applying attachment theory to case study

CLINICAL CASE STUDY article

“a child’s nightmare. mum comes and comforts her child.” attachment evaluation as a guide in the assessment and treatment in a clinical case study.

• Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy

There is a gap between proposed theoretical attachment theory frameworks, measures of attachment in the assessment phase and their relationship with changes in outcome after a psychodynamic oriented psychotherapy. Based on a clinical case study of a young woman with Panic Attack Disorder, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the psychodynamic diagnostic manual. Treatment planning and post-treatment changes were described with the main aim to illustrate from a clinical point of view why a psycho-dynamic approach, with specific attention to an “attachment theory stance,” was considered the treatment of choice for this patient. The Symptom Check List 90 Revised (SCL-90-R) and the Shedler–Westen Assessment Procedure (SWAP–200) were administered to detect patient’s symptomatic perception and clinician’s diagnostic points of view, respectively; the Adult Attachment Interview and the Adult Attachment Projective Picture System (AAP) were also administered as to pay attention to patient’s unconscious internal organization and changes in defense processes. A qualitative description of how the treatment unfolded was included. Findings highlight the important contribution of attachment theory in a 22-month psychodynamic psychotherapy framework, promoting resolution of patient’s symptoms and adjustment.

Introduction

Attachment theory in Bowlby’s (1969/1982 , 1973 , 1980 , 1988 ) and Ainsworth’s (1963 , 1967 ) tradition postulates that an individual’s experience of early parental care contributes to the development of internal representations of self and others as safe and available. This theory offered the clinicians a scientific grounded model, which postulated and empirically demonstrated the origin of psychopathology in early separation experiences and in adverse emotional experiences ( Oppenheim and Goldsmith, 2007 ; Cassidy and Shaver, 2008 ). The most recent literature endorses that attachment theory is consonant with all assessment and treatment approaches which evaluate childhood experiences as an important contributor to adult functioning (e.g., Wallis and Steele, 2001 ; Blatt and Levy, 2003 ; Diamond, 2004 ; Bakermans-Kranenburg et al., 2005 ; Buchheim et al., 2007 ; Zegers et al., 2008 ; Buchheim and George, 2011 ). Throughout the case formulation and the planning of treatment, attachment theory has also the potential to provide-at least-a useful foundation for defining the target of change in psychotherapy (e.g., features of internal working models or attachment patterns), understanding the processes through which change occurs (e.g., through the development of a secure base and exploration of working models; e.g., Fonagy, 1999 , 2001 ; Cozzolino, 2002 ; Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Wallin, 2007 ; Fosha, 2009 ; Holmes, 2010 ; Siegel, 2010 ). As Bowlby originally stated, while reconsidering classical attachment theory, Davila and Levy 2006 , p. 990) stressed “five key tasks for psychotherapy: (a) establishing a secure base, which involves providing patients with a secure base from which they can explore the painful aspects of their life; (b) exploring past attachments, which involves helping patients explore past and present relationships, including their expectations, feelings, and behaviors; (c) exploring the therapeutic relationship, which involves helping the patient examine the relationship with the therapist and how it may relate to relationships or experiences outside of therapy; (d) linking past experiences to present ones, which involves encouraging awareness of how current relationship experiences may be related to past ones; and (e) revising internal working models, which involves helping patients to feel, think, and act in new ways that are unlike past relationship.” Despite the increasing interest in the relevance of attachment theory as a framework to understand the unfolding of psychodynamic treatment, there is a gap between the proposed theoretical frameworks and the empirical measures of attachment used in the assessment, and only few studies addressed the interplay between attachment pattern measures, and their implication for unfolding and outcome in a psychoanalytic oriented treatment ( Buchheim and Kachele, 2001 ; Dahlbender et al., 2004 ; Buchheim, 2005 ; Lis et al., 2008 , 2011 ; Isaacs et al., 2009 ).

Interpersonal problems, adult attachment, and emotion regulation have been increasingly studied across adult anxiety disorders. Literature linked attachment and separation in infants and preschool children to separation anxiety disorder, agoraphobia, and panic attacks later in life, underlining how insecure attachment can lead to an increased risk for attachment psychopathology and subsequent social and emotional maladjustment/attachment and separation anxiety/school or work phobia/attachment correlations ( Routh and Bernholtz, 1991 ). Of all the forms of anxiety, separation anxiety seems to be the one which is most likely to be associated with an anxious attachment style, because sufferers are by definition highly sensitive to real or perceived threats to relationships ( Main et al., 1985 ). Separation anxiety would appear to be a core form of anxiety associated with panic attack disorder and with attachment problems ( Hazan and Shaver, 1987 ; Bartholomew and Horowitz, 1991 ; Eng et al., 2001 ). Dysfunctional and not good-enough parenting and hereditary factors appear to play a role in generating early separation anxiety. However, the child’s anxiety itself may generate overprotective parenting ( Manicavasagar et al., 1999 , 2009 ) which, in turn, could make children approach their caregivers both in response to dangerous external stimuli and to caregiver’s permanent monitoring availability and attentiveness; moreover, overprotecting or over responsive parents could obstacle the expression of the explorative system, even when a “secure base” is provided ( Pacchierotti et al., 2002 ). Although attachment theory suggests that anxious attachment styles are mostly associated with risks of developing anxiety disorders, neither all anxious attached patients develop panic attack disorder, nor all secure attached patients do not develop it: the latter is a weird and rare condition because, theoretically, secure early relationships with adults are the basis for the development of a sense of control and predictability accounting for normal subjects’ tendency not to interpret ambiguous internal stimuli as threatening ( Shear, 1991 ).

Based on a clinical case study of a young woman with Panic Attack Disorder- Matilde-, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) 1 . The patient’s choice is motivated by this “rare combination”: a PAD patient with secure attachment. The first aim of this paper was to provide incremental usefulness to the picture of the patient’s idiographic and intra-subjective features, using a multi- method assessment based on (1) two performance-based attachment measures – the Adult Attachment Interview (AAI; George et al., 1984 / 1985 / 1996 ), and The Adult Attachment Projective Picture System (AAP; George and West, 2001 , 2012 ), (2) the Shedler–Westen Assessment Procedure (SWAP–200; Westen and Shedler, 1999a , b ), and (3) a self-report symptom scale, the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1983 ; Funder, 1997 ; Meyer et al., 1999 ; Ozer, 1999 ).The second aim was to describe how Matilde’s assessment findings – and more specifically attachment pattern analysis – could represent useful guidelines for the unfolding of a psychoanalytic therapy with a supportive approach, in an attachment theory framework ( Misch, 2000 ).

We hypothesized that the AAI, the AAP, the SCL-90-R, and the SWAP–200 would help in focusing on the most relevant dimensions of patient’s psychological functioning which make a meaningful diagnosis ( Barron, 1998 ; Shedler and Westen, 2007 ) at the beginning and at the end of treatment. Attention was directed to the interplay between modification of overt symptoms and behaviors, and changes in personality functioning and adaptation; more specifically, we focused on patterns and complexities in the patient’s internal organization and interpersonal functioning ( Shectman and Harty, 1986 ; Peebles-Kleiger, 2002 ; Bram, 2010 ). A reduction in psychopathological symptoms and an improvement in mental functioning according to the PDM M -axis and S -axis were expected at the end of the therapy.

Clinical Case Presentation: Matilde

Matilde was a pleasant 20-year-old young woman, who looked younger than her age. She was a self-referred patient, and was assessed for a high level of anxiety at a university-based psychology-training clinic 2 . Matilde had a diagnosis of Panic Attack Disorder in Axis I (DSM-IV; American Psychiatric Association [APA], 1994 ), and no diagnosis in Axis II. Although she was a 2-year student at the Medical School with outstanding results, she felt “ anxious, confused, and insecure, ” “ I do not know if this Faculty is good for me, maybe Biology would be better, or Pharmacy … I do not know really, I am so confused; I do not understand what is happening to me …. I am no more sure about anything. ” Insecurity caused her quite severe crying crises, pervasive anxiety, and some physical symptoms, such as psychomotor agitation and tachycardia. She had taken light tranquilizers in the last 3 months. She felt unable to control or understand her present distress. Since she started University, her life had been totally busy with studying, leaving no time or desire to engage in social relationships. She did not talk about any actual satisfying relationships. The only “ friends ” she kept in touch with were schoolmates from high school, with whom she shared school topics. She had never had a boyfriend, and felt very uncomfortable talking about romantic or sexual topics. Matilde moved away from her small native town to attend University, and she was sharing an apartment with other students next to the Medical School. She went back home to her family during University vacations. She came from an intact family, which she was very proud of. She had a 10-year-old sister, Sarah, to whom she was very attached. Sarah was described as very different from Matilde: very funny, an ironic with a lot of energy. They spent a lot of time playing together, and Matilde was unconcerned about her worries when she was with Sarah. Matilde describes her childhood with some enjoyment and unconcern while her present appears very worrying, uncertain and without any source of protection and soothing. Matilde supports a good relation with her mother, although the father is described as rigid and very involved in practical duties.

Approach to the Case: Procedure and Instruments

At the initial assessment phase Matilde underwent three interview sessions, two test sessions and one feedback session. In particular, Matilde’s evaluation involved the administration of the AAI and the AAP, the SCL-90-R, and the SWAP–200. All results were integrated with clinical interview contents to formulate a case conceptualization, according to specific dimensions of the PDM. In the feedback session, a once-a-week psychodynamic psychotherapy with a supportive approach was proposed to and accepted by Matilde. The therapy lasted 22 months. At treatment conclusion Matilde accepted to be re-administered the AAP and the SCL-90-R. Based on the last three sessions also the SWAP–200 was re-administered. All the tools administered were scored and interpreted by independent judges 3 . A brief description of used tools follows after timetable of administration (Table 1 ).

TABLE 1. Timetable of administered tools.

Symptom Checklist 90 Revised ( Derogatis, 1983 ) is a 90-item self-report questionnaire scored on a five-point Likert scale of distress from 0 (none) to 4 (extreme), indicating the rate of occurrence of symptoms during the time reference ( Derogatis et al., 1973 ). It is intended to measure symptom intensity on 10 different dimensions: somatization (SOM), obsessive–compulsive (O–C), interpersonal sensitivity (I-S), depression (DEP), anxiety (ANX, hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), and sleep difficulties (SLEEP). A Global Severity Index (GSI) of distress is calculated. According to the Italian Manual, an intensity raw score higher than one was qualified as penetrating in the clinical range. The internal consistency coefficient alphas for the nine symptom dimensions ranged from 0.77 for Psychoticism, to 0.90 for Depression. Test–retest reliability coefficients ranged between 0.80 and 0.90 after 1 week of therapy. The few validity studies of the SCL-90-R demonstrate levels of concurrent, convergent, discriminant, and construct validity comparable to other self-report inventories ( Derogatis, 1983 ).

The Shedler–Westen Assessment Procedure ( Westen and Shedler, 1999a , b ) is a set of 200 personality-descriptive statements developed for clinicians to assess adult personality traits and pathologies ( Shedler and Westen, 1998 ). Starting from clinical interviews, the assessor is asked to describe the patient by arranging the statements into eight categories, from those that are not descriptive (assigned a value of “0”) to those that are highly descriptive (assigned a value of “7”) for each of the 200 personality-descriptive variables. The instrument is based on the Q-sort method that requires clinicians to arrange items into a fixed distribution ( Block, 1978 ). The SWAP–200 could be interpreted at a nomothetic as well as at an idiographic level. Nomothetic interpretations are carried out following two profiles. The first is the PD-T score profile of the 10 Personality Disorders included in DSM–IV (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive); the Q-T profile covers 11 dimensions (psychological health, dysphoric, antisocial, schizoid, paranoid, obsessive, histrionic, narcissistic, avoidant, depressive high functioning, emotional dysregulation, dependent, hostile). Both PD-T and Q-T profiles include a score on a Healthy Functioning scale. Inter-rater reliability coefficients range from 0.70 to 0.80. Support for the validity of the SWAP–200 is derived from its ability to predict relevant variables in expected ways, including family psychiatric history, history of abuse, social, and school functioning, violence, suicidal behaviors and attempts, attachment status, and eating disorder diagnostic groups ( Westen and Muderrisoglu, 2003a , b ). Idiographic narrative case description is also included in the SWAP–200 (e.g., Lingiardi et al., 2006 ). Both levels were used to assess Matilde. Moreover, the SWAP–200 ( Westen and Shedler, 1999a , b ) is one of the instruments listed by PDM work-group members to be used to measure the dimensions of the M -axis.

The Adult Attachment Interview ( George et al., 1984 , 1985 , 1996 ; Hesse, 2008 ) is an about 1 h audio-recorded semi-structured interview that explores an adult’s mental representations of attachment, guiding the individual through a series of questions about past and present relationships with each parent and attachment-relevant events during childhood. The AAI focuses on the assessment of the attachment internal working model ( Bowlby, 1969/1982 ) and assumes developmental continuity of the attachment system along life. AAI final attachment classification is evaluated on two different set of scales (1) Experience Scales that evaluate for example Loving, Rejecting, Neglect, Role Reversal, Pressure to achieve and (2) State of Mind Scales that assess Coherence, Metacognitive Processes, Lack of Recall, Passivity of Discourse, Idealization, Anger, Derogation attitudes toward caregivers, Unresolved mourning or trauma, Feared loss of one’s own child. Starting from these scales, each interview is classified in one of the primary attachment patterns: secure/autonomous, dismissing/avoidant, and preoccupied/entangled or “cannot classify.” Where applicable, the “unresolved” pattern with respect to loss, trauma, or abuse could be scored. Multiple scoring is allowed (e.g., F/DS). AAI validation rests on more than 25 years of developmental and clinical research ( van IJzendoorn and Bakermans-Kranenburg, 2008 ). Rigorous psychometric testing and meta-analyses of the AAI demonstrate its stability, and discriminant and predictive validity in both clinical and non-clinical populations. In a recent meta-analysis of 61 clinical samples ( van IJzendoorn and Bakermans-Kranenburg, 2008 ), strong associations were found between psychiatric diagnoses (i.e., anxiety disorders, borderline personality disorder) and attachment insecurity.

The Adult Attachment Projective Picture System ( George and West, 2001 ) is based on a standardized set of seven drawn pictures divided in Alone and Dyadic stimuli 4 . The pictures describe major attachment events, potential threat of separation, illness, solitude, death, and abuse. The stimuli are: child at window (window); departure; bench; bed; ambulance; cemetery; and child at corner (corner). Individuals are asked to make up a story for each image in which they describe what is going on in the picture, what led up to the scene, what the characters are thinking or feeling and what might happen next. The responses are audiotaped for transcription and verbatim analysis. The AAP assesses attachment in the Bowlby-Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ). The AAP Coding System, leads to four adult attachment classification patterns, – secure/autonomous, dismissing, preoccupied, unresolved – as they were traditionally assessed in the AAI, even if no multiple scoring is allowed. The AAP also assesses attachment personal elements that individuals may exclude from conscious awareness. Attachment classification using the AAP is determined by evaluating patterns of responses using a set of seven scales grouped under three major categories: discourse, content, and defensive processing. These dimensions evaluate the attachment story content related to the hypothetical characters portrayed in the stimuli, to defenses, and to self-other boundaries in narrative discourse ( George and West, 2001 , 2012 ). Discourse codes evaluate personal experience. Content codes include agency of self and connectedness for alone pictures, and Synchrony for dyadic pictures. Finally, the AAP codes for defensive exclusion, segregated systems, deactivation, and cognitive disconnection ( Bowlby, 1980 ). They represent different degrees of “protection” from dangerous distressful events. Segregated systems describe a mental state in which painful attachment-related memories are isolated and blocked from conscious thought and rooted in experiences of trauma or loss through death ( Bowlby, 1980 ). Deactivating defensive processes are defined as attempts to dismiss, cool off, or shift attention away from attachment events, individuals, or feelings in response to the picture stimuli. Cognitive disconnection processes literally disconnect the elements of attachment from their source, thus undermining consistency and the capability of holding in one’s mind a unitary view of events, emotions, and the individuals associated with them. The most recent review of AAP reliability and validity was published in George and West (2012) . AAP–AAI convergence for secure versus insecure classifications was 0.95 (κ = 0.75, p = 0.000); convergence for the four major attachment groups was 0.89 (κ = 0.84, p = 0.000; George and West, 2001 , 2012 ; West and George, 2002 ). The AAP has also been shown to be useful in studying the neurobiological and emotional expression correlates of attachment in non-clinical and clinical samples ( Buchheim and Benecke, 2007 ; Buchheim et al., 2007 , 2008 , 2009 ; Fraedrich et al., 2010 ) as well as in single case studies ( Lis et al., 2011 ).

Both AAI and AAP show individual strengths in measuring attachment patterns, but their combined use increments their overall usefulness. The AAI, the golden standard measure of adult attachment ( Bakermans-Kranenburg and van Ijzendoorn, 1993 ), focuses on the assessment of the representational model and coherence of mind, and assumes developmental continuity of the attachment system, evaluating abuse and loss in one’s personal history. The AAP, based on the Bowlby–Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ), assesses current views of self, attachment figures, and expectations about the productiveness of attachment relationships, elucidating how current experience activates attachment accomplishment, disappointment, and trauma from the past ( West et al., 1995 ; George and West, 2012 ). The AAP is also more trauma sensitive and underscores defense patterns (e.g., Hesse, 2008 ; George and West, 2012 ). The combined use of the AAI and the AAP gives the chance to portray a complex image of the patient’s attachment pattern, providing a detailed narrative about life attachment activators such as separation, fear, solitude, and danger, shedding light on the unconscious defensive mechanisms and exploring the accessibility of attachment figures during the life-span (e.g., Hesse, 2008 ; George and West, 2012 ). The SCL-90-R contributed to get Matilde’s self-evaluation of symptoms.

