and mindfulness on mental health. A systematic research synthesis was conducted to (1) locate empirical studies targeting adult attachment, mindfulness (as a state, trait, or intervention), and mental health, (2) synthesise findings, and (3) evaluate conceptual and methodological approaches to make recommendation for future research.
Method
Search and Screening Procedures
All searches were conducted between October 2018 and December 2018. The databases Pyschinfo and MedLine via the ProQuest and JSTOR platforms were utilised to collect published articles. A combination of terms — attachment, insecure, adult, mindfulness, trait, couples, intimate, relationships, marriage/marital, psychological, depression, anxiety, emotion, affect, stress, autonomic, and cortisol — were used to aggregate peer-reviewed literature. A review of each article's abstract was conducted to remove false positives and extrapolate studies that met inclusion and exclusion criteria. Reference lists of articles obtained were reviewed to locate additional empirical articles not identified by the results of the database searches.
Inclusion criteria for the current review were: (1) empirical studies that evaluated (2) at least one adult attachment orientation, (3) mindfulness as either a state, trait or intervention, and (4) at least one index of mental health, and (5) published in a peer-reviewed English language journal. Studies with primary aims relevant to attachment, mindfulness, and mental health but focused on subdomains of the constructs were excluded. For example, studies examining self-compassion, parent-child attachment bonds, and marital quality were excluded as they were considered to not inform direct links between adult attachment, mindfulness, and mental health.
Results
A total of 10 studies were included in the current SRS. Results of the search are depicted in Figure 1. The initial search yielded 162 potential studies. The 162 study's abstracts were evaluated using inclusion and exclusion criteria. Upon reviewing each abstract, 17 studies were identified as having met the inclusion and exclusion criteria. The full text of 17 studies were then evaluated to confirm whether each study met inclusion and exclusion criteria. Among the 17 studies, 7 studies either omitted one index of mental health and/or did not directly evaluate mindfulness and attachment. In addition, one study did not directly evaluate adult insecure attachment orientations. However, this study evaluated partner behaviours among a sample of couples associated with insecure attachment orientations, namely disengagement, withdrawal, attempts to control, coerciveness, negativity and verbal aggression. Thus, this study was included in the current SRS. The remaining studies (n = 9) included both adult attachment, mindfulness as a state, trait or intervention, and at least one index of mental health.
Flow diagram of systematic search.
Study Participants
An overview of studies is depicted in Table 1. Studies were conducted in Australia, Canada, Spain, Taiwan, and the United States. Sample sizes ranged from 39 to 505, and the majority of studies (n = 7) examined over 100 participants. The majority of studies (n = 7) involved participants who were undergraduate students or between 18–25 years of age. Participants in the remaining studies (n = 3) were on average 40 years of age or older. The majority of studies (n = 7) examined individuals who were not in a romantic relationship or were analysed independent of a romantic partner. Studies (n = 4) also evaluated heterosexual couples who were either largely married, engaged or dating exclusively. Three studies evaluated participants seeking psychological intervention.
Summary Table of the Studies Examining Adult Attachment, Mindfulness, and Health Related Outcomes
Study Design
One study utilised a randomised control trial (RCT) study design (e.g., Hsaio et al., Reference Hsiao, Jow, Kuo, Yang, Lam, Chang and Chang2016). One study used a quasi-experimental study design via experimental and control groups pretest–posttest (e.g., Caldwell & Shaver, Reference Caldwell and Shaver2015). Two studies utilised a one-group, pretest–posttest experimental study design (e.g., Hertz, Laurent, & Laurent, Reference Hertz, Laurent and Laurent2015; Laurent, Hertz, Nelson, & Laurent, Reference Laurent, Hertz, Nelson and Laurent2016). One study utilised a longitudinal design (e.g., Martin, Gillath, Deboeck, Lang, & Kerr, Reference Martin, Gillath, Deboeck, Lang and Kerr2017). Five studies utilised a cross-sectional study design (Davis, Moris, & Drake, Reference Davis, Morris and Drake2016; Linares, Jauregui, Herrero-Fernández, & Estévez, Reference Linares, Jauregui, Herrero-Fernández and Estévez2016; Macaulay, Watt, MacLean, & Weaver, Reference Macaulay, Watt, MacLean and Weaver2015; McDonald et al., Reference McDonald, Sherman, Petocz, Kangas, Grant and Kasparian2016; Pickard, Caputi, & Grenyer, Reference Pickard, Caputi and Grenyer2016). Studies also demonstrated variation in proposed models to evaluate the relationship between attachment, mindfulness and mental health. Mindfulness was modelled as a mediating variable for half the studies (n = 5). The remaining studies evaluated how mindfulness as a moderating variable, distal predictor, or participation in a mindfulness intervention affected the relationship among adult attachment and mental health.