Assessment Findings

Results from DSM-IV diagnosis, SCL-90-R and SWAP–200 during the assessment phases are described in Table 2 . Results from attachment tools are reported below and AAI subscales are shown in Tables 3 and 4 .

TABLE 2. Results from SCL-90-R and SWAP–200 in assessment phase.

TABLE 3. AAI experience scales.

TABLE 4. AAI state of mind scales.

Matilde’s AAI was scored F2/Ds3, secure with features of dismissing or some restriction in feelings of attachment (F2 = free somewhat dismissing or restricted in attachment; DS3 = dismissing restricted in feelings with some evidences of Lack of Memories; George and Solomon, 1996 ; see Tables 3 and 4 ). Matilde secure pattern was so defined because she was able to explore his or her thoughts and feelings about childhood experiences, with fresh speech, humor and forgiveness, without becoming angrily or passively overwhelmed while discussing them. Generally, Matilde appeared to be aware of the nature of experiences with her parents and of the effects of such experiences on her present state of mind and on her personality. Nevertheless, she remained a little bit restricted in her emotional expressions, preferring to rationalize. State of mind scales tapped a dismissing feature, showing a slight tendency to idealize parents and some lack of memories. Further information about Matilde derived from a qualitative analysis of the AAI. She did not report any severe illness, traumatic or abuse experience. However, separations caused her some distress, but she felt always supported and listened by her mother. She described herself as a very calm girl but, during early childhood, she was very shy and very worried about separation: “ I became very agitated when I did not see my parents, when they were not there, when they were away from home, ” “ Once we were at the lake. I was on the one side of the road and my parents were on the other side. Some people passed and so I could not see my parents anymore. I did not see them anymore and I began to scream .” However, she remembered that during her summer camp experience, when there were no well-known friends or schoolmates: “ I felt the distance from home, I felt lost and confused … I was very happy to go back home. The bus journey to go back home was very stressful,” “I do not like changes. I am worried about changes. ”

She described the relationship with her mother as: affectionate, playful, reciprocal, supportive, and protective. When she was asked to recall a specific example in respect with “supportive relationship” she reported that “ I gulped a small toy and it remained caught in my throat. I had to be taken to the hospital. I was very agitated, I screamed that I was frightened of dying. Mammy was very supporting … I mean comforting. ” She was able to identify a specific episode, but in a superficial and not qualitative consistent manner ( Grice’s qualitative maxim ): the adjective-descriptor (supportive) of relationship with her mother was supported with a second generalized positive descriptor (comforting). The adjectives she chose to describe the relationship with her father were: always affectionate, playful, formal ( “home rules had to be respected, for instance times for lunch and dinner” ), respectful ( “Nothing escaped from him; his words had always a weight” ), and important. Such aspects were more linked to father’s role as a parent and to school achievement: “I felt very bad about his criticism.” Matilde felt closer to her mother than to her father, from whom she felt more detached. Moreover, during school years she always felt a little bit anxious and agitated about school achievement and completion. Beside all these difficulties, she always felt supported and sustained by her mother, and at the end she demonstrated herself as very forgiving toward her father’s severity. When asked to imagine the possibility of being separated from her child, Matilde reported to feel “ a big void, a big feeling of lost, of mourning, a big pain, an absence of being complete ” and the three wishes about this child when he would be 20-years old were: “ to be able to choose, to have a clear reasoning, not being confused, and to be able to be autonomous. ”

Matilde was judged as secure on the AAP (F): she showed, at the representational level, a flexible and organized thinking about attachment situations and relationships ( Bowlby, 1969/1982 ). She was confident that she could rely on attachment figures to achieve care, safety and protection and, when alone, she could access internalized attachment relationships ( George and Solomon, 1996 , 1999 ). In response to two of the alone stimuli – Window and Cemetery- as a secure individual, she demonstrated the ability to think (i.e., Internalized Secure Base) and to take constructive action. She also used flexible defensive processes to integrate attachment feelings and events. Using these resources she was able to re-organize her attachment-related feelings, also in the few cases (Bed and Cemetery Stories) when she became disorganized by feelings of loss and danger. From the pattern of story responses it appears that Matilde, above all other response qualities, genuinely valued and represented the capacity for integration of self and relationships. The responses to the Alone pictures demonstrated Matilde’s internal resources, such as the potential availability and responsiveness of attachment figures. As a representative example of this attitude the Cemetery picture (a man stands by a gravesite headstone) story is reported.

“A gentleman who had a bad day or felt sad or depressed or undervalued because of an episode that happened during the day and goes and visits his father … he feels reassured because he found a place where to think about his life by himself and then he will go back home and will be able to reconsider what happened from a different point of view.”

In Cemetery, Matilde reveals the intensity of feelings of pain associated with loss: she tries to deal with them through some form of uncertainty and desire to withdraw (cognitive disconnection). These forms of organized defensive mechanisms keep Matilde’s attachment system activated but they cannot prevent her from becoming dysregulated, as evidenced by painful attachment-related feelings of loss represented by the appearance of a them where no clear distinction is made between life and death (“he goes and visit his father”). A segregated system (spectral domain) was activated by the picture features, which portray a man visiting a grave. However, Matilde was able to depict the man as engaged in some kind of “thinking.” The man is able to “reconsider what happened from a different point of view.” This process belongs to Internalized Secure Base, and portrays Matilde’s ability to clearly differentiate between the living and the dead. The Dyadic picture stimuli portray attachment-caregiving dyads. The responses to Dyadic picture stimuli demonstrate Matilde’s representation of the self and other in attachment situations when attachment figures are present and accessible, but they also demonstrate the use of attachment figures to quell the attachment anxiety aroused in the scenes depicted in the cards. Bed picture (a child and woman sit opposite to each other on the child’s bed) could be a representative example.

“A boy had a nightmare during the night and his mother woke up eh … now he is scared and he would like to be close to his mum … the mum is trying to soothe him and she will be able to do it … the boy will come back to sleep quietly … (Anything else?) no.. maybe the bad dream was … was about the fact of staying alone without his mom … and now … he wants his mom first!”

In Matilde’s story, the child signals his attachment need after a “nightmare” (segregated system in AAP) and the mother is able to provide a contingent and soothing answer, containing the potential breakdown of the attachment system and resolving the segregated system. Both AAI and AAP classified Matilde as secure with somewhat dismissing or restricted feelings in attachment without elements of unresolved abuse or trauma. However, both tools detected some shortcomings about fears of separation and danger. The AAI was not able to draw attention in an exhaustive way to how Matilde experienced abandonment fears and felt scared without the presence of her parents. Instead the AAP clearly depicted this nuance, under a secure pattern, showing that her attachment was threatened by painful attachment-related feelings of loss, and by a nightmare (in Bed picture), a signal of danger. In both tools she demonstrated her ability to re-organize herself, but these disturbing feelings kept being alive underneath her reorganized secure pattern.

Case Formulation Based on PDM Axes

S -axis – Matilde had a diagnosis of DSM-IV ( American Psychiatric Association [APA], 1994 ), and showed a slightly High Functioning profile with Obsessive, Schizoid-Avoidant and Dysphoric characteristics, in both PD and Q factors in SWAP–200. Matilde’s SCL-90-R symptom profile revealed depression, anxiety, obsessive–compulsive, and somatization scores in the clinical range (Table 2 ).

M -axis – this Axis describes nine dimensions, which systematize the capacities that contribute to an individual’s personality and overall level of psychological health or pathology.

Capacity for regulation, attention, and learning

In the clinical interview, she said, “ I lost control of my body and thinking. ” She appeared in a profound state of crisis and she appeared to be unable to cope with it and with connected feelings of anxiety and distress. She (a) adhered rigidly to daily routines and became anxious or uncomfortable when they were altered, (b) had trouble making decisions and was indecisive or vacillated when faced with choices, (c) was overly concerned with rules, procedures, order, organization, and schedules: all obsessive strategies which would interfere with processes that support attention and learning from experience. However, according to Bowlby, being secure at both AAI and AAP means that Matilde had basic capacities for regulation. Matilde appeared to believe in the seeking of proximity and support as effective ways in regulating distress, in particular in AAP Dyadic pictures. However, at the moment of assessment, she was not able to recur to her internalized security patterns, showing how an emotional regressive crisis was rising up. Although Matilde subjectively felt unable to cope with it and was very frightened by it, according to the AAP and AAI, the dysregulation appeared momentary and not prolonged. It seems she was still functioning as she described herself in the early childhood memory, when she could not see her parents and she got anxious at the thought of being lost. However, her basic secure attachment suggests that, thanks to the therapy, she could re-establish her capacity of self-regulation, a secure person’s basic characteristic.

Capacity for interpersonal relationships

Although she was excessively devoted to work and productivity, compromising leisure and relationships, her secure attachment pattern at the AAI and AAP indicated that Matilde had a positive representation of available adults who can offer protection, support, care, and comfort in threatening and stressful situations. The AAP supported also her potential ability to be connected with other relational systems such as partners and peers, almost in a concrete manner, since she was able to tell stories in which she described specific connections with friends and other people in general. However, her agency, connectedness, and synchrony were at the moment “quite silent” in her everyday life. She needed help to regain these resources.

Quality of internal experiences

In AAI and AAP she felt reassured by (her) mother’s proximity, soothing, and comfort. However, episode and story plots clearly indicated some separation anxieties and worries in respect to changes, which she faced using dismissing defense mechanisms. AAP clearly depicted how under a secure pattern, her attachment was threatened by painful attachment-related feelings of loss and danger. Until that moment, such feelings were isolated and blocked from conscious thought. Even if she was able to deal with these experiences in childhood thanks to her mother’s comfort, her fear of loss connected to the fear of being alone and unprotected seem to re-emerge We hypothesized that she was having trouble in coping with new adolescence-through-young adulthood tasks, such as the adult separation-individuation process. According to the SWAP–200, she experienced a sense of personal dissatisfaction, poor self-regard, low self-esteem, lack of confidence, and chronic self-criticism. Her unrealistically high standards together with her expectation of being “perfect” above all in her achievements, made her feel guilty, depressed and despondent, with negative self-regard toward others, and the world at large.

Affective experience, expression, and communication

According to the SWAP–200, Matilde tended to defend herself via the inhibition of emotion expression, by means of abstract thinking and intellectualized terms, and appeared unable to recognize her wishes and impulses. Apparently, intellectualization and disavowal defenses (above all rationalization) led her to the avoidance of expressed conflict and emotions – both positive and painful. This emotional constriction resulted in a bottled up affect being channeled into panic attacks. The SWAP–200 stressed the risk of recurrent episodes of overt anxiety, tension, nervousness, and irritability and difficulty in acknowledging or expressing underlying feelings of anger and resentment. The AAP and AAI confirmed that underneath this block of affection there was a rich and positive affective state she had internalized during childhood life experiences. However, although not so rigid, her present affective state of constriction and inhibition was consistent with the rigid attempt to neutralize affect using deactivating defenses in the AAP. The emotions, which were bottled up in the segregated system, surely carried a negative and overwhelming emotional tone, which at the moment she was unable to deal with.

Defensive patterns and capacities

The SWAP–200 indicated the extent to which Matilde tended to defend her from expressing emotions, by abstract thinking and intellectualized terms. Although her defenses were at a mature-neurotic level, they were not solid enough to allow her to avoid the recourse to symptoms and anxiety. From an attachment viewpoint-AAP-Matilde shows a different picture underneath. Here defenses appeared organized and flexible, but in order to keep a regulated attachment she relied more on deactivation than on cognitive disconnection ( George and West, 2012 ).

Capacity to form internal representations

Matilde was able to form internal representations of self and others, and her experiences were symbolized mentally. However, in the current state of distress, some emotions and conflicts were expressed somatically through her somatic symptoms and panic attack episodes.

Capacity for differentiation and integration (ego strength, self-cohesion, stability of reality testing). Overall, her AAP stories and her narrative in the AAI revealed that she was able to look realistically at herself, people, and relationships. Also during the clinical interview, a solid, stable and good child image emerged, but was not integrated with an adolescent and adult image: Matilde’s ego was fragile and was shattered by a large number of symptoms, her self-image was damaged and not well integrated; moreover, she looked younger than her age and never talked about sexuality or intimate relationships.

Self-observing capacities

Matilde did not demonstrate good self-observation capacities. Her level of current distress, extension of intellectualization and rationalization defenses, avoidant and constricted emotional style did not allow for an adult and mature emotional insight.

Capacity to construct or use internal standards and ideals. SWAP–200 showed how she currently set unrealistically and childish high standards for herself and how she appeared intolerant of her own human defects.

Therapeutic Stance and Therapy Guiding Conception

Matilde looked younger than her age and did not talk about sexuality or intimate relationships and we supposed that she did not undergo a true adolescent process. Looking at her secure attachment pattern, the therapist hypothesized that the present state of dysregulation and symptomatic picture is transitory and derived from the new young adulthood tasks she has now to deal with during her transition toward adulthood, such as moving to University. From a psychoanalytic as well as an attachment-oriented viewpoint, we hypothesized she was not able to face adolescent and adult separation-individuation processes. According to attachment theory, attachment relationships foster integration of attachment with relationships in peer behavioral systems during adolescence and adulthood: these include friendships and romantic relationships ( West and George, 1999 ; Allen, 2008 ; George and Solomon, 2008 ; George and West, 2012 ). Psychoanalytic theories also agree that the individual needs to face adolescence as a separation-individuation process, where adolescents need to acquire an individual separate self-identity through identification with parents and separation from childhood ties. The AAP and AAI were taken into account, making the therapist sensible to specific topics concerning separation, loss, and loneliness, able to reactivate and unleash childhood attachment-related memories of fear of being lost and completely alone during treatment itself. Matilde needed to explore this topic with a therapist who would represent for her, in the transference, a secure parent similar to the one she had already experienced in her life via her mother’s supporting stance. In particular, the therapist expected that supportive psychotherapy would integrate the “segregated” themes locked in Matilde’s experience: she might then be able to consciously accept and deal with her blocked emotions and affects, as to regainenjoyment of life and satisfaction in the relationship with significant figures, re-finding the haven of safety of self and others that she had experienced in her childhood.

The clinical case formulation suggested for Matilde a therapeutic approach in the context of a “partial rapprochement” between attachment theory and psychoanalytic individual psychotherapies as the best solution ( Skean, 2005 ; Slade, 2008 ; Steele et al., 2009 ). This intervention would include: (a) The use of therapeutic relationship and alliance as vehicles for a “secure base” constitution, in order to observe and understand the client’s interpersonal behavior ( Spence, 1982 ; Binder et al., 1987 ; Dozier et al., 1994 ; Slade, 2008 ; Steele et al., 2009 ); (b) Relationships with the self and others (internal and external), in terms of personality functioning but also from client’s transference and therapist’s counter-transference points of view of ( McWilliams, 1999 ; Skean, 2005 ); moreover, patient’s real or transferential relationships and past-present pattern of emotional responses and behaviors were examined ( Gabbard, 2009 ). However, a particular emphasis was put on the supportive versus insight-oriented modes of therapy ( Skean, 2005 ), because Matilde needed: (a) to reduce physical and psychical symptoms ( S-Axis ; Gabbard, 2009 ), and reestablish a consistent level of functioning ( Dewald, 1971 ; Ursano and Silberman, 1996 ; Douglas, 2008 ); (b) to strengthen her fragile ego. Her defenses were at a mature-neurotic level, but were not solid enough to stop the recourse to symptoms and anxiety ( PDM: Defenses; Capacity for Differentiation and Integration ), (c) to change her self-definition, improving self-esteem, and getting a more integrated perception of the self, ( PDM: Qualiy of internal experiences; Capacity for Differentiation and Integration ); (d) To function better in everyday life investing lessin achievements and study matters ( Dewald, 1971 ; Ursano and Silberman, 1996 ; PDM: Rehabilitation ); (e) to improve her coping skills and to learn consistent strategies to manage her painful internalized feelings ( PDM: Capacity for regulation, attention, and learning ); (f) to increase her capacity to express affects both on the positive and negative aspects evidenced by AAI and that were consciously often inhibited and not acknowledged (PDM: Affective Experience, Expression, and Communication) ; (g) to encourage more consistent ways of relating to others ( PDM: Capacity for Intepersonal Relationships; Misch, 2000 ). In addition, her concrete and intellectualized thinking (SWAP–200) made also difficult for her to deal with interpretations, suggesting again the need of a more supportive approach.