Measures
Measures used in the reviewed studies are shown in Table 1. The majority of studies measured anxious and avoidant attachment (n = 6), with fewer studies having measured secure attachment (n = 3). The most common (n = 4) measure of attachment was the Experiences in Close Relationships Revised scale (ECR-R; Fraley, Waller, & Brennan, Reference Fraley, Waller and Brennan2000). Additional measures included the Experiences in Close Relationship scale (Brennan, Clark, & Shaver, Reference Brennan, Clark, Shaver, Simpson and Rholes1988), the Relationship Questionnaire (RQ; Bartholomew & Horrowitz, Reference Bartholomew and Horowitz1991), and the State Adult Attachment Measure (SAAM; Gillath, Hart, Noftle, & Stockdale, Reference Gillath, Hart, Noftle and Stockdale2009). The Attachment Narrative Emotional Disclosure Task as modified by Brody and Park (Reference Brody and Park2004) was also used to evaluate changes in attachment-related language and beliefs. The System for Coding Interactions in Dyads (Malik & Lindahl, Reference Malik, Lindahl, Kerig and Baucom2004) was used to evaluate partner behaviours during conflict that the current study operationalised as attachment-related behaviours.
The most common (n = 5) measure of mindfulness was the Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, Reference Baer, Smith, Hopkins, Krietemeyer and Toney2006). The FFMQ evaluates an overall measure of dispositional mindfulness and five mindfulness subscales: Observe, Describe, Act with awareness, Non-judgmental, and Non-reactivity. Additional measures of mindfulness included the Mindfulness Attention and Awareness Scale (MAAS; Brown & Ryan, Reference Brown and Ryan2003), Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, Reference Baer, Smith and Allen2004), Freiburg Mindfulness Inventory-short form (FMI-14; Walach, Buchheld, Buttenmüller, Kleinknecht, & Schmidt, Reference Walach, Buchheld, Buttenmüller, Kleinknecht and Schmidt2006), Toronto Mindfulness Scale (TMS; Lau et al., Reference Lau, Bishop, Segal, Buis, Anderson, Carlson and Devins2006), and the Cognitive and Affective Mindfulness Scale Revised (CAMS-R; Feldman, Hayes, Kumar, Greeson, & Laurenceau, Reference Feldman, Hayes, Kumar, Greeson and Laurenceau2007).
Multiple measures evaluated at least one index of mental health (see Table 1 for all measures of mental health). Measures of depression or anxiety were most common among studies (n = 7). Measures of depression and anxiety included the Depression Anxiety Stress Scale (DASS; Antony, Bieling, Cox, Enns, & Swinson, Reference Antony, Bieling, Cox, Enns and Swinson1998) and State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, Reference Spielberger, Gorsuch, Lushene, Vagg and Jacobs1983). Stress response was measured using cortisol saliva sampling. Global measures of wellbeing were also evaluated by measures such as the Meaning of Life Questionnaire (MLQ; Steger, Frazier, Oishi, & Kaler, Reference Steger, Frazier, Oishi and Kaler2006). For parsimony, additional citations on measures of mental health and covariates are omitted here.