Brief Outline of the Therapy Unfolding

As expected, during the first months of therapy Matilde showed a high symptomatic picture. She appeared very distressed and confused, with a sense of failure, of inability to reach her standards. Long boring and intellectualized descriptions of daily routines and of University achievement, anxiety, uncertainties and doubts about her achievements were her main topics. The therapist acted as a secure attachment figure ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ), as a caregiver who offered security and soothing to Matilde’s distress. She worked actively helping Matilde to contain anxiety, shame, and anger ( Winston et al., 2004 ). The therapist, very slowly and respecting her defenses, tried to reduce Matilde’s anxiety, to increase her self-esteem and hope, and to make her more aware about herself as a person, and not only as a student who had to achieve some standards. She begun anyway to talk about how she could count on her mother, the only person that always helped her when she felt anxious and distressed. This finally opened a window on her family and her separation difficulties during childhood, and she started to tellhow she felt alone and how much she needed her mother’s soothing, how much difficult it was to face her first experience of a 2-week summer camp, as well as to begin elementary school, middle school, and high school. She also admitted that anyway with her mother’s help she was able to face these separations. She began to recognize, following therapist’s verbalizations, that at that time she was beginning a new kind of “school-experience,” similarly to the situation at present. In parallel with this initial understanding of her fear of facing changes and separation, all symptoms increased, especially anxiety symptoms. “ It is a nightmare ” were her words. She told the therapist that she called mommy every morning and evening but it was not enough. She felt lost and alone. The episodes reported by Matilde at this phase of the therapy were very similar to the ones she reported in the AAI, and the ways she dealt with the present separation from her mother were similar to the ones she previously used during her childhood: going concretely to her mother to be soothed and supported. Moreover, she used the same words she previously used in the two AAP stories where segregated systems were unleashed but resolved. It could be hypothesized that in the transference with the therapist Matilde’s attachment system was activated and “seen in action” ( George and West, 2012 ). As she said during the AAI, it was always difficult for her to deal with changes. Now in the transference with the therapist she was reliving her fears, the same fears she experiencedin childhood, the ones that were unleashed at the beginning of the University andthat she was able to face only through anxiety and obsessive symptoms. It was difficult for her to connect this experience with the new separation experience from home and from herself as a child, now that she had to face University and all the complex processes connected with entering adulthood. In the transference with the therapist she was reviving an acute separation anxiety and she was also unconsciously angry at the therapist’s impossibility to help her. The therapist tried unsuccessfully to interpret and to connect this profound regression with Matilde’s previous separation anxieties. Words were not useful. Wallin (2007) supports that “ what patients are unable to explain with words, tends to be evocated, enacted or incorporated ” ( Zaccagnini and Zavattini, 2009 ). The working alliance showed for the first time some ruptures, and the risk of treatment disruption itself became a subject of discussion ( Appelbaum, 2005 ; Colli and Lingiardi, 2009 ). Matilde’s alliance rupture style was characterized by the presence of withdrawal maneuvers: emotional disengagement from the therapist, skipping from topic to topic, responding in an overly intellectualized fashion, and very short answers ( Safran and Muran, 2000 ). In such a moment of regression, she really needed a concrete comfort and physical contact with her mother. The therapeutic stance was not enough for her; she decided that the best way to deal with the situation was to go back home. Matilde went home, “ to be near to her family. ” Coming back to her parents represented for her the haven of safety she described in her AAP. Parents were still used as attachment figures during early, middle and late adolescence and also during young adulthood ( Fraley and Davis, 1997 ), especially under conditions of extreme stress ( Huntsinger and Luecken, 2004 ; Kamkar et al., 2012 ). She stayed home with her family for 3 weeks. When she came back, she appeared less anxious and more integrated: little by little, Matilde was more able to feel the setting as a place where exploration of her personal life and new experiences could be initiated, shared, and enjoyed. She was able to develop positive feelings toward the therapist ( Misch, 2000 ). She began to integrate positive and negative feelings in life events, becoming more and more flexible, increasing her ability to tolerate changes and learning to find new solutions to life schedule. She reached some goals toward adulthood and began to find real friends, also far from home, and to spend energy in different activities (e.g., organization, church, neighborhood, etc.). She loved challenges and she felt pleasure in realizing her goals and in pursuing long-term ambitions. A boyfriend appeared. The symptoms disappeared. She continued to use a great amount of razionalization in order to explain some affective aspect of her experiences. from the point of view of attachment, she mantained a tendency to change the topic when she approached emotional issues using displacement defenses in order not to deal with her core difficulties. The therapeutic goal of accomplishing a true adolescent process was also achieved. A solid and good child image was now more integrated with an adolescent and adult image. Some developmental tasks were reached on the way toward adultood (friendship and romantic relationship). The therapist discussed with Matilde the fact that some shortcomings were still present in her personality functioning, but both agreed that she wished now to try to go on with her life by herself. As Freud (1966) suggested, the aim of psychotherapy at a developmental age is to help the patient to proceed along his or her developmental lines. Now Matilde managed to integrate some issues concerning the developmental step of adolescence and young adulthood and she wished to try new experiences by herself.

Follow-Up Findings

Results from DSM-IV diagnosis, SCL-90-R, and SWAP–200 in the follow-up phase are described in Table 5 .

TABLE 5. Results from SCL-90-R and SWAP–200 in follow-up phase.

The AAP was scored secure, but without any segregated systems. As a representative example of some new attitudes, Matilde’s stories for Window and Departure pictures are reported.

Window (a child looks out a window): a girl who woke up eh … parents are not there, they are at work and she knows she is alone at home. She is quiet. She is looking out of the window thinking about her mom and the fact she will come back home in the afternoon. She is thinking about who she can invite in … who can … can keep … her company. She is quiet, excited by the day without parents (What might happen next?) she will find someone … a … a friend … a neighbor … finally she will have fun (Anything else?) No.

Matilde tells one of the most common AAP stories for the Window picture: a typical home-related scenario in which a little girl needs to manage her solitude. The girl is “ quiet ” although she is alone home. So, Matilde is not threatened by the girl’s loneliness, but she is somehow able to enjoy the possibility of being alone. The absence of segregated systems demonstrates the absence of dysregulating events, which could have led to her being alone (her parents are just working) and of girl’s traumatic reactions. More specifically, the girl is depicted “ thinking about her mom, ” activating her ability to internalize the secure base and being “ content in solitude. ” In fact, this connection with the thought of her mother’s coming back in the afternoon keeps the girl regulated and lets her also think about something specific to do alone: “ she looks out of the window thinking about who she can invite in … who can keep … her company. ” The little girl can recall the affiliative system (“ friend ”) to handle her loneliness. Her ability to think makes Matilde confident and envisages the possibility of changing things in the immediate future (“ she invited friends ”). From a developmental point of view, Matilde is now a late adolescent-young adult: she is prone to consider also peers and friends as a secure base to refer to in moderately distressful situations.

Departure (an adult man and woman stand facing each other with suitcases positioned nearby): a woman is going to leave for a business trip and she is saying goodbye to her husband … he took her to the station … she was already planning what she needed to do during the trip … yes during this period of work … he is quiet and he thinks about their relationship, about how they enjoy to be together, what he would do without … in these few days without his wife…however … she will leave and he will spend a few dull days … (Anything else?) No.

In Departure, Matilde is able to tell a typical AAP story, which portrays a couple at the train station. The husband thinks about their relationship and he feels that his days will be dull without his wife. Matilde’s story suggests togetherness and a goal-corrected partnership. She portrays the husband as involved in a contingent, reciprocal and mutually engaging relationship.

Qualitative Clinical Evaluation at the End of Therapy

Matilde did not have any DSM-IV diagnosis in Axis I and her personality functioning resulted carachterized by obsessive high functioning features (PDM S -axes, SWAP–200). She had no more panic attacks accompanied by strong physical arousal, and her experiences were now more mentally symbolized. Her SCL-90-R final symptom profile revealed a magnitude within the normal range. Only two symptomatic distress levels, obsessive–compulsive, and anxiety, still penetrated the clinical range, but their intensity had diminished compared to the assessment phase.

Her self-image improved: she now experienced a sense of personal satisfaction, sufficient self-esteem and self-confidence (PDM M -axes). The “negative-stressful” components of her affective world were still present but the level of self-blame, and emotional constriction greatly diminished. She was now less inhibited and became more spontaneous in expressing emotions, and also anger. Matilde still showed a pattern of Mature-Neurotic defenses and an absence of primitive defenses. Rationalization, intellectualization, undoing, and displacement were the mostly used defenses, but were now more flexible, less pervasive and she was able to avoid recourring to symptoms and anxiety. The AAP confirmed a flexible use of defenses and reduction in thereliance on dectivation defenses; however, her kind of defense structure still did not allow neither an emotional insight about her motivations and behaviors, or psychological mindedness.

Matilde remained secure in her attachment pattern, changing her defensive approach through a more integrated and coherent one, in which no more segregated systems or disregulation were present: she was now able to use again her self-regulation capacities autonomously (PDM M -axes). Her attachment adolescent crisis was resolved; she was out of her “nightmare.” She still seemed naïve and used an excessive part of her mental energy to keep emotions and feelings at bay, showing a limited ability to appreciate metaphor, analogy, or nuance. In the context of a supportive stance, comprising a secure and holding environment and an atmosphere based on emotional safety, she was able to work on her fear of loss and changes allowing her internalized attachment status to reach an adult structure. She was now able to deal with adult tasks using her internalized parental figures, thinking about how they could protect her. Matilde now found pleasure, satisfaction, and enjoyment in everyday-life activities. Her underneath security pattern now re-emerged allowing her to maintain a loving relationship, and to engage and keep long-standing and intimate friendships and relationships (PDM M -axes). She now set less unrealistically high personal standards and she was now able to find meaning in belonging and contributing to a wider community (e.g., organization, church, neighborhood, etc.). Table 6 shows Matilde’s qualitative picture at baseline and at follow up.

TABLE 6. Qualitative Matilde’s picture of features at baseline and at the end of psychotherapy.

This clinical case study highlighted the importance of assessing patient’s idiographic and intra-subjective features ( Hilliard, 1993 ). The nature of the clinical case perspective requires a rich diagnostic process that includes both a nosographic approach (such as DSM-IV) and a more multifaceted point of view to assess the specific patient’s psychological functioning ( Barron, 1998 ; Shedler and Westen, 2007 ). There have been few studies investigating the psychotherapy process in supportive therapies ( Orlinsky et al., 2004 ), and very few studies were devoted to inserting also the contribution of validated measures of attachment. Slade (2008) endorsed that, although attachment theory terms have been incorporated in the present psychoanalytic theory, only few therapists have really integrated core elements of the attachment perspective in their clinical thought. Above all, few of them inserted measures of attachment and their strategies to understand the therapy unfolding ( Rockland, 1989 ; Porcerelli et al., 2011 ). Assessing attachment means more than just determining a patient’s attachment classification status. The benefit from the inclusion of attachment assessment to a multi-method approach is the chance of using results to elucidate the patient’s representational and defensive patterns related to attachment activation ( Bowlby, 1980 ).

This paper tried to illustrate a clinical case where results from attachment tools together with PDM assessment could help to give a more integrate picture and to form and inform the unfolding of the therapy. The incremented validity about symptoms and attachment internal working models evaluation added a specific qualitative contribution to each tool (e.g., SCL-90-R gave the self perception of symptomatology and SWAP–200 the clinical perception of it; AAI and AAP increased biographical information and defense mechanism, respectively). The paper presented a case formulation in which a psychodynamic approach was integrated with an attachment theory framework both in the assessment and post-assessment phases and with a “ supportive psychotherapy approach. ” The secure attachment status, as derived from the AAI and the AAP, helped to structure Matilde’s therapy, adding information to the therapeutic intervention: Matilde’s secure attachment resulted helpful to establish a therapeutic plan, to facilitate the therapeutic alliance and the answer to the therapy, and to help her to face her symptoms and internal difficulties ( Douglas, 2008 ; Steele and Steele, 2008 ). The AAP and AAI were taken into account, making the therapist sensible to the specific topics concerning separation and loss, which were reactivated throughout treatment. Matilde needed to explore them in the context of a “ safe haven, ” the same context she had previously experienced in her life with her mother’s supporting stance. On her side, the therapist recreated and maintained a well knownholding environment, affective mirroring and personal warmth ( Markowitz, 2008 ) and an atmosphere based on emotional safety ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). She provided Matilde with the secure base she temporary lost, a starting point from where the exploration of painful experiences in her present life could finally begin. This gave her the possibility to recall some hidden memories, leading to self-exploration ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Holmes, 2010 ). The “supportive approach” and the role of attachment framework turned out to be a key factor in the assessment and in the development of an effective therapeutic relationship with Matilde. Within a psychoanalytic framework, through the unfolding relationship with the therapist, Matilde brought her interpersonal world into the treatment room and allowed the therapist to experience aspects of her structuring of reality ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). The conclusion of the therapy showed a more integrated picture, where symptoms were no more outstanding and Matilde seemed to be out of her big “nightmare” and ready to face her life tasks in a more integrated and young-adult way. The post-treatment AAP confirmed that Matilde was able to integrate these issues of separation and loss. She was a very defensive neurotic patient blocked at latency, and showed some shortcomings related to the separation-individuation process ( Mahler et al., 1975 ) both from a psychoanalytic and from an attachment point of view.

The treatment helped Matilde to make a developmental step toward maturity: “from childish features to adolescent ones, reaching the capacity of (emotionally) exploring the possibility of living independently from parents (…) because they know that they can turn to parents in case of real need” ( Allen and Land, 1999 , p. 322). The therapist was both an “attachment figure” that helped Matilde to face new experiences, as well as a transference object ( Dozier et al., 1994 ). Matilde’s development resulted in increased abilities in managing the goal-corrected partnership with each parent, in which behavior is not determined only by adolescent’s current needs and wishes, but also by recognition of the need to manage certain set goals for the partnership ( Bowlby, 1973 ).

As all clinical case studies, this study suffered from some limitations ( Hodkinson and Hodkinson, 2001 ): results are not generalizable in the conventional sense; it looks expensive, if attempted on a large scale and the complexity examined is difficult to represent simply and briefly. Furthermore, clinical case studies results stronger when researchers’ expertise and intuition are maximized, but this raises doubts about their “objectivity”: this type of research is easily subjected to criticisms by those who do not like the messages that they contain; and finally it cannot answer a large number of relevant and appropriate research questions that future studies could address (e.g., in this sense, it could be highly valuable for future research to compare PAD patients with different attachment styles). However, this particular case study could be considered an original and extremely valuable one, because it is grounded in “lived reality.” This helps us to understand complex inter-relationships between diagnosis, measures and their clinical application, facilitating the development of conceptual/theoretical issues and the exploration of unexpected and unusual situations, such as PAD in a secure attached patient. As regards the choice of this patient, the present paper can provide “provisional truths, in a Popperian sense” ( Hodkinson and Hodkinson, 2001 ): it represents the best account of such assessment and treatment in the current literature, and it should stand, until contradictory findings or better theories are developed.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

• ^ The PDM was developed to describe “the depth as well as the surface of emotional, cognitive, and social patterns” (p. 1) of an individual’s functioning, as to improve the diagnosis and treatment of psychological disorders. PDM comprises three areas: personality patterns (Axis P ), mental functioning ( M -axis), and symptoms ( S -axis). Our attention focused mainly on mental functioning or M -axis, “a microscopic look at mental life” (p. 8), although some attention was paid to symptoms and concerns or S -axis.
• ^ The patient self-referred to a psychodynamic service, where therapists are trained to use an Operationalized Psychodynamic Diagnosis approach during consultation sessions, preferring free or “per area” clinical sessions to interviews (e.g., SCID).
• ^ The self report SCL-90-R was digitally computed. Inter-reliability reached Cohen’s k = 1 for AAI and AAPs final classifications; 0.93 for AAI subscales; 0.85 for AAP codings; 0.72 for SWAP–200 final scales.
• ^ (1) Neutral (children playing ball); (2) child at window (alone); (3) departure (dyad); (4) bench (alone); (5) bed (dyad); (6) ambulance (dyad); (7) cemetery (alone); (8) child in corner (alone).

Ainsworth, M. D. (1963). “The development of infant-mother interaction among the Ganda,” in Determinants of Infant Behavioral , ed. B. M. Foss (New York: Wiley), 67–104.

Ainsworth, M. D. (1967). Infancy in Uganda: Infant Care and the Growth of Love . Baltimore, MD: Johns Hopkins University Press.

Allen, J. P. (2008). “The attachment system in adolescence,” in Handbook of Attachment: Theory, Research and Clinical Applications, 2nd Edn, eds J. Cassidy and P. R. Shaver (New York: Guilford Press), 419–435.

Allen, J. P., and Land, D. (1999). “Attachment in adolescence,” in Handbook of Attachment Theory Research and Clinical Application , eds J. Cassidy and P. R. Shaver (New York: Guilford), 319–335.

American Psychiatric Association [APA] (1994). Diagnostic and Statistical Manual of Mental Disorders , 4th Edn, Washington, DC: American Psychiatric Association.

Appelbaum, A. H. (2005). Supportive Psychotherapy. Arlington, VA: American Psychiatric Publishing, Inc.

Bakermans-Kranenburg, M. J., and van Ijzendoorn, M. H. (1993). A psychometric study of the adult attachment interview: reliability and discriminant validity. Dev. Psychol. 29, 870–879. doi: 10.1037/0012-1649.29.5.870

CrossRef Full Text

Bakermans-Kranenburg, M. J., Van Ijzendoorn, M. H., and Juffer, F. (2005). Disorganized infant attachment and preventive interventions: a review and meta-analysis. Infant Ment. Health J. 23, 191–216. doi: 10.1002/imhj.20046

Barron, W. J. (1998). Marking Diagnosis Meaningful. Enhancing Evaluation and Treatment of Psychological Disorders. Washington, DC: American Psychological Association. doi: 10.1037/10307-000

Bartholomew, K., and Horowitz, L. M. (1991). Attachment styles among young adults: a test of a four-category model. J. Pers. Soc. Psychol. 61, 226–244. doi: 10.1037/0022-3514.61.2.226

Binder, J. L., Henry, W. P., and Strupp, H. H. (1987). An appraisal of selection criteria for dynamic psychotherapies and implications for setting time limits. Psychiatry 50, 154–166.

Pubmed Abstract | Pubmed Full Text

Blatt, S. J., and Levy, K. N. (2003). Attachment theory, psychoanalysis, personality development, and psychopathology. Psychanal. Inq. 23, 102–150. doi: 10.1080/07351692309349028

Block, J. (1978). The Q-Sort Method in Personality Assessment and Psychiatric Research. Palo Alto, CA: Consulting Psychologist Press.

Bowlby, J. (1969/1982). Attachment and Loss, Vol. 1, Attachment . New York: Basic Books.

Bowlby, J. (1973). Attachment and Loss , Vol. 2, Separation: Anxiety and Anger . New York: Basic Books.

Bowlby, J. (1980). Attachment and Loss , Vol. 3, Loss: Sadness and Depression . New York: Basic Books.

Bowlby, J. (1988). A Secure Base. New York: Basic Books.

Bram, A. D. (2010). The relevance of the rorschach and patient-examiner relationship in treatment planning and outcome assessment. J. Pers. Assess. 92, 91–115. doi: 10.1080/00223890903508112

Pubmed Abstract | Pubmed Full Text | CrossRef Full Text

Buchheim, A. (2005). Inaccessible attachment: a paradox? Personlinch. Theor. Therap. 9, 155–164.

Buchheim, A., and Benecke, C. (2007). Mimisch-affektives verrhalten bei patientinnen mit angststörungen während des adult attachment interviews: Eine pilotstudie. Psychother. Psychol. Med. 57, 343–347. doi: 10.1055/s-2006-952030

Buchheim, A., Erk, S., George, C., Kächele, H., Kircher, T., Martius, P.,et al. (2008). Neural correlates of attachment trauma in borderline personality disorders: a functional magnetic resonance image study. Psychiatry Res. 30, 223–235. doi: 10.1016/j.pscychresns.2007.07.001

Buchheim, A., and George, C. (2011). “Attachment disorganization in borderline personality disorder and anxiety disorder,” in Disorganization of Attachment and Caregiving , eds J. Solomon and V. George (New York: Guilford Press), 343–383.

Buchheim, A., George, C., and Kächele, H. (2007). “My dog is dying today: attachment narratives and psychoanalytic interpretation of an initial interview,” in Attachment and Sexuality, eds D. Diamond, S. J. Blatt, and J. D. Lichtenberg (Hillsdale, NJ: The Analytic Press), 161–178.

Buchheim, A., Heinrichs, M., George, C., Pokorny, D., Koops, E., Henningsen, P.,et al. (2009). Oxytocin enhances the experience of attachment security. Psychoneuroendocrinology 34, 1417–1422. doi: 10.1016/j.psyneuen.2009.04.002

Buchheim, A., and Kachele, H. (2001). Adult attachment interview of a patient with a borderline personality organization: a single case study integrating attachment and psychoanalytic perspective. Personlich. Theor. Therap. 5, 113–130.

Cassidy, J., and Shaver, P. R. (Eds.). (2008). Handbook of Attachment: Theory, Research, and Clinical Applications , 2nd Edn, New York: Guilford Press, 3–27.

Colli, A., and Lingiardi, V. (2009). The collaborative interactions scale: a new transcript-based method for the assessment of therapeutic alliance ruptures and resolutions in psychotherapy. Psychother. Res. 19, 718–734. doi: 10.1080/10503300903121098

Cozzolino, L. (2002). The Neuroscience of Psychotherapy: Building and Rebuilding the Human Brain . New York: Norton & Company.

Crits-Christoph, P., and Connolly, M. B. (1999). Alliance and technique in short-term dynamic therapy. Clin. Psychol. Rev. 19, 687–704. doi: 10.1016/S0272-7358(98)00079-8

Dahlbender, R. W., Buchheim, A., and Doering, S. (2004). OPD and AAI: integrative diagnostics of structure, conflict and attachment representation. Personlinch. Theor. Therap. 8, 251–261.

Davila, J., and Levy, K. N. (2006). Introduction to the special section on attachment theory and psychotherapy. J. Consult. Clin. Psychol. 74, 989–993. doi: 10.1037/0022-006x.74.6.989

Derogatis, L. R. (1983). SCL-90-R Administration, Scoring Procedures Manual-I . Towson, MD: Clinical Psychometric Research, 14–15.

Derogatis, L. R., Lipman, R. S., and Covi, L. (1973). The SCL-90: an outpatient psychiatric rating scale-preliminary report. Psychopharmacol. Bull. 9, 13–28.

Dewald, P. A. (1971). Psychotherapy: A Dynamic Approach . New York: Basic Books, Inc.

Diamond, D. (2004). Attachment disorganization: the reunion of attachment theory and psychoanalysis. Psychoanal. Psychol. 21, 276–299. doi: 10.1037/0736-9735.21.2.276

Douglas, C. J. (2008). Teaching supportive psychotherapy to psychiatric resident. Am. J. Psychiatry 165, 445–452. doi: 10.1176/appi.ajp.2007.07121907

Dozier, M., Cue, K. L., and Barnett, L. (1994). Clinicians as caregivers: the role of attachment organization in treatment. J. Consult. Clin. Psychol. 62, 93–800. doi: 10.1037/0022-006x.62.4.793

Eng, W., Heimberg, R. G., Hart, T. A., Schneier, F. R., and Liebowitz, M. R. (2001). Attachment in individuals with social anxiety disorder: the relationship among adult attachment styles, social anxiety, and depression. Emotion 1, 365–380. doi: 10.1037/1528-3542.1.4.365

Fonagy, P. (1999). Pathological attachments and therapeutic action. Paper to the Developmental and Psychoanalytic Discussion Group, American Psychoanalytic Association Meeting , Washington, DC.

Fonagy, P. (2001). Attachment Theory and Psychoanalysis. New York: Other Press.

Fosha, D. (2009). “Healing attachment trauma with attachment (... and then some!),” in Clinical Pearls of Wisdom: 21 Leading Therapists Offer their Keyinsights , ed. M. Kerman (New York: Norton), 43–56.

Fraedrich, E., Lakatos, K., and Spangler, G. (2010). Brain activity during emotion perception: the role of attachment representation. Attach. Hum. Dev. 12, 231–248. doi: 10.1080/14616731003759724

Fraley, R. C., and Davis, K. E. (1997). Attachment formation and transfer in young adults’ close friendships and romantic relationships. Pers. Relat. 4, 131–144. doi: 10.1111/j.1475-6811.1997.tb00135.x

Freud, A. (1966). Normality and Pathology in Childhood. London: Hogart Press.

Funder, D. C. (1997). The Personality Puzzle. New York: W. Norton.

Gabbard, G. O. (2009). Textbook of Psychotherapeutic Treatments. Arlington, VA: American Psychiatric Publishing, Inc. doi: 10.1176/appi.books.9781585623648

George, C., Kaplan, N., and Main, M. (1984). Adult Attachment Interview (Unpublished manuscript). Berkeley: University of California.

George, C., Kaplan, N., and Main, M. (1985). Adult Attachment Interview , 2nd Edn (Unpublished manuscript). Berkeley: University of California.

George, C., Kaplan, N., and Main, M. (1996). Adult Attachment Interview, 3nd Edn (Unpublished manuscript). Berkeley: University of California

George, C., and Solomon, J. (1996). Representational models of relationships: links between caregiving and attachment. Infant Ment. Health J. 17, 198–216. doi: 10.1002/(SICI)1097-0355(199623)17:3<198::AID-IMHJ2>3.0.CO;2-L

3.0.CO;2-L" target="_blank">CrossRef Full Text

George, C., and Solomon, J. (1999). Attachment Disorganization. New York: Guilford Publications.

George, C., and Solomon, J. (2008). “The caregiving system: a behavioral systems approach to parenting,” in Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd Edn, eds J. Cassidy and P. R. Shaver (New York: Guilford Press), 833–856.

George, C., and West, M. (2001). The development and preliminary validation of a new measure of adult attachment: the adult attachment projective. Attach. Hum. Dev. 3, 30–61. doi: 10.1080/14616730010024771

George, C., and West, M. (2012). The Adult Attachment Projective Picture System. New York: Guilford Press.

Hazan, C., and Shaver, P. (1987). Romantic love conceptualized as an attachment process. J. Pers. Soc. Psychol. 52, 511–524. doi: 10.1037/0022-3514.52.3.511

Hesse, E. (2008). “The adult attachment interview: protocol, methods of analysis, and empirical studies,” in Handbook of Attachment: Theory, Research, and Clinical Applications, 2nd Edn, eds J. Cassidy and P. R. Shaver (New York: Guilford Press), 552–598.

Hilliard, R. B. (1993). Single-case methodology in psychotherapy process and outcome research. J. Consult. Clin. Psychol. 61, 373–380. doi: 10.1037/0022-006x.61.3.373

Hodkinson, P., and Hodkinson, H. (2001). The Strengths and Limitations of Case Study Research. Paper Presented to the Learning and Skills Development Agency Conference. Making an Impact on Policy and Practice , Cambridge.

Holmes, J. (2010). Exploring in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy . New York: Routledge.

Huntsinger, E. T., and Luecken, L. J. (2004). Attachment relationships and health behavior: the mediational role of self-esteem. Psychol. Health 19, 515–526. doi: 10.1080/0887044042000196728

Isaacs, M. B., George, C., and Marvin, R. S. (2009). Utilizing attachment measures in child custody evaluations: incremental validity. J. Child Cusotdy 6, 139–162. doi: 10.1080/15379410902894882

Kamkar, K., Doyle, A., and Markiewicz, D. (2012). Insecure attachment to parents and depressive symptoms in early adolescence: mediating roles of attributions and self-esteem. Int. J. Psychol. Stud. 4, 3–18. doi: 10.5539/ijps.v4n2p3

Lingiardi, V., Shedler, J., and Gazzillo, F. (2006). Assessing personality change in psychotherapy with the SWAP–200: a case study. J. Pers. Assess. 86, 23–32. doi: 10.1207/s15327752jpa8601-04

Lis, A., Mazzeschi, C., Di Riso, D., and Salcuni, S. (2011). Attachment, assessment and psychological intervention: a case study of anorexia. J. Pers. Assess. 93, 434–444. doi: 10.1080/00223891.2011.594125

Lis, A., Mazzeschi, C., Salcuni, S., and Di Riso, D. (2008). Attachment and Personality in Clinical Settings: Assessment and Treatment Issues . Madrid: EditorialPsimàtic.

Mahler, M. S., Pine, F., and Bergman, A. (1975). The Psychological Birth of the Human Infant: Symbiosis and Individuation . New York: Basic Books.

Main, M., Kaplan, N., and Cassidy, J. (1985). Security in infancy, childhood, and adulthood: a move to the level of representation. Monogr. Soc. Res. Child Dev. 50, 66–104. doi: 10.2307/3333827

Mallinckrodt, B., Porter, M. J., and Kivlighan, D. M. Jr. (2005). Client attachment to therapist, depth of in-session exploration, and object relations in brief psychotherapy. Psychother. Theory Res. Pract. Train. 42, 85–100. doi: 10.1037/0033-3204.42.1.85

Manicavasagar, V., Silove, D., Marnane, C., and Wagner, R. (2009). Adult attachment styles in panic disorder with and without comorbid adult separation anxiety disorder. Aust. N. Z. J. Psychiatry 43, 167–172. doi: 10.1080/00048670802607139

Manicavasagar, V., Silove, D., Wagner, R., and Hadzi-Pavlovic, D. (1999). Parental representations associated with adult separation anxiety and panic disorder-agoraphobia. Aust. N. Z. J. Psychiatry 33, 422–428. doi: 10.1046/j.1440-1614.1999.00566.x

Markowitz, J. C. (2008). How “supportive” is internet-based supportive psychotherapy? Am. J. Psychiatry 165, 534. doi: 10.1176/appi.ajp.2007.07121853

McWilliams, N. (1999). Psychoanalytic Case Formulation. New York: Guilford Pubblications, Inc.

Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Kubiszyn, T. W., Moreland, K. L.,et al. (1999). Benefits and Cost of Psychological Assessment in Healthcare Delivery: Report of the Board of Professional Affairs Psychological Assessment Work Group, Part I . Washington, DC: American Psychological Association.

Misch, D. A. (2000). Basic strategies of dynamic supportive therapy. J. Psychother. Pract. Res. 9, 173–189.

Oppenheim, D., and Goldsmith, D. F. (2007). Attachment Theory in Clinical Work with Children. New York: Guilford Press.

Orlinsky, D. E., Ronnestad, M. H., and Willutzki, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and Change, in Bergin and Garfield’s handbook of psychotherapy and behavior change , 5th Edn, ed. M. Laambert (New York: John Wiley and Sons).

Ozer, D. J. (1999). “Four principles for personality assessment,” in Handbook of Personality: Theory and Research, 2nd Edn, eds O. P. John and L. A. Pervin (New York: Guilford Press), 671–686.

Pacchierotti, C., Bossini, L., Castrogiovanni, A., Pieraccini, F., Soreca, I., and Castrogiovanni, P. (2002). Attachment and panic disorder. Psychopathology 35, 347–335. doi: 10.1159/000068597

Parish, M., and Eagle, M. N. (2003). Attachment to the therapist. Psychoanal. Psychol. 20, 271–286. doi: 10.1037/0736-9735.20.2.271

PDM Task Force. (2006). Psychodynamic Diagnostic Manual (PDM) . Silver Spring, MD: Alliance of Psychoanalytic Organizations.

Peebles-Kleiger, M. J. (2002). Beginnings: The Art and Science of Planning Psychotherapy . Hillsdale, NJ: The Analytic Press.

Porcerelli, J. H., Cogan, R., and Bambery, M. J. (2011). The mental functioning axis of the Psychodynamic diagnostic manual: an adolescent case study. J. Pers. Assess. 93, 177–184. doi: 10.1080/00223891.2011.542724

Rockland, L. H. (1989). Psychoanalytically oriented supportive therapy. J. Am. Acad. Psychoanal. 17, 451–462.

Routh, D. K., and Bernholtz, J. E. (1991). “Attachment, separation and phobias,” in Intersections with Attachment , eds J. L . Gewirtz, W. M. Kurtines, and J. L. Lamb (Hove: Psychology Press), 295–310.

Safran, J. D., and Muran, J. C. (2000). Negotiating the Therapeutic Alliance: A Relational Treatment Guide . New York: Guilford Press.

Shear, M. K. (1991). The concept of uncontrollability. Psychol. Inq. 2, 88–93. doi: 10.1207/s15327965pli0201-23

Shectman, F., and Harty, M. K. (1986). “Treatment implications of object relationships as they unfold during the diagnostic interaction,” in Assessing Object Relations Phenomena, ed. M. Kissen (Madison, CT: International Universities Press), 279–303.

Shedler, J., and Westen, D. (1998). Refining the measurement of Axis II: a Q-sort procedure for assessing personality pathology. Assessment 5, 333–353. doi: 10.1177/107319119800500403

Shedler, J., and Westen, D. (2007). The Shedler–Westen assessment procedures (SWAP): making personality diagnosis clinically meaningful. J. Pers. Assess. 89, 41–55. doi: 10.1080/00223890701357092

Siegel, D. J. (2010). The Mindful Therapist: A Clinician’s Guide to Mind Sight and Neural Integration . New York: W. W. Norton & Company.

Skean, K. R. (2005). The case of “CG”: balancing supportive and insight-oriented, psychodynamic therapy with a client undergoing intense life stresses. Prag. Case Stud. Psychother. 1, 1–18. doi: 10.14713/pcsp.v1i3.860

Slade, A. (2008). The Implications of Attachment Theory and Research for Adult Psychotherapy: Research and Clinical Perspectives . New York: Guilford Press.

Spence, D. P. (1982). Narrative Truth and Historical Truth. New York: Norton.

Steele, H., and Steele, M. (2008). Clinical Applications of the Adult Attachment Interview. New York: Guilford Press, 69–96.

Steele, H., Steele, M., and Murphy, A. (2009). The adult attachment interview: a clinical tool for facilitating and measuring process and change in psychotherapy. Psychother. Res. 19, 633–643. doi: 10.1080/10503300802609698

Ursano, R. J., and Silberman, E. K. (1996). “Psychoanalysis, psychoanalytic psychotherapy, and supportive psychotherapy,” in The American Psychiatric Press Synopsis of Psychiatry, eds R. E. Hales and S. C. Yudofsky (Washington, DC: American Psychiatric Association), 969–989.

van IJzendoorn, M. H., and Bakermans-Kranenburg, M. J. (2008). “The distribution of adult attachment representations in clinical groups: a meta-analytic search for patterns of attachment in 105 AAI studies,” in Clinical Applications of the Adult Attachment Interview, eds H. Steele and M. Steele (New York: Guilford Press), 69–96.

Wallin, D. J. (2007). Attachment in Psychotherapy. New York: Guilford Press.

Wallis, P., and Steele, H. (2001). Attachment representations in adolescence: further evidence from psychiatric residential settings. Attach. Hum. Dev. 3, 259–269. doi: 10.1080/14616730110096870

West, M., and George, C. (1999). Abuse and violence in intimate adult relationship: new perspectives from attachment theory. Attach. Hum. Dev. 1, 137–156. doi: 10.1080/14616739900134201

West, M., and George, C. (2002). Attachment and dysthymia: the contributions of preoccupied attachment and agency of self to depression in women. Attach. Hum. Dev. 4, 278–293. doi: 10.1080/14616730210167258

West, M., Rose, S. M., and Sheldon-Keller, A. (1995). Interpersonal disorders in schizoid and avoidant personality disorders: an attachment perspective. Can. J. Psychiatry 40, 411–414.