Findings on Insecure Attachment, Mindfulness, Depression and Anxiety
Multiple studies identified attachment orientations and mindfulness together related to depression and anxiety. Mindfulness and subsequent difficulties in emotion regulation indirectly linked secure, preoccupied, fearful and dismissive attachment with depression (Pickard et al., Reference Pickard, Caputi and Grenyer2016). The non-judgmental subscale of mindfulness mediated the negative association between adult attachment and depression (Linares et al., Reference Linares, Jauregui, Herrero-Fernández and Estévez2016). As related to anxiety, the observe, awareness, and acceptance mindfulness subscales mediated the link between anxious attachment and anxiety sensitivity-cognitive concerns (Macaulay et al., Reference Macaulay, Watt, MacLean and Weaver2015). Moreover, the observe subscale indirectly linked attachment anxiety and anxiety sensitivity physical concerns (Macaulay et al., Reference Macaulay, Watt, MacLean and Weaver2015). For avoidant attachment, the acceptance mindfulness subscale mediated the link between attachment avoidance and cognitive, physical, and social anxiety sensitivity concerns (Macaulay et al., Reference Macaulay, Watt, MacLean and Weaver2015).
Additional studies found attachment and mindfulness related to one or more index of mental health. For example, mindfulness had a large effect in moderating the relationship between attachment anxiety and overall psychological wellbeing (Davis et al., Reference Davis, Morris and Drake2016). Another study found attachment anxiety mediated the link between mindfulness and depression, anxiety and stress (McDonald et al., Reference McDonald, Sherman, Petocz, Kangas, Grant and Kasparian2016). Longitudinal data from another study revealed bi-weekly changes in anxious attachment significantly predicted changes in depression via state mindfulness (Martin et al., Reference Martin, Gillath, Deboeck, Lang and Kerr2017). Similarly, longitudinal data from an additional study revealed state mindfulness indirectly linked changes in anxious and avoidant attachment to changes in depression and anxiety (Martin et al., Reference Martin, Gillath, Deboeck, Lang and Kerr2017).
Findings on Insecure Attachment, Mindfulness, and Stress Response
Findings from two studies supported attachment orientations and mindfulness related to stress response. Results from a mediation analysis of data drawn from couples following a conflict discussion task revealed attachment anxiety and avoidance indirectly linked mindfulness with faster cortisol recovery and lower negative cognitions and affect (Hertz et al., Reference Hertz, Laurent and Laurent2015). Alternatively, an inverse mediation model revealed mindfulness indirectly linked attachment anxiety and avoidance to lower negative cognitions and affect (Hertz et al., Reference Hertz, Laurent and Laurent2015). In another study, mindfulness moderated partner attempts to control, coerciveness, negativity and conflict, and withdrawal for couples following a conflict discussion task (Laurent et al., Reference Laurent, Hertz, Nelson and Laurent2016). In the same study, state mindfulness positively related to cortisol recovery following couple conflict (Laurent et al., Reference Laurent, Hertz, Nelson and Laurent2016).
Mindfulness Interventions, Insecure Attachment, and Mental Health
Two studies evaluated a mindfulness-based intervention to address attachment and promote mental health. Data from one study revealed engagement in the three-day 8-hour Restoring Embodied Awareness Compassionate Connection and Hope (REAC2H) program predicted lower levels of rumination, negative emotion, emotional suppression, and emotion dysregulation as compared to the control group (Caldwell & Shaver, Reference Caldwell and Shaver2015). In addition, participants demonstrated higher cognitive processing, more present tense, and fewer past tense words when writing about stressful or traumatic childhood attachment experiences compared to the control group (Caldwell & Shaver, Reference Caldwell and Shaver2015). In another study, participants engaged in a mindfulness-integrated couples support group for breast cancer survivors and their partners (Hsiao et al., Reference Hsiao, Jow, Kuo, Yang, Lam, Chang and Chang2016). Findings revealed higher mindfulness was associated with lower anxious attachment and improved cortisol stress responses for breast cancer survivors and their partners compared to the control group (Hsiao et al., Reference Hsiao, Jow, Kuo, Yang, Lam, Chang and Chang2016). Findings for this study remained constant at 14 months.
Discussion
The current systematic research synthesis aimed to obtain and evaluate empirical studies examining the interplay among adult attachment and mindfulness related to mental health. Findings revealed multiple studies provided evidence which supported adult attachment and mindfulness together related to mental health. The meaningful results as well as conceptual and methodological limitations of the studies are discussed.