Westen, D., and Muderrisoglu, S. (2003a). Assessing personality disorders using a systematic clinical interview: evaluation of an alternative to structured interviews. J. Pers. Disord. 17, 351–369. doi: 10.1521/pedi.17.4.351.23967

Westen, D., and Muderrisoglu, S. (2003b). Reliability and validity of personality disorders assessment using a systematic clinical interview: evaluation of an alternative to structured interviews. J. Pers. Disord. 17, 350–368.

Westen, D., and Shedler, J. (1999a). Revising and assessing Axis II: I. Developing a clinically and empirical valid assessment method. Am. J. Psychiatry 156, 258–272.

Westen, D., and Shedler, J. (1999b). Revising and assessing Axis II: II. Toward an empirically based and clinically useful classification of personality disorderds. Am. J. Psychiatry 156, 273–285.

Winston, M. D., Rosenthal, R. N., and Pinsker, H. (2004). Introduction to Supportive Psychotherapy. Arlington, VA: American Psychiatric Publishing, Inc.

Zaccagnini, C., and Zavattini, G. C. (2009). Introduzione a D. J. Wallin, Psicoterapia e Teoria dell’Attaccamento. Bologna, Il Mulino, 7–21.

Zegers, M. A., Schuengel, C., Van, I. M. H., and Janssens, J. M. (2008). Attachment and problem behavior of adolescents during residential treatment. Attach. Hum. Dev. 10, 91–103. doi: 10.1080/14616730701868621

Keywords : assessment, attachment, psychodynamic supportive therapy, outcome research, clinical case study

Citation: Salcuni S, Di Riso D and Lis A (2014) “A child’s nightmare. Mum comes and comforts her child.” Attachment evaluation as a guide in the assessment and treatment in a clinical case study. Front. Psychol. 5 :912. doi: 10.3389/fpsyg.2014.00912

Received: 21 May 2014; Accepted: 30 July 2014; Published online: 20 August 2014.

Reviewed by:

Copyright © 2014 Salcuni, Di Riso and Lis. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Silvia Salcuni, Department of Developmental and Socialization Psychology, University of Padua, via Venezia 12, 35100 Padova, Italy e-mail: [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Newsletter Sign Up
• Write For Us
• Advanced Search

Psychotherapy Articles

The Implications of Attachment Theory in Counseling and Psychotherapy

Over the past decade, researchers have found that Bowlby ’s attachment theory (1973, 1988) has important implications for counseling and psychotherapy (Cassidy & Shaver, 1999, Lopez, 1995; Lopez & Brennan, 2000; Mallinckrodt, 2000). Attachment theory is a theory of affect regulation and interpersonal relationships. When individuals have caregivers who are emotionally responsive, they are likely to develop a secure attachment and a positive internal working model of self and others.

Currently, adult attachment could be described in terms of two dimensions, adult attachment anxiety and adult attachment avoidance. Adult attachment anxiety is conceptualized as the fear of interpersonal rejection and abandonment , excessive needs for approval from others, negative view of self, and hyper-activation of affect regulation strategies in which the person over-reacts to negative feelings as a mean to gain others’ comfort and support (Mikulincer, Shaver, & Pereg, 2003). Conversely, adult attachment avoidance is characterized by fear of intimacy, excessive need for self-reliance, reluctance for self-disclosure, negative view of others, and deactivation of affect regulation strategy in which the person tries to avoid negative feelings or withdraw from intimate relationships (Mikulincer et al., 2003).

Bowlby (1988) acknowledged that attachment patterns are difficult to change in adulthood even though it is not impossible. Studies related to examining mediators of the relation between attachment and mental health outcomes are particularly important for counseling and psychotherapy because mediators can be potential interventions to help individuals relieve their distress. In addition, identifying the mediators can help individuals reduce the impact of attachment patterns without having to change the patterns, which is a more difficult task (e.g., Bowlby, 1988). Below are some suggestions from empirical studies in this area.

First, attachment theory serves as a solid foundation for understanding the development of ineffective coping strategies and the underlying dynamics of a person’s emotional difficulties. Clinicians can help those with attachment anxiety and avoidance understand how past experiences with caregivers or significant others have shaped their coping patterns and how these patterns work to protect them initially but later contribute to their experiences of distress (Lopez, Mauricio, Gormley, Simko, & Berger, 2001; Wei, Heppner, & Mallinckrodt, 2003).

For example, those with attachment anxiety may learn that if they are “perfect,” they will be more likely to gain others’ love and acceptance (Wei, Heppner, Russell, & Young, 2006; Wei, Mallinckrodt, Russell, & Abraham, 2004). Conversely, those with attachment avoidance may drive themselves to be perfect in order to cover up their hidden sense of imperfections. They may think, “If I am perfect, no one will hurt me” (Flett, Hewitt, Oliver, & Macdonald, 2002). Unfortunately, perfectionism is associated with greater depressive symptoms (e.g., Chang, 2002, Hewitt & Flett, 1991). Therefore, potential clinical interventions can focus on modifying these individuals’ perfectionistic tendencies.

Second, clinicians can help those with attachment anxiety and avoidance find alternative ways to meet their unmet needs. Most people who seek help want to learn how to cope with dysfunction in their daily life and modify their dysfunctional or ineffective coping strategies. However, merely focusing on modifying the dysfunctional coping strategies does not guarantee that people will eventually cope well.

In particular, people have acquired and continued to use dysfunctional strategies because these have served an adaptive function by helping individuals meet their basic psychological needs such as connection, competence , and autonomy in the past. For example, people’s motivation to be perfect may stem from their attachment figures’ failure to meet basic psychological needs. In other words, some individuals may wish to be perfect because during their development, they have learned that others will like them (i.e., fulfilling a need for connections), view them as capable (i.e., fulfilling a need for competence), and respect them (i.e., fulfilling a need for autonomy) if they are perfect. Unless these individuals’ unmet basic needs are satisfied by other means and learn other strategies, altering these individuals’ maladaptive strategies may be limited in terms of effectiveness.

Also, if individuals believe their maladaptive strategies are the only ways to meet their psychological or emotional needs, then they may still choose not to give up these strategies, despite the negative mental health outcomes associated with these strategies. Therefore, helping people find alternative ways to meet their unmet needs is critical to solving their problems thoroughly. Wei, Shaffer, Young, and Zakalik (2005) provided empirical evidence that those with attachment anxiety and avoidance can decrease their shame, depression, and loneliness through meeting their basic psychological needs for connection, competence, and autonomy.

Therefore, clinicians not only need to focus on changing maladaptive coping strategies, but also need to understand the underlying unmet needs that are satisfied by the use of these strategies as well as help individuals learn alternative ways to satisfy their psychological or emotional needs.

Third, clinicians need to know that people with different insecure attachment patterns (i.e., anxiety and avoidance patterns) may use different coping strategies to manage their life difficulties, which are associated with increased distress. For example, consistent with the prediction of attachment theory, those with attachment anxiety tend to use emotional reactivity (i.e., a hyper-activation strategy in which the person over-reacts to negative feelings) as a coping strategy, which is associated with distress. Conversely, those with attachment avoidance are inclined to use emotional cutoff (i.e., a deactivation strategy in which the person tries to avoid negative feelings) strategy, which is related to increased distress (Wei, Vogel, Ku, & Zakalik, 2005).

Fourth, Mallinckrodt (2000) suggested providing counter-complimentary interventions when working with individuals with high attachment anxiety and avoidance. That is, counseling intervention can focus on breaking clients’ old patterns. For example, Wei, Ku, and Liao (2007) discovered that those with attachment anxiety, because of their negative view of self, can increase their well-being through enhancing their self-compassion.

Gilbert and Irons (2005) suggested that writing a compassionate letter to the self or making an audiotape filled with compassionate thoughts or self-soothing statements can increase self-compassion. Also, those with high attachment anxiety can imagine how they felt when they were being taken care of by therapists or supportive others who represent alternative attachment figures. Eventually, those with high attachment anxiety can learn to be their own attachment figures (i.e., be their own parent) to provide self-compassion or self-care .

Conversely, because of their negative view of others and the deactivated attachment system (e.g., actively keeping distance from others or suppressing emotions), those with high attachment avoidance may gradually become less able to understand others and lose touch with others’ feelings or thoughts (Wei et al., 2007). The counter-complimentary strategy is thus to help them learn new ways to react empathically to others’ emotional experiences. Pistole (1989, 1999) proposed the concept of care-giving from attachment theory as a metaphor for the counseling relationship and process.

In other words, therapists can be empathetic to individuals with high attachment avoidance in order to re-parent them. The therapists thus serve as role models for them so that these individuals can eventually learn to be empathetic to others, which may improve their subjective well-being.

Another study found that due to their negative view of self, assisting those with high attachment anxiety to increase their level of social self-efficacy (i.e., a strategy to increase their positive view of self) is an important strategy to decrease their loneliness and future depression. Conversely, those with high attachment avoidance tended to be reluctant for self-disclosure and hold a negative view of others. For these individuals, the study confirmed that counter-complimentary interventions which enhances their comfort level of self-disclosing to others (i.e., a strategy to decrease their reluctance in self-disclosure and increase their closeness with others) is an important strategy to decrease their loneliness and future depression (Wei, Russell, & Zakalik, 2005).

In summary, attachment theory can be used to understand the development of coping patterns or relationship patterns and the underlying dynamics of a person’s emotional difficulties. Clinicians not only can help those with high attachment anxiety and avoidance to modify their ineffective coping strategy, but also can help them understand the underlying unmet needs that are satisfied by their ineffective coping strategy and learn alternative ways to satisfy their psychological or emotional needs (e.g., a need to connection, competence, and autonomy). Moreover, clinicians need to know that people with different insecure attachment patterns (i.e., anxiety and avoidance patterns) may use different coping strategies to manage their life difficulties. It is recommended that clinicians provide counter-complimentary intervention to help break clients’ old patterns.

Meifen Wei, Ph.D.

Cite This Article

Wei, M. (2008, October). The implications of attachment theory in counseling and psychotherapy. [Web article]. Retrieved from https://societyforpsychotherapy.org/the-implications-of-attachment-theory-in-counseling-and-psychotherapy

Bowlby, J. (1973). Attachment and loss . Vol. 2: Separation. New York: Basic Books.

Bowlby, J. (1988). A secure base: Parent–child attachment and healthy human development .  New York: Basic Books.

Cassidy, J., & Shaver, P. R. (1999). Handbook of attachment: Theory, research, and clinical applications . New York: Guilford Press.

Flett, G. L., Hewitt, P. L., Oliver, J. M., & Macdonald, S. (2002). Perfectionism in children and their parents: A developmental analysis. In G. L. Flett & P. L. Hewitt (Eds.),  Perfectionism: Theory, research, and treatment (pp. 89–132). Washington, DC: American Psychological Association.

Gilbert, P., & Irons, C. (2005). Focused therapies and compassionate mind training for shame and self-attacking. In P. Gilbert (Ed.), Compassion: Conceptualizations, research and use in psychotherapy (pp. 263-325). New York, NY: Routledge.

Hewitt, P. L., & Flett, G. L. (1991). Dimensions of perfectionism in unipolar depression. Journal of Abnormal Psychology, 100 , 98–101.

Lopez, F. G. (1995). Contemporary attachment theory: An introduction with implications for counseling psychology. The Counseling Psychologist, 23 , 395–415.

Lopez, F. G., & Brennan, K. A. (2000). Dynamic processes underlying adult attachment organization: Toward an attachment theoretical perspective on the healthy and effective self. Journal of Counseling Psychology, 47 , 283–301.

Lopez, F. G., Mauricio, A. M., Gormley, B., Simko, T., & Berger, E. (2001). Adult attachment orientations and college student distress: The mediating role of problem coping styles.  Journal of Counseling & Development, 79 , 459–464.

Mallinckrodt, B. (2000). Attachment, social competencies, social support, and interpersonal process in psychotherapy. Psychotherapy Research, 10 , 239-266.

Mikulincer, M., Shaver, P. R., & Pereg, D. (2003). Attachment theory and affect regulation: The dynamic development, and cognitive consequences of attachment-related strategies.  Motivation and Emotion, 27 , 77-102.

Pistole, M. C. (1989). Attachment: Implications for counselors. Journal of Counseling & Development, 68 , 190-193.

Pistole, M. C. (1999). Caregiving in attachment relationships: A perspective for counselors.   Journal of Counseling & Development, 77 , 437-446.

Wei, M., Heppner, P. P., & Mallinckrodt, B. (2003). Perceived coping as a mediator between attachment and psychological distress: A structural equation modeling approach. Journal of Counseling Psychology, 50 , 438-447.

Wei, M., Heppner, P. P., Russell, D. W., & Young, S. K. (2006). Maladaptive perfectionism and ineffective coping as mediators between attachment and subsequent depression: A prospective analysis. Journal of Counseling Psychology, 53 , 67-79.

Wei, M., Ku, T.-Y., & Liao, K. Y.-H. (2007, August). Attachment, empathy to self and others, and subjective well-being . Poster presented at the 115th annual convention of the American Psychological Association, San Francisco, CA.

Wei, M., Mallinckrodt, B., Larson, L. A., & Zakalik, R. A. (2005). Attachment, depressive symptoms, and validation from self versus others. Journal of Counseling Psychology, 52 , 368-377.

Wei, M., Mallinckrodt, B., Russell, D. & Abraham, T. (2004). Maladaptive perfectionism as a mediator and moderator between attachment and depressive mood. Journal of Counseling Psychology, 51 , 201-212.

Wei, M., Russell, D. W., & Zakalik, R. A. (2005). Adult attachment, social self-efficacy, comfort with self-disclosure, loneliness, and subsequent depression for freshmen college students:  A longitudinal design. Journal of Counseling Psychology, 52 , 602-614.

Wei, M., Shaffer, P. A., Young, S. K., & Zakalik, R. A. (2005). Adult attachment, shame, depression, and loneliness: The mediation role of basic psychological needs satisfaction.   Journal of Counseling Psychology, 52 , 591-601.

Wei, M., Vogel, D. L., Ku, T., & Zakalik, R. A. (2005). Adult attachment, affect regulation, negative mood, and interpersonal problems: The mediating role of emotional reactivity and emotional cutoff. Journal of Counseling Psychology, 52 , 14-24.

You Might Also Like:

What do you mean by counter complimentary treatment plans?

Useful overview in helping me shape a conversation as I go into a session this afternoon. Thank you 😉

Your style is unique compared to other folks I have read stuff from. Many thanks for posting when you have the opportunity, Guess I will just book mark this page.

As a christian from a dysfunction family background, I have had conflict with pastoral staff that have themselves come from christian families with parents that were caring and attentive to their needs. The pastors will preach on the healing of Jesus, but will make no opportunity to provide such healing. Whether this is because they themselves don’t see the need for healing, or they can’t sympathize with the trauma of others I can say. Find myself trying to understand attachment theory and cure myself. Functional people from good family upbringings are all theory and useless from a practical sense..

Submit a Comment Cancel reply

Your email address will not be published. Required fields are marked *

Submit Comment

Privacy Overview

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Res Psychother
• v.22(3); 2019 Dec 19

Advances in research on attachment-related psychotherapy processes: seven teaching points for trainees and supervisors

Alessandro talia.

1 Institute for Psychosocial Prevention, Heidelberg University Hospital, Heidelberg, Germany

Svenja Taubner

Madeleine miller-bottome.

2 Department of Psychology, New School for Social Research, New York, NY, USA

Contributions: all the authors participated in defining the content of the paper. AT and MMB wrote the first draft of the paper; ST revised and edited the manuscript.

While the rich body of attachment theory and research has inspired many psychotherapists, trainees and less experienced clinicians interested in attachment-informed work can often feel unsure about what processes are attachment-related and how to attend to them during therapy. Recent advances in attachment-informed psychotherapy research offer some practical guidance. Studies published over the last five years show that patients and therapists of different attachment classifications communicate in distinct ways during therapy sessions. In particular, Talia and his colleagues have introduced the Patient Attachment Coding System and the Therapist Attunement Scales, two measures that accurately predict patients’ and therapists’ Adult Attachment Interview and Reflective Functioning score based on the occurrence of distinct communication markers during therapy sessions. This paper discusses the implications of these recent studies for psychotherapy training and presents seven teaching points for supervisors and for the next generation of clinicians.

Introduction

The influence of attachment theory on psychological treatments seems to be ever increasing (Slade, 2016 ). There is a wide array of treatment models drawing from an evidence base that emphasizes secure attachment as the building block of good mental health (Cassidy & Shaver, 2016 ). Many clinicians and scholars across disciplines and theoretical orientations follow Bowlby in recognizing the transformative power of the therapeutic relationship in its parallels with an attachment bond ( e.g ., Eagle, 2013 ; Fredrickson, 2013; Johnson, 2012 ; Liotti, 2004 ). Some manualized treatments even go so far as to apply attachment theory to the development of specific therapeutic techniques ( e.g ., Bateman & Fonagy, 2016 ). This all but universal embrace of attachment theory within the field of psychotherapy has been supported by research with the Adult Attachment Interview (AAI, Main, Kaplain, & Cassidy, 1985 ), an interview that probes for autobiographical narratives about early attachment experiences. The clinicians of today have been inspired by this popular extra-clinical attachment assessment, and they are now ready for an evidence-based guide for identifying markers of attachment in psychotherapy sessions and targets for intervention.

Thanks to research with the Patient Attachment Coding System (PACS, Talia, Miller-Bottome, & Daniel, 2017 ) and the Therapeutic Attunement Scales (TASc, Talia, Muzi, Lingiardi, & Taubner, 2018 ), two measures of attachment developed for the psychotherapy context and validated with the AAI, the clinical applications of attachment theory can be extended to the moment-to-moment process of psychotherapy sessions. Whereas the AAI has shown that individuals represent their early relationships with their parents in distinct ways, until the introduction of the PACS and the TASc it was unclear how such differences could be observed in patients’ in-session behavior (Eagle, 2006 ; Obegi & Berant, 2009 ). Several clinical authors advanced hypotheses regarding how the various attachment classifications manifest in psychotherapy, often assuming that the AAI narrative features translate in therapy as transference-like attitudes and approaches to the therapy relationship ( e.g ., Wallin, 2007 ; but see Daniel, 2009 and 2011 for an alternative perspective). Evaluating and expanding on these early insights, research with the PACS and the TASc provides a method for tracking attachment differences as reflecting differences in how patients and therapists establish trust in the truth and relevance of what they communicate (which Fonagy & Allison, 2014 , call epistemic trust ). These innovations can guide assessment as well as therapeutic interventions, particularly for trainees and less experienced clinicians, who may feel unsure about how to recognize and respond to attachment-related process in sessions.

This paper presents such recent research along with specific clinical implications that can contribute to the training of psychotherapists. We begin by summarizing research on how patients and therapists of different attachment classifications communicate in session. We emphasize specifically research findings with the PACS and the TASc, and we do not attempt to offer a comprehensive presentation of contemporary attachmentinformed psychotherapy research (the interested reader is referred to recent compendia such as Daniel, 2014 , and Holmes & Slade, 2017 ). We continue presenting a number of teaching points for therapy training and supervision based on these findings.

Specifically, we discuss how knowledge of in-session attachment markers can help trainees and their supervisors: i) construct an attachment-based case formulation; ii) develop more process-oriented clinical listening; iii) identify triggers for negative countertransference; iv) assess therapeutic impasses; v) create deliberate practice exercises; vi) increase mindfulness of one’s own listening and reactivity patterns; and vii) provide new supervisory techniques and training objectives. We believe that this research can offer useful insights into areas of development for psychotherapy trainees as well as their supervisors.

The perspective on attachment-informed psychotherapy presented in this paper departs from Bowlby’s emphasis on attachment as a motivational system activated by threats and distress and focuses on the broader phenomenon of the pragmatics of verbal communication and meaning-making in the therapeutic relationship. While we focus here on a relatively newly discovered dimension of interpersonal dialogue in psychotherapy, we do not mean to de-emphasize Bowlby’s focus on separation and loss. This new horizon of attachment research only builds upon the wealth of work demonstrating our intrinsic drive for closeness and safety with others, as well as our reliance on others for learning about the world and making meaning of how we experience it.

Attachment and communication in the clinical context

Can we identify the attachment classifications of our patients simply by tracking how they speak in-session? The PACS was developed in an attempt to answer this very question (Talia et al., 2014). The authors of the PACS began by conducting a qualitative analysis of the transcribed sessions of a small sample of patients whose AAI classifications were obtained in advance. Through this work, they realized that patients of different attachment classifications could be distinguished according to how they used language at an interpersonal level. Patients classified as secure on the AAI engaged in a free and collaborative dialogue with the therapist and established connection with ease. Patients classified as dismissing appeared almost to be talking to themselves, providing scant cues for support, as if releasing the therapist from getting too involved. Patients classified as preoccupied seemed to enlist the therapist’s constant validation of their perspective and left little room for independent contributions and separateness in the relationship.

This initial analysis led the authors of the PACS to hypothesize that attachment classifications are expressed in psychotherapy as generalized patterns for communicating one’s experience. The association between these communication characteristics and the AAI was so strong that they could serve as a standalone measure of attachment, without the need for additional structured assessments. The authors of the PACS then compiled a list of items that characterized the discourse of patients with different attachment classifications, which now form the basis for coding the main scales of the PACS. The validity of this coding method was established in a large-scale study showing that the PACS independently predicts patients’ pre-treatment AAI classification (N=156; k=.82), in a sample of patients from three countries and including both psychodynamic and cognitive–behavioral treatments (Talia et al., 2017).

Beyond the utility of the PACS as a speedier assessment of attachment in psychotherapy research, most relevant for the focus of the current paper is that the research with this instrument has identified distinct communication markers that clinicians can learn to listen for during sessions. The PACS works by identifying the presence and frequency of fifty markers embedded within in-session discourse (for example, 5. The patient discloses distressful emotions experienced in the present; 38. The patient laughs over distress; 45. The patient quotes past thoughts with direct discourse). The occurrence of these characteristics in a psychotherapy session transcript leads to rating a number of subscales and five main PACS scales: Proximity seeking (which rates the extent to which the patient openly expresses vulnerability); Exploring (which rates the extent to which the patient demonstrates agency and openness with regards to their positive experience); Contact maintaining (which rates the extent to which the patient communicates about the therapeutic relationship); Avoidance (which rates the patients’ reluctance to describe in detail examples, attitudes, and internal experiences); Resistance (which rates the patient’s lack of clarity and orderliness in the exposition). A patient is assigned one of three PACS attachment classifications (secure, dismissing, and preoccupied) and one of nine sub-classifications based on the overall configuration of these scales. While it is outside of the scope of this paper to provide a comprehensive description of the PACS (the interested reader can read more about the instrument and coding examples in Talia et al., 2017, 2019a ), the following paragraphs will present a short description of three domains in which one can observe the distinguishing features of the main attachment classifications.

Attachment-related differences in narrative construction

One of the most obvious in-session differences between patients of different attachment classifications can be found in their narratives. In his seminal work, Jeremy Holmes ( 2001 ) proposed that narrative tendencies similar to those found in the AAI find expression in the stories patients share therapy. Holmes speculated that secure patients’ narratives are more coherent and balanced, dismissing patients’ narratives are overly succinct and unemotional, and preoccupied patients are overwhelmed by their experiences and struggle to fit them into clear stories.

Psychotherapy research on attachment-related in-session processes provides empirical support to these hypotheses. In particular, the secure classification in the PACS is associated with telling narratives that are vivid and to the point . In relaying their narratives, these patients’ describe distinct physical actions in close causal succession, which makes them easier to be visually imagined by the listener. Secure patients also make it clear why they are recounting a particular story - either because the narrative serves to illustrate some previous claim, or because the narratives themselves are constructed so that the most salient information is presented at the end, like a climax to a harrowing tale or a punchline to a joke (Talia & Miller-Bottome, 2014).

In contrast to secure patients, dismissing patients detail narratives infrequently or their narratives are exceedingly terse (Daniel, 2011 ) they contain more pauses (Daniel, Folke, Lunn, Gondan, & Poulsen, 2018 ), and lack vividness (Talia et al., 2017). While these patients’ discourse is coherent and easy to follow, it may give the impression that the speaker is not interested in receiving support or validation from the therapist. Preoccupied patients, on the other hand, may construct detailed narratives, but they often fail to make clear why they are telling a particular story. Their narratives are characterized by exaggerated one-sidedness, extended quotations of past dialogues, and incoherence and vagueness, such that contributions from the therapist seem unwelcome. The PACS has shown that these differences can be observed in any sort of narrative in psychotherapy, regardless of whether they are related to attachment or a distressful topic (Talia et al., 2017).

Attachment-related differences in expressing attitudes

Secure speakers not only recall specific memories, but they also tend to provide salient evaluations (of others, themselves, and the therapist) and express the feelings that are related to these. For example, secure patients will generally follow up a description of a hurtful treatment by a significant other by criticizing the other and mentioning how he or she made them feel. As another example, secure patients will praise the helpfulness of the therapist and elaborate by describing a feeling of closeness and gratitude (Miller-Bottome, Talia, Safran, & Muran, 2018 ).

Insecure patients are distinctively different in this respect. Some of these patients criticize or praise without mentioning any feelings. They either speak in overly objective, exaggerated terms (a hallmark of some preoccupied speakers, who are classified C1 in the PACS and E2 in the AAI) or by downplaying the emotional effect that experiences had on them (a hallmark of some dismissing speakers, classified A2 in the PACS and Ds3 in the AAI). Other patients would mention their internal experiences and thoughts from the past without expressing an independent stance in the present, in ways that appear detached (and then classified A1 in the PACS and Ds1 in the AAI) or indecisive and confused (and then classified C1 in the PACS and E1 in the AAI).

Attachment-related differences in perspective-taking

Research with the PACS reveals a third aspect that is closely associated with patients’ attachment classification: the capacity for mentalizing. Mentalizing is defined as the ability to understand behavior based on mental states that underlie the behavior and may serve to explain it (Allen, Fonagy, & Bateman, 2008 ). Consistent with early intuitions by Fonagy and his colleagues (Fonagy, Steele, Steele, Higgitt, & Moran, 1991 ), secure patients often describe their own and other people’s intentions and behavior while discussing relevant beliefs and desires. They speak with candor, but do not try to enlist the listener’s approval or support, as if they rest relatively assured that they will be trusted and listened to (Talia et al., 2019a ). Insecure patients have difficulties in engaging in such a collaborative meaning-making process. Some of them are reluctant to make guesses about mental states, some sound too self-assured, and some are vague and difficult to understand. By failing to provide justification for how they and their significant others acted in the way they did, they limit their interlocutors’ ability to understand and believe them entirely. Thus, similarly to the other attachment-related differences discussed above, differences in perspective- taking reflect differing capacities in fostering epistemic trust (Fonagy & Allison, 2014 ).

Attachment-related differences in therapists

Encouraged by the finding that patients’ discourse in one session is a reliable predictor of their independently obtained AAI classification, Talia et al. ( 2018 ) more recently hypothesized that a therapist’s attachment status might influence their work with their patients as well. Initially, they did not expect to find associations between therapists’ in-session discourse and their AAI classification as strong as those found in work with the PACS. Therapists’ work was thought to be a learned skill, with therapist attachment status only being one among many influences on therapists’ behavior in-session. Nevertheless, pronounced characteristics in therapists’ interventions were found to distinguish between the three main AAI classifications. The TASc was then devised to assess therapists’ attachment based on any session of therapy and validated on an independent sample of fifty psychodynamic psychotherapists who had been independently assessed with the AAI.

In the TASc, the therapists are classified as secure when they make use of three characteristic types of interventions. First, they offer their own views on patients’ experience in a way that is open to correction and elaboration from the patient (rated on the Self-state conjecture scale). For example, they would ask if a patient was feeling a certain emotion, or they would make a tentative conjecture about the patient’s current wishes and needs. Second, they would validate patients’ previously expressed experience by offering their own subjective perspective in support (rated on the Empathic validation scale). Third, they would convey their subjective experience of the patient (rated on the Joining scale). Open questions, advice, psycho-education, and repetitions of what the patient has said ( i.e. clarifications) were not found to differentiate between attachment classifications.

In contrast to the therapists classified secure, the ones classified as dismissing use the markers described above only sparingly. Therapists classified as preoccupied use markers from the Empathic validation and Joining scales but not from the Self-state conjecture scale, whose characteristic tentativeness is largely absent in their interventions. Therapists with dismissing and preoccupied AAI classifications also use two additional sets of markers. The therapists with a dismissing classification seem to release themselves from offering their subjective perspective on their patients’ internal experience, for example by repeating back a patient’s disclosure in a downplayed form ( e.g . so you’re feeling a bit sad ). The therapists with a preoccupied classification speak in a way that appears to restrict the possibility of the patient to correct them, for example by conveying their opinions on patients’ significant others in a seemingly entitled way. These communication markers are rated on two other scales, Detaching and Coercing.

Patient Attachment Coding System and Therapeutic Attunement Scales markers reflect instances of cooperative discourse

We think it is important to note that the markers of insecure in-session attachment discovered with the PACS and the TASc do not themselves constitute alliance ruptures, negative transference enactments, or forms of resistance. Although insecure in-session markers of attachment can evoke frustration, confusion, and disconnection in therapists, their pervasiveness and stability in patients’ discourse across topics from the first sessions of treatment and even in interviews outside of psychotherapy (Talia et al., 2019b) suggests that they are something the speaker alone brings to the therapeutic interaction. They should thus be regarded as independent from the speaker’s experience of the interaction or even the formation of a strong personal bond. On the other hand, alliance ruptures or negative transference enactments typically involve a subjective experience of affective discord and arise from a strain in the trust in the therapist or the process (Miller-Bottome et al., 2018 ); such events are thus a function of the experiences and histories particular to that therapeutic dyad.

Moreover, we believe it is helpful to think of the PACS and the TASc markers as instances of cooperative discourse, rather than defensive evasions from the therapeutic relationship or the process. On closer inspection, insecure PACS markers are typically instances in which the speaker discloses their beliefs and desires, details examples to support their claims, and provides justification to their actions and plans. Despite perhaps being limited in their capacity to describe their experiences to another person, these discourse markers represent speakers’ efforts at being understood and believed. This can be contrasted with ruptures, in which the patient disengages from the dialogue or blocks collaboration with the therapist by, for example, providing telegraphic responses or by denying any internal experience at all (Eubanks Carter, Muran, & Safran, 2015b). We believe that distinguishing the insecure PACS markers from alliance ruptures may help therapists develop a richer conceptualization of the patient and increase their capacity to empathize with the patient’s attempts to collaborate.

In the section that follows, each teaching point will present a re-framing or re-construal of how we conceptualize attachment in psychotherapy and the related clinical implications for therapy training.

Seven teaching points for clinical training

Attachment classifications provide trainees and supervisors a diagnostic tool for case formulation.

Because of its trans-theoretical applications and its reliance on validated assessments, attachment theory is a significant resource for case formulation (Steele & Steele, 2008 ). Until recently, however, attachment-informed case formulation has suffered a number of limitations. First of all, the previous emphasis on individual differences in attachment as transference-like perceptions and expectations tended to obscure many subtle aspects of the therapeutic interaction that are nonetheless clinically important (Eagle, 2006 ; Wachtel, 2010 ). Second, not many clinical settings allow for the administration and transcription of a structured interview, especially for clinicians who work in private practice settings, and especially if one wants to administer such interviews more than once or twice and track change. The PACS seems to combine the in-depth reach of observer-based measures while meeting the practical demands of clinicians and researchers (Talia et al., 2017 ).

It is probably not realistic to ask that all therapy trainees immerse themselves in learning how to code with formal attachment assessments; yet those involved in the training of clinicians must study actual attachment-related in-session communication if they want to make sure that their students’ clinical work is truly attachment informed (Slade, 2016 ). In particular, supervisors and teachers can teach their trainees about some of the core aspects of insession attachment described by the PACS; the three domains of in-session discourse described in the previous section are a good point of departure. Drills can be designed to show students how to gauge the fundamental elements of a patient’s attachment pattern and training videos can be used to test students’ learning.

Attachment-informed case formulation will yield a number of indications. At the most general level, in-session attachment classifications may lead to a type of initial case formulation that identifies the patient’s overall level of personality functioning, not unlike Kernberg’s focus on the patient’s personality organization (Kernberg, 1976 ), the recent assessments developed for the DSM-5 Alternative model for Personality disorders (Zimmermann, Kerber, Rek, Hopwood, & Krueger, 2019 ), or assessment with the Psychodynamic Diagnostic Manual (PDM, Lingiardi & Williams, 2015 ). There is a need for more studies that rigorously test the association between attachment categories and personality ( e.g ., Roisman, et al., 2007 ), on the model of what accomplished in research on the associations between personality and RF (see e.g ., Katznelson, 2014 ). Until then, clinicians should be aware that the discourse markers used in coding secure attachment in the AAI (and in the PACS) reflect central aspects of personality functioning, including identity diffusion vs integration (Blatt & Levy, 2003 ; Main, Goldwyn, & Hesse, 2002 ), mentalizing (Jessee, Mangelsdorf, Wong, Schoppe-Sullivan, & Brown, 2016 ; Talia et al., 2019a ), and capacity for intimacy and conflict resolution (Miller- Bottome et al., 2018 ).

Finally, a case formulation informed by attachment research can lead the clinician to draw a roadmap of the therapy tasks that have to be accomplished. Research with the PACS underlines that the markers used to identify secure attachments overlap with therapy processes that have been historically considered as necessary for any treatment to be successful: disclosing one’s emotions and needs, constructing clear narratives, reflecting on the therapeutic relationship are only some examples. In this way, attachment-informed case formulation is at the same time a formulation of patients’ problems in interpersonal communication and a way to identify therapeutic tasks that the therapist and the patient need to emphasize.

Learning in-session markers of attachment helps clinicians develop an ear for verbatim process

It seems to us that it is common amongst trainees to focus too much on the content of patients’ communications in sessions and too little on how patients communicate. Clinicians interested in attachment-informed work can sometimes rely too heavily on inference; guessing the patients’ attachment pattern solely based on the details of patients’ relationships and the categories of experiences patients disclose: traumatic, pleasurable, affirming, disappointing (Wallin, 2007 ). For example, clinicians often misunderstand a patient’s discussion of wanting to avoid contact with her husband to mean that the attachment pattern is dismissing. Without any strong support from research, many clinicians conflate the quality of the attachment experiences the patient reports with their attachment patterns. This can translate in supervision to meetings devoted to a chronicling of a patient’s life history or a summation of the topics discussed by the patient at the expense of a more detailed picture of the interaction. Supervisors and trainers must keep in mind that, with no discussion of process (the sequence of dialogue, the phrasing and wording of patients’ speech turns, their responses to the therapist’s comments and vice versa ), no assessment of patients’ attachment patterns is possible.