Data gathered from the current review identified adult attachment and mindfulness together related to anxiety, depression, stress response, and overall mental health. Risk for poor mental health includes an implicit and automatic cognitive bias toward tendency to suppress and avoidance of negative stimuli and heightened sensitivity to threats in the environment (Mathews & MacLeod, Reference Mathews and MacLeod2005). These risks mirror the implicit and automatic approach and avoidance of negative stimuli and heightened awareness of threats in the environment characterised by insecure attachment orientations. In fact, insecure attachment orientations are linked to poorer mental health (Mikulincer & Shaver, Reference Mikulincer and Shaver2012) and stress response (Marriner, Caciolli, & Moore, Reference Marriner, Caciolli, Moore, Kaniasty, Moore, Howard and Buchwald2014). Mindfulness, on the other hand, is characterised by a purposeful non-judgmental attention and awareness of present moment experiences and predicts improved mental health (Brown et al., Reference Brown, Ryan and Creswell2007) and stress response (Finocchiaro & Moore, Reference Finocchiaro, Moore, Moore, Kaniasty, Buchwald and Sesé2013). Multiple empirical studies support the conceptual links between the opposing patterns of responding among insecure attachment orientations and mindfulness (Stevenson et al., Reference Stevenson, Emerson and Millings2017), although the degree to which these relationships affected mental health was unclear. This review has presented evidence for attachment and mindfulness as accounting for the interpersonal and intrapersonal mechanisms linking romantic relationships and mental health.
Emotion regulation appeared to be an important mechanism by which adult attachment and mindfulness related to mental health. Emotion regulation is defined as ‘the process by which individuals influence which emotions they have, when they have them, and how they experience and express these emotions’ (Gross, Reference Gross1998, p. 275). Prior studies demonstrated emotion regulation is shared by insecure attachment and mindfulness (Stevenson et al., Reference Stevenson, Emerson and Millings2017). One study identified that emotion regulation and trait mindfulness mediated the link between dimensions of attachment and depression (Pickard et al., Reference Pickard, Caputi and Grenyer2016). Another study found that emotion regulation and attachment anxiety mediated the link between trait mindfulness and depression and anxiety (McDonald et al., Reference McDonald, Sherman, Petocz, Kangas, Grant and Kasparian2016). The two opposing models of these studies are congruent with the call for additional research to determine specifically how attachment, mindfulness, and emotional regulation are related (Stevenson et al., Reference Stevenson, Millings and Emerson2019). Despite this uncertainty, findings from the present review suggest that emotion regulation is a significant mechanism between attachment and mindfulness as related to mental health.
Multiple studies indicated mindfulness as a mechanism to promote secure attachment and in turn mental health. Research on attachment has demonstrated attachment orientations are malleable to change overtime (Gillath et al., Reference Gillath, Hart, Noftle and Stockdale2009). For example, having individuals simply think about a responsive and supportive attachment figure during stressful situations promotes an emotional balance and adaptability characterised by secure attachment (Gillath, Selcuk, & Shaver, Reference Gillath, Selcuk and Shaver2008). Higher mindfulness is also believed to facilitate shifts toward a more secure attachment (Ryan et al., Reference Ryan, Brown and Creswell2007). The current review highlighted studies that demonstrated mindfulness indeed provided a mechanism to promote shifts toward secure attachment and in turn improved mental health.
The current review identified mindfulness to be an important mechanism for the association between attachment and mental health among clinical samples. One study found changes in mindfulness mediated changes in attachment and mental health for participants in counselling (Martin et al., Reference Martin, Gillath, Deboeck, Lang and Kerr2017). Another study found mindfulness-based practices integrated into a couples support group led to reductions in insecure attachment orientations and stress for cancer patients and their partner (Hsiao et al., Reference Hsiao, Jow, Kuo, Yang, Lam, Chang and Chang2016). In addition, a mindfulness-integrated attachment program led to reductions in negative attachment-oriented thoughts and emotions to address childhood trauma in adulthood (Caldwell & Shaver, Reference Caldwell and Shaver2015). These studies suggest the integration of mindfulness and attachment appears to have potential in addressing mental health within a clinical setting.