The research discussed in this paper enables the therapist to develop a different kind of detail-orientation that extends beyond the surface of patients’ communication and into the crucial differences between a patient saying I’m feeling so sad about it (a marker of secure attachment), I felt sad yesterday, but that’s to be expected (a marker of dismissing attachment) and I’m so sad, it’s just like ‘I know you’re a cheater!’ (a marker of preoccupied attachment). The differences in tense, syntax, and focus in each of these remarks can be felt in the here-and-now sense of connection and collaboration with the patient. Ideally, supervisors can help their supervisees pay attention to these aspects in the transcripts or the videos of the supervisee’s sessions. If recording technology is not available, supervisors armed with the PACS can focus on communication in addition to content with questions such as How did he say it - what were his exact words? or How did he reply to your intervention?. This perspective may remind the reader of perspectives on psychoanalytic technique most often associated with authors such as Schlesinger ( 2003 ), Shapiro ( 1965 ), and many others ( e.g ., Boston Change Process Study Group, 2018 ; Joseph, 1989 ; Ogden, 1977 ) who emphasize examining the form, function, and process of patients’ communications in clinical phenomena like transference.

In-session attachment markers identify triggers for common countertransference reactions and alliance ruptures

Trainees are often beset by a strained connection or by a lack of collaboration that sometimes feel untraceable to any one remark by the patient. Recent attachment-informed psychotherapy research may be of some help in this regard. The discourse markers of the PACS suggest that patients of different attachment classifications speak in ways that differ subtly but may have a potent interpersonal impact. The way in which preoccupied patients speak may tend to engender in the therapist feelings of being overwhelmed or angry, while the way in which dismissing patients speak may engender more boredom and disinterest instead. Some studies support the idea that distinct emotional reactions in the therapist are associated with insecure attachment classifications in the patient (Daniel, Lunn, & Poulsen, 2015 ; Martin, Buchheim, Berger, & Strauss, 2007 ), while secure AAI classifications have been shown to be associated with more positive observed therapeutic relationships (Folke, Daniel, Poulsen, & Lunn, 2016 ).

The fine-tuned ear facilitated by attending to in-session attachment markers can help the trainee identify the momentary shifts in patients’ discourse that may trigger negative countertransference reactions in themselves. Thanks to these processes, the trainee can track in real time the subtle but distinct discursive acts associated with untoward reactions in the therapist: excessive quotation of discourse from past interactions, minimizing or downplaying remarks, or the insistence upon stating a thought in response to a probe about emotion, just to name a few. This application of attachment research may be invaluable. Identifying the source for such common reactions as frustration, confusion, boredom, emotional distance can help the trainee understand and thus better tolerate these internal states, often anxiety- or shame- inducing.

It is important to note that tracking such in-session discourse markers can be carried out mentally by the therapist without that he or she explicitly remarks upon them. An improved ability to trace the moment-to-moment sources of countertransference reaction may, alone, facilitate a restructuring of the therapists’ internal experience; in turn, this may lead to more skillful and less reactive therapeutic interventions. We expect that such restructuring will in time help the trainee develop a greater capacity to accept patients and their suffering for what they are, along the lines of that radical acceptance that Marsha Linehan recommends to encourage in borderline patients (Linehan & Wilks, 2015 ) and that Holmes and Slade ( 2017 ) have seen as lying at the heart of attachment-informed psychotherapy.

Accurate assessment of in-session attachment markers can help clinicians detect and attend to ruptures with greater sensitivity

Accurate assessment of in-session markers of attachment can help clinicians stay grounded in the face of perceived ruptures and impasses. Trainees can easily mistake insecure markers as signals that a rupture has occurred. This can lead to over-detection and reactivity to perceived ruptures, which in our observations can beget further ruptures. To avoid this, trainees must grasp a duality inherent in insecure markers: they are at once patients’ way of communicating information and establishing trust in the clarity and validity of which they speak and also characteristics that may stymie mutual exploration of their internal experience. Research with the PACS and TASc suggests that these markers are not volitional or defensive reactions to the process, but constraints patients’ capacity to communicate in an open and balanced way.

How can this re-construal help therapists in the moment? Therapists are often trained to go against the grain . Across different theoretical orientations, therapists are taught to attend to what appears to be a symptom or a defense and to remark upon these in a manner that encourages the patient doing something differently (Frederickson, 2013 ; Gray, 1990 ). Recent research on insession attachment suggests that a different stance is possible with respect to attachment-related markers. These markers arise every few seconds in speaking about a variety of topics, regardless of the listener, and they comprise patterns so automatic and fundamental to patients’ self-expression that they are largely inaccessible to conscious awareness. Thus, therapists and supervisors who recognize these markers may choose to orient to them not as defenses to be blocked or even to be labeled and attended to, but as an intrinsic and enduring characteristic of the patient to be worked with , at least initially.

The research on the type, sequence, and frequency of interventions most effective for the different attachment classification is still in its infancy, and more specific recommendations necessitate more qualitative analyses and case studies. In the meantime, supervisors can encourage a spirit of judicious experimentation in going against one’s immediate instincts and going with the patient’s communication style. For example, a dismissing patient’s minimal response can be interpreted not as a dismissal of the therapist, but as an invitation for the therapist to add more. A preoccupied patient’s excessive or confusing replaying of past episodes or overriding of the therapist’s comments may not be interpreted as an attempt to devalue or ignore, but to provide the therapist with as much information as possible.

A slightly different implication emerges for treating secure patients. Up until now, it was largely assumed that insecure patients experience alliance ruptures at a greater frequency than their secure counterparts, who were thought to experience a greater degree of trust and safety in the therapeutic relationship ( e.g . Eames & Roth, 2000 ). However, research suggests that what distinguishes secure patients is their capacity to repair ruptures when they do arise (Miller-Bottome, Talia, Eubanks, Safran, & Muran, 2019). Secure patients may facilitate rupture repair by openly disclosing feeling anxious, angry, or distant from their therapist, reflecting on possible sources of these negative emotions, and stating their needs in present terms. Such disclosures can be commonly mis-recognized as a sign of attachment insecurity when in fact they initiate the process of repair. Supervisors informed by attachment-research can remind their supervisees that secure patients will disclose that they have experienced a rupture in a more open and collaborative fashion, and that what distinguishes secure patients from insecure patients is the ability to facilitate repair.

In-session attachment markers can be used as a guide to intervention and a template for role-play and deliberate practice exercises

While the TASc can be used, similarly to the PACS, for tracking therapeutic interventions retrospectively , it can also be used to help trainees deliver more interventions that are associated with secure attachment, that is, as a tool for attachment-informed training (Talia et al., 2018 ). We will suggest here two types of exercises, both of which can be practiced in pairs during awareness-focused role playing (Eubanks Carter, Muran, & Safran, 2015a), with one trainee playing the patient and one playing the therapist. Because the markers of therapist attachment are empathic interventions that are expected to be common in any therapeutic orientation, it should be possible to practice these exercises regardless of the treatment model that the students are learning.

In the first exercise, the trainee who plays the therapist attempts to abstain from using open questions, clarifications, advice, and psycho-education, which are not linked to any one attachment classification in particular and thus do not seem to serve directly any attachment-related process. The trainee playing the therapist may also focus on practicing one particular type of secure attachment intervention ( e.g ., Self-state conjecture, Empathic validation, or Joining) or individual markers from any one of these scales. This exercise may help the therapist bolster his or her attention to attuning to the patient, which in ordinary circumstances may be disrupted when connecting to the patient is too challenging, emotionally or otherwise. A deliberate focus on active attunement may thus spotlight weaknesses in therapists’ empathic attunement and suggest areas for practice.

In the second exercise, the trainee who plays the patient attempts to imitate the characteristic way of speaking and mannerisms of one of his or her patients (for example, as described by Nebbiosi, 2016 ), paying particular attention to PACS markers that appear most frequently in the patient’s discourse. This exercise may help trainees develop greater empathy for the cooperative intentions that underlie patients’ communication. At the same time, it may be helpful to compare the reactions of their colleagues playing the therapist in the role play with their own reaction as therapists, both in terms of their subjective experience and in terms of what interventions seem most helpful.

In both exercises, the supervisor may intervene especially when the parameters are violated, and encourage trainees to focus on what felt like making or receiving that particular intervention. Similarly to supervision in Alliance- Focused Training (Eubanks Carter, Muran, & Safran, 2015a), the supervisor may encourage trainees to verbalize their feelings and intuitions in the roleplay as part of a metacommunication process. In this way, the PACS and the TASc can help supervisors and trainees to structure deliberate practice and role playing so that trainees can gradually learn to tailor their responses in a way that is informed by contemporary research on in-session attachment-related processes.

Therapists’ knowledge of their attachment classifications can increase self-awareness and acceptance of their contributions to the therapeutic process

Another focus in attachment-informed supervision should be the analysis of videotapes of trainees’ sessions and the insecure markers observable in the trainee’s speech turns. The supervisor can then begin to attune to the experience of the trainee when they were using that particular type of communication. What were they trying to accomplish? What do they think was the experience of the patient in receiving the intervention? Similar to the previous exercises, the ultimate goal in this work is not to train the novice therapist to mimic by rote communication of secure therapists. Rather, the effort is to become more mindful of one’s own communication style so that one can choose one’s remarks more carefully. Being present and authentic should be prioritized on drilling security.

With time, we expect this type of work to produce a cascade of positive results. First, novice therapists will learn to listen to how they listen . What do they need from a patient in order to understand them and feel connected to them? What triggers boredom and when? What type of information do they tend to ask more of? This kind of selfmonitoring can enhance awareness and acceptance of one’s own characteristics as well as a greater understanding of one’s impact of the patient. In the same way as certain patterns of attachment elicit predictable responses in therapists, certain patterns of attachment in the therapist may elicit certain responses in patients. Knowing one’s attachment pattern can inform of the anticipated responses one may tend to evoke. Patients may find dismissing therapist inscrutable, opaque, or detached. Preoccupied therapists may seem like omniscient experts or overwhelming. This knowledge may prepare the trainee for the types of rupture that are likely to arise with their patients.

Increased mindfulness aided by these attachment measures will help trainees take ownership of their own thresholds for establishing trust and understanding in dialogue with another person. From this awareness, the therapist can make interventions that are focused on helping the patient be more open and collaborative but grounded in their own contributions to the process. For example, trainees can be guided by their supervisors towards interventions such as I think I need you to get to the point because I personally tend to get lost with too much detail or The reason why I am asking all these questions is because it’s my way to make sure I’ve understood you . Only when therapists learn to ground themselves in their own characteristic ways of listening and responding can they help their patients change theirs.

Supervisors should learn about their supervisee’s attachment in order to get the most out of supervision

By obtaining information about their trainees’ attachment classification, through interviews or videotape analysis with the TASc, teachers and supervisors can set learning objectives that are tailored to the specific student. This is especially important because the markers of secure attachment in therapists overlap with many core tasks of psychotherapy. Any psychotherapy technique - be it detailed inquiry, empty chair dialogue, or transference interpretation - is likely to be influenced by the attachment-related communication style of the therapist (Wrape, Callahan, Rieck, & Watkins, 2017 ). As a consequence, it is likely that insecure trainees may struggle when engaging in these and other activities, and supervisors and trainers should emphasize helping their insecure students work on enhancing their active listening skills.

Another area in which differences in trainees’ attachment might manifest is their narratives about their patients (patients’ attachment classifications predict how patients speak about their therapist, Diamond, Clarkin, Stovall Mc-Clough, & Levy, 2003 ; Talia et al., 2019b ). We hypothesize that dismissing therapists will report their sessions by offering internally coherent descriptions of the core in-session dynamics, but without paying sufficient attention to details (either to what happened in session or to the exact content of patient’s narratives). On the other hand, preoccupied therapists may get lost in detail, perhaps following all the minute aspects of the patient’s narratives or in-session behavior, without making clear their assessment and formulation of the case.

It may thus be useful to ask from the beginning that the dismissing supervisees try to focus on reporting events in as much detail as possible - who said what to whom - perhaps taking notes as copious as possible at the end of each sessions as an aid for recall; and that they focus on their emotions during the session and their present attitude (of liking or disliking the patient) as they speak. On the other hand, preoccupied therapist may benefit from being consistently asked to connect their observations to succinct formulations; they could also be asked to imagine alternative perspectives when considering their patients’ mental states, and to speak as precisely as possible.

We expect that some trainees and supervisors may have reservations about discovering or sharing their attachment status. This is in part because attachment-informed psychotherapy research has sometimes pathologized insecure attachment classifications. In some psychoanalytic schools, insecure attachment in the therapists may be even seen as a sign that the trainee has not been analyzed sufficiently and perhaps indicate that admission into training programs should be discouraged.

The perspective proposed in this paper is different. As we discussed above, we do not view the communication styles related to insecure attachment as related to psychological conflict and resistance, nor do we view it as equal with a past history of trauma or adverse experiences in early family relationships. Rather, the communication patterns related to attachment are comparable to a personality trait perceptible to anyone in interaction, rather than internal interpersonal schemata.

Conclusions

This paper reviewed findings from recent research with two new measures of patient and therapist attachment in psychotherapy and outlined a set of clinical implications stemming from these findings that can contribute to the training of psychotherapists. New evidence regarding how attachment patterns manifest in the therapeutic interaction cast the construct of attachment in new light. The evidence shows that attachment is observable in therapy as distinct differences in how individuals listen and communicate in order to achieve shared understanding with another person. Insecure attachment in patients and therapists, rather than implying a pathological mistrust of closeness, is revealed as differences in the level of detail, clarity, and evidence they provide in communicating with another person. All seven teaching points described in the paper involve helping trainees become aware of their and their patients’ attachment, and to work with attachment as a trait adapted for collaboration rather than a symptom or pathology to be healed.

Acknowledgments

AT wishes to thank Gerry Byrne for having inspired some of the ideas contained in this paper.