Interpretation of these findings should be considered in light of conceptual and methodological issues. A primary conceptual and methodological issue involved the majority of studies tested mediation models using cross-sectional data. This is problematic because mediation analyses imply temporal relationships and cross-sectional data do not permit causal inferences. The precise order by which these relationships unfold over time therefore remains relatively unknown. Adult attachment and mindfulness were also largely measured by self-report instruments, and research suggests these measures may not accurately capture adult attachment (Bowles, Reference Bowles2010) and mindfulness (Bergomi et al., Reference Bergomi, Tschacher and Kupper2013). These issues illustrate the need for basic and applied research that examines the temporal order and improved measurement of attachment, mindfulness, and mental health. Such research might provide important preliminary evidence to pursue mindfulness-attachment integrated practices to address mental health within clinical or community settings.
Implications for Future Research
Future research can be propelled by exploring key processes within current romantic relationships. This is because in adulthood romantic partners serve as a primary base for felt security and safety (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). This felt security can address unmet attachment needs often interfering with couple ability to communicate effectively (Bowles, Reference Bowles and Katsikitis2005). This process may occur through having romantic partners reflect on their own internal working model of attachment in conjunction with a corrective relationship experience (Mikulincer & Shaver, Reference Mikulincer and Shaver2016). Specifically, the ability to self-reflect within the context of romantic relationships is positively related to secure attachment and mindfulness likely promotes ability to self-reflect during attachment threatening interactions (Gerace, Day, Casey, & Mohr, Reference Gerace, Day, Casey and Mohr2017). Research may therefore be propelled by evaluating how mindfulness and pro-relationship patterns of responding might shift couples toward a more secure attachment orientation and improved mental health.
Future studies may also consider evaluating the interdependent nature of romantic partners. This is because health outcomes are in part a function of the interpersonal and intrapersonal processes between romantic partners (Pietromonaco & Collins, Reference Pietromonaco and Collins2017). For example, it is possible partner A's attachment influences partner B's ability to regulate emotions and in turn partner B's mental health. Future studies may consider proposing and testing such interpersonal models of health as such models were not evaluated within the studies located.
The link between attachment and mindfulness might extend to additional indices of health. One study found mindfulness indirectly linked attachment anxiety and avoidance with eating pathology (Pepping, O'Donovan, Zimmer-Gembeck, & Hanisch, Reference Pepping, O'Donovan, Zimmer-Gembeck and Hanisch2015). Additional indices such as sleep may also be of interest as sleep is an important area related to attachment (Arsiwalla, Reference Arsiwalla2017), mindfulness (Shallcross, Visvanathan, Sperber, & Duberstein, Reference Shallcross, Visvanathan, Sperber and Duberstein2018), and romantic relationships (Troxel, Reference Troxel2010). Future research might continue exploring how the links between adult attachment and mindfulness extend to additional indices of health.
Limitations
The present SRS is not without limitations. The SRS was restricted to empirical articles printed in the English language despite the constructs existence in multiple languages. Although it was impractical to include all research across languages and so the current study missed studies not printed in the English language. The narrow search parameters may also be a limitation. For example, attachment and mindfulness have been linked to quality of relationships (Karremans et al., Reference Karremans, Schellekens and Kappen2017) and quality of relationships predict health (Whisman & Baucom, Reference Whisman and Baucom2012). In addition, due to inadequate information, the current investigation did not calculate effect sizes to evaluate the significance of findings between studies.
Conclusion
The present study helped shed light on the interpersonal and intrapersonal mechanisms by which romantic relationships impact mental health. Data identified by the current systematic research synthesis revealed attachment and mindfulness together related to mental health. This evidence demonstrated attachment and mindfulness together explained variations in depression, anxiety, stress response, and overall mental health and wellbeing for individuals and couples. Additional research, however, is needed to distinguish the specific role emotion regulation and key processes within a current romantic relationship or the interdependence between partners has on such associations. Research on attachment, mindfulness, and mental health appears in its infancy. Hopefully the current article can be a catalyst for such studies.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with Helsinki Declaration of 1975, as revised in 2008.