• Allen J. G., Fonagy P., Bateman A. W. (2008). Mentalizing in clinical practice . Arlington, VA: American Psychiatric Publishing. [ Google Scholar ]
• Bateman A., Fonagy P. (2016). Mentalization-based treatment for personality disorders: A practical guide . Oxford: Oxford University Press. [ Google Scholar ]
• Blatt S. J., Levy K. N. (2003). Attachment theory, psychoanalysis, personality development, and psychopathology . Psychoanalytic Inquiry, 23 ( 1 ), 102-150. [ Google Scholar ]
• Boston Change Process Study Group (2018). Moving through and being moved by: embodiment in development and in the therapeutic relationship . Contemporary Psychoanalysis, 54 ( 2 ), 299-321. doi: 10.1080/00107530.2018.1456841 [ Google Scholar ]
• Cassidy J., Shaver P. R. (2016). Handbook of attachment (3rd. ed.) . New York, NY: Guilford Press. [ Google Scholar ]
• Daniel S. (2014). Adult attachment patterns in a treatment context: Relationship and narrative . London: Routledge. [ Google Scholar ]
• Daniel S. I. F. (2009). The developmental roots of narrative expression in therapy: Contributions from attachment theory and research . Psychotherapy: Theory, Research, Practice, Training, 46 ( 3 ), 301-316. doi: 10.1037/a0016082 [ PubMed ] [ Google Scholar ]
• Daniel S. I. F. (2011). Adult attachment insecurity and narrative processes in psychotherapy: An exploratory study . Clinical Psychology & Psychotherapy, 18 ( 6 ), 498-511. doi: 10.1002/ cpp.704 [ PubMed ] [ Google Scholar ]
• Daniel S. I. F., Folke S., Lunn S., Gondan M., Poulsen S. (2018). Mind the gap: In-session silences are associated with client attachment insecurity, therapeutic alliance, and treatment outcome . Psychotherapy Research, 28 ( 2 ), 203-216. doi: 10.1080/10503307.2016.1177673 [ PubMed ] [ Google Scholar ]
• Daniel S. I. F., Lunn S., Poulsen S. (2015). Client attachment and therapist feelings in the treatment of bulimia nervosa . Psychotherapy, 52 ( 2 ), 247-257. doi: 10.1037/a0038886 [ PubMed ] [ Google Scholar ]
• Diamond D., Clarkin J., Stovall-McClough C., Levy K. (2003). Patient-therapist attachment in the treatment of borderline personality disorder . Bulletin of Menninger Clinic , 67 ( 3 ), 227–259. doi: 10.1521/bumc.67.3.227.23433 [ PubMed ] [ Google Scholar ]
• Eagle M. N. (2006). Attachment, psychotherapy, and assessment: A commentary . Journal of Consulting and Clinical Psychology, 74 ( 6 ), 1086-1097. doi: 10.1037/0022-006X.74.6.1086 [ PubMed ] [ Google Scholar ]
• Eagle M. N. (2013). Attachment and psychoanalysis: Theory, research, and clinical implications . New York: Guilford Press. [ Google Scholar ]
• Eames V., Roth A. (2000). Patient attachment orientation and the early working alliance-a study of patient and therapist reports of alliance quality and ruptures . Psychotherapy Research, 10 , 421–434. doi: 10.1093/ptr/10.4.421 [ PubMed ] [ Google Scholar ]
• Eubanks-Carter C., Muran J. C., Safran J. D. (2015a). Alliance- focused training . Psychotherapy, 52 ( 2 ), 169-173. doi: 10.1037/a0037596 [ PubMed ] [ Google Scholar ]
• Eubanks-Carter C., Muran J. C., Safran J. D. (2015b). Rupture Resolution Rating System (3RS) . Mount Sinai-Beth Israel Brief Psychotherapy Research Program . Unpublished Manuscript. doi: 10.13140/2.1.1666.8488 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Folke S., Daniel S. I., Poulsen S., Lunn S. (2016). Client attachment security predicts alliance in a randomized controlled trial of two psychotherapies for bulimia nervosa . Psychotherapy Research, 26 ( 4 ), 459-471. doi: 10.1080/10503307.2015.1027319 [ PubMed ] [ Google Scholar ]
• Fonagy P., Allison E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship . Psychotherapy, 51 ( 3 ), 372-380. doi: 10.1037/a0036505 [ PubMed ] [ Google Scholar ]
• Fonagy P., Steele M., Steele H., Moran G. S., Higgitt A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment . Infant Mental Health Journal, 12 ( 3 ), 201-218. doi: 10.1002/1097-0355(199123)12:3%3C201::AIDIMHJ2280120307% 3E3.0.CO;2-7 [ Google Scholar ]
• Frederickson J. (2013). Co-creating change: Effective dynamic therapy techniques . Kansas City, MO: Seven Leaves Press. [ Google Scholar ]
• Gray P. (1990). The nature of therapeutic action in psychoanalysis . Journal of the American Psychoanalytic Association, 38 ( 4 ), 1083-1097. doi: 10.1177%2F000306519003800408 [ PubMed ] [ Google Scholar ]
• Holmes J. (2001). The search for the secure base . Attachment theory and psychotherapy . London: Brunner Routledge. [ Google Scholar ]
• Holmes J., Slade A. (2017). Attachment in Therapeutic Practice . London: SAGE. doi: 10.1037/0033-3204.41.4.472 [ Google Scholar ]
• Jessee A., Mangelsdorf S. C., Wong M. S., Schoppe-Sullivan S. J., Brown G. L. (2016). Structure of reflective functioning and adult attachment scales: overlap and distinctions . Attachment & Human Development, 18 ( 2 ), 176-187. doi: 10.1080/14616734.2015.1132240 [ PubMed ] [ Google Scholar ]
• Johnson S. M. (2012). The practice of emotionally focused couple therapy: Creating connection . New York: Routledge. [ Google Scholar ]
• Joseph B. (1989). The patient who is difficult to reach . Feldman M., Spillius E. B. (Eds.), Psychic equilibrium and psychic change: Selected papers of Betty Joseph (pp. 75– 87) . London: Routledge (Original work published in 1975). [ Google Scholar ]
• Katznelson H. (2014). Reflective functioning: A review . Clinical psychology review, 34 ( 2 ), 107-117. [ PubMed ] [ Google Scholar ]
• Kernberg O. F. (1976). Object relations theory and clinical psychoanalysis . New York, NY: Jason Aronson. [ Google Scholar ]
• Linehan M. M., Wilks C. R. (2015). The course and evolution of dialectical behavior therapy . American Journal of Psychotherapy, 69 ( 2 ), 97-110. doi: 10.1176/appi.psychotherapy.2015.69.2.97 [ PubMed ] [ Google Scholar ]
• Lingiardi V., McWilliams N. (2015). The psychodynamic diagnostic manual. 2nd ed. (PDM-2) . World Psychiatry, 14 ( 2 ), 237-239. doi: 10.1002%2Fwps.20233 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Liotti G. (2004). Trauma, dissociation, and disorganized attachment: Three strands of a single braid . Psychotherapy: Theory, Research, Practice, Training, 41 ( 4 ), 472-486. [ Google Scholar ]
• Main M., Goldwyn R., Hesse E. (2002). Adult attachment scoring and classification systems, Version 7.1 . Unpublished manuscript, University of California at Berkeley. [ Google Scholar ]
• 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. doi: 10.2307/3333827 [ Google Scholar ]
• Martin A., Buchheim A., Berger U., Strauss B. (2007). The impact of attachment organization on potential countertransference reactions . Psychotherapy Research, 17 ( 1 ), 46-58. doi: 10.1080/10503300500485565 [ Google Scholar ]
• Miller-Bottome M., Talia A., Eubanks C., Safran J. D., Muran J. C. (2019). Secure in-session attachment predicts Rupture Resolution: Negotiating a secure base . Psychoanalytic Psychology, 36 ( 2 ), 132-138. doi: 10.1037/pap0000232 [ Google Scholar ]
• Miller-Bottome M., Talia A., Safran J. D., Muran J. C. (2018). Resolving alliance ruptures from an attachment-informed perspective . Psychoanalytic Psychology, 35 ( 2 ), 175-183. doi: 10.1037/pap0000152 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Nebbiosi G. (2016). The smell of paper: On the usefulness of musical thought in psychoanalytic practice . Psychoanalytic Dialogues, 26 ( 1 ), 1-9. [ Google Scholar ]
• Obegi J. H., Berant E. (Eds). (2009). Attachment theory and research in clinical work with adults . New York, NY: Guilford Press. [ Google Scholar ]
• Ogden T. (1977). Projective identification and psychotherapeutic technique . London: Routledge. [ Google Scholar ]
• Roisman G. I., Holland A., Fortuna K., Fraley R. C., Clausell E., Clarke A. (2007). The Adult Attachment Interview and self-reports of attachment style: An empirical rapprochement . Journal of personality and social psychology , 92 ( 4 ), 678. [ PubMed ] [ Google Scholar ]
• Schlesinger H. J. (2003). The texture of treatment: On the matter of psychoanalytic technique . Hillsdale, NJ: The Analytic Press. [ Google Scholar ]
• Shapiro D. (1965). Neurotic Styles . Oxford, England: Basic Books. [ Google Scholar ]
• Slade A. (2016). The implications of attachment theory and research for adult psychotherapy research and practice . Cassidy J., Shaver P. R. (Eds.), Handbook of attachment (3rd ed.) . New York, NY: Guilford Press. [ Google Scholar ]
• Steele H., Steele M. (Eds.). (2008). Clinical applications of the Adult Attachment Interview . New York: Guilford Press. [ Google Scholar ]
• Talia A., Daniel S. I. F., Miller-Bottome M., Brambilla D., Miccoli D., Safran J. D., Lingiardi V. (2014). AAI predicts patients’ in-session interpersonal behavior and discourse: a move to the level of the relation for attachment-informed psychotherapy research . Attachment & Human Development, 16 ( 2 ), 192-209. doi:10.1080/ 14616734.2013.859161 [ PubMed ] [ Google Scholar ]
• Talia A., Miller-Bottome M. (2014). Patient Attachment Coding System 2.0. Unpublished manuscript . Institute of Psychosocial Prevention, Heidelberg University, Germany. [ Google Scholar ]
• Talia A., Miller-Bottome M., Daniel S. I. F. (2017). Assessing attachment in psychotherapy: validation of the patient attachment coding system (PACS) . Clinical Psychology & Psychotherapy, 24 ( 1 ), 149-161. doi:10.1002/cpp.1990 [ PubMed ] [ Google Scholar ]
• Talia A., Miller-Bottome M., Katznelson H., Pedersen S. H., Steele H., Schröder P., Lingiardi V. (2019a). Mentalizing in the presence of another: Measuring reflective functioning and attachment in the therapy process . Psychotherapy Research, 29 ( 5 ), 652-665. doi:10.1080/10503307.2017. 1417651 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Talia A., Miller-Bottome M., Wyner R., Lilliengren P., Bate J. (2019b). Patients’ Adult Attachment Interview classification and their experience of the therapeutic relationship: are they associated? Research in Psychotherapy: Psychopathology, Process and Outcome , 22 ( 2 ), 174-187. doi: 10.4081/ripppo.2019.361 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Talia A., Muzi L., Lingiardi V., Taubner S. (2018). How to be a secure base: Therapists’ attachment representations and their link to attunement in psychotherapy. Attachment & Human Development . Advance online publication . doi: 10.1080/14616734.2018.1534247 [ PubMed ] [ Google Scholar ]
• Wachtel P. L. (2010). One-person and two-person conceptions of attachment and their implications for psychoanalytic thought . The International Journal of Psychoanalysis, 91 ( 3 ), 561-581. [ PubMed ] [ Google Scholar ]
• Wallin D. (2007). Attachment and psychotherapy . New York, NY: Guilford Press. [ Google Scholar ]
• Wrape E. R., Callahan J. L., Rieck T., Watkins C. E. (2017). Attachment theory within clinical supervision: Application of the conceptual to the empirical . Psychoanalytic Psychotherapy, 31 ( 1 ), 37-54. doi: 10.1080/02668734.2016. 1261927 [ Google Scholar ]
• Zimmermann J., Kerber A., Rek K., Hopwood C. J., Krueger R. F. (2019). A brief but comprehensive review of research on the Alternative DSM-5 Model for Personality Disorders . Current Psychiatry Reports , 21-92. doi: 10.1007/s11920-019-1079-z [ PubMed ] [ Google Scholar ]

John Bowlby’s Attachment Theory

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

John Bowlby (1907 – 1990) was a psychoanalyst (like Freud) and believed that mental health and behavioral problems could be attributed to early childhood.

Key Takeaways

• Bowlby’s evolutionary theory of attachment suggests that children come into the world biologically pre-programmed to form attachments with others, because this will help them to survive.
• Bowlby argued that a child forms many attachments, but one of these is qualitatively different. This is what he called primary attachment, monotropy.
• Bowlby suggests that there is a critical period for developing attachment (2.5 years). If an attachment has not developed during this time period, then it may well not happen at all. Bowlby later proposed a sensitive period of up to 5 years.
• Bowlby’s maternal deprivation hypothesis suggests that continual attachment disruption between the infant and primary caregiver could result in long-term cognitive, social, and emotional difficulties for that infant.
• According to Bowlby, an internal working model is a cognitive framework comprising mental representations for understanding the world, self, and others, and is based on the relationship with a primary caregiver.
• It becomes a prototype for all future social relationships and allows individuals to predict, control, and manipulate interactions with others.

Evolutionary Theory of Attachment

Bowlby (1969, 1988) was greatly influenced by ethological theory, but especially by Lorenz’s (1935) study of imprinting .  Lorenz showed that attachment was innate (in young ducklings) and therefore had a survival value.

During the evolution of the human species, it would have been the babies who stayed close to their mothers that would have survived to have children of their own.  Bowlby hypothesized that both infants and mothers had evolved a biological need to stay in contact with each other.

Bowlby (1969) believed that attachment behaviors (such as proximity seeking) are instinctive and will be activated by any conditions that seem to threaten the achievement of proximity, such as separation, insecurity, and fear.

Bowlby also postulated that the fear of strangers represents an important survival mechanism, built-in by nature.

Babies are born with the tendency to display certain innate behaviors (called social releases), which help ensure proximity and contact with the mother or attachment figure (e.g., crying, smiling, crawling, etc.) – these are species-specific behaviors.

These attachment behaviors initially function like fixed action patterns and share the same function. The infant produces innate ‘social releaser’ behaviors such as crying and smiling that stimulate caregiving from adults.

The determinant of attachment is not food but care and responsiveness.

Bowlby’s monotropic theory

A child has an innate (i.e., inborn) need to attach to one main attachment figure (i.e., monotropy).

Bowlby’s monotropic theory of attachment suggests attachment is important for a child’s survival.

Attachment behaviors in both babies and their caregivers have evolved through natural selection. This means infants are biologically programmed with innate behaviors that ensure that attachment occurs.

Although Bowlby did not rule out the possibility of other attachment figures for a child, he did believe that there should be a primary bond which was much more important than any other (usually the mother).

Other attachments may develop in a hierarchy below this. An infant may therefore have a primary monotropy attachment to its mother, and below her, the hierarchy of attachments may include its father, siblings, grandparents, etc.

Bowlby believes that this attachment is qualitatively different from any subsequent attachments.  Bowlby argues that the relationship with the mother is somehow different altogether from other relationships.

The child behaves in ways that elicit contact or proximity to the caregiver.  When a child experiences heightened arousal, he/she signals to their caregiver.

Crying, smiling, and locomotion are examples of these signaling behaviors.  Instinctively, caregivers respond to their children’s behavior, creating a reciprocal pattern of interaction.

Critical Period

A child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.

Bowlby (1951) claimed that mothering is almost useless if delayed until after two and a half to three years and, for most children, if delayed till after 12 months, i.e., there is a critical period.

If the attachment figure is broken or disrupted during the critical two-year period, the child will suffer irreversible long-term consequences of this maternal deprivation.  This risk continues until the age of five.

Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as the failure to develop an attachment.

The underlying assumption of Bowlby’s Maternal Deprivation Hypothesis is that continual disruption of the attachment between infant and primary caregiver (i.e., mother) could result in long-term cognitive, social, and emotional difficulties for that infant.

The implications of this are vast – if this is true, should the primary caregiver leave their child in daycare, while they continue to work?

Maternal Deprivation

Bowlby’s maternal deprivation hypothesis suggests that continual attachment disruption between the infant and primary caregiver (i.e., mother) could result in long-term cognitive, social, and emotional difficulties for that infant.

Bowlby (1988) suggested that the nature of monotropy (attachment conceptualized as being a vital and close bond with just one attachment figure) meant that a failure to initiate or a breakdown of the maternal attachment would lead to serious negative consequences, possibly including affectionless psychopathy.

Bowlby’s theory of monotropy led to the formulation of his maternal deprivation hypothesis.

John Bowlby (1944) believed that the infant’s and mother’s relationship during the first five years of life was crucial to socialization.

According to Bowlby, if separation from the primary caregiver occurs during the critical period and there is no adequate substitute emotional care, the child will suffer from deprivation.

This will lead to irreversible long-term consequences in the child’s intellectual, social, and emotional development.

Bowlby initially believed the effects to be permanent and irreversible:

• delinquency,
• reduced intelligence,
• increased aggression,
• depression,
• affectionless psychopathy

Bowlby also argued that the lack of emotional care could lead to affectionless psychopathy,

Affectionless psychopathy is characterized by a lack of concern for others, a lack of guilt, and the inability to form meaningful relationships.

Such individuals act on impulse with little regard for the consequences of their actions.  For example, showing no guilt for antisocial behavior.

The prolonged deprivation of the young child of maternal care may have grave and far-reaching effects on his character and so on the whole of his future life (Bowlby, 1952, p. 46).

Bowlby believed that disrupting this primary relationship could lead to a higher incidence of juvenile delinquency, emotional difficulties, and antisocial behavior. To test his hypothesis, he studied 44 adolescent juvenile delinquents in a child guidance clinic.

Bowlby 44 Thieves

To investigate the long-term effects of maternal deprivation on people to see whether delinquents have suffered deprivation.

According to the Maternal Deprivation Hypothesis, breaking the maternal bond with the child during their early life stages is likely to affect intellectual, social, and emotional development seriously.

Between 1936 and 1939, an opportunity sample of 88 children was selected from the clinic where Bowlby worked. Of these, 44 were juvenile thieves (31 boys and 13 girls) who had been referred to him because of their stealing.

Bowlby selected another group of 44 children (34 boys and 10 girls) to act as ‘controls (individuals referred to the clinic because of emotional problems but not yet committed any crimes).

On arrival at the clinic, each child had their IQ tested by a psychologist who assessed their emotional attitudes toward the tests. The two groups were matched for age and IQ.

The children and their parents were interviewed to record details of the child’s early life (e.g., periods of separation, diagnosing affectionless psychopathy) by a psychiatrist (Bowlby), a psychologist, and a social worker.  The psychiatrist, psychologist, and social worker made separate reports.

Bowlby found that 14 children from the thief group were identified as affectionless psychopaths (they were unable to care about or feel affection for others); 12 had experienced prolonged separation of more than six months from their mothers in their first two years of life.

In contrast, only 5 of the 30 children not classified as affectionless psychopaths had experienced separations.

Out of the 44 children in the control group, only two experienced prolonged separations, and none were affectionless psychopaths.

The results support the maternal deprivation hypothesis as they show that most of the children diagnosed as affectionless psychopaths (12 out of 14) had experienced prolonged separation from their primary caregivers during the critical period, as the hypothesis predicts

Bowlby concluded that maternal deprivation in the child’s early life caused permanent emotional damage.

He diagnosed this as a condition and called it Affectionless Psychopathy. According to Bowlby, this condition involves a lack of emotional development, characterized by a lack of concern for others, a lack of guilt, and an inability to form meaningful and lasting relationships.

Bowlby directly observed parental separation’s harm in evacuating children from bombing during WWII, strengthening his hospital research indicating it profoundly impacts children’s emotional and behavioral development.

Limitations

The supporting evidence that Bowlby (1944) provided was in the form of clinical interviews of, and retrospective data on, those who had and had not been separated from their primary caregiver.

This meant that Bowlby asked the participants to look back and recall separations.  These memories may not be accurate.

A criticism of the 44 thieves study was that it concluded affectionless psychopathy was caused by maternal deprivation.  This is correlational data and only shows a relationship between these two variables. It cannot show a cause-and-effect relationship between separation from the mother and the development of affectionless psychopathy.

Other factors could have been involved, such as the reason for the separation, the role of the father, and the child’s temperament. Thus, as Rutter (1972) pointed out, Bowlby’s conclusions were flawed, mixing up cause and effect with correlation.

Many of the 44 thieves in Bowlby’s study had been moved around a lot during childhood, and had probably never formed an attachment.  This suggested that they were suffering from privation, rather than deprivation, which Rutter (1972) suggested was far more deleterious to the children. This led to a very important study on the long-term effects of privation, carried out by Hodges and Tizard (1989).

The study was vulnerable to researcher bias. Bowlby conducted the psychiatric assessments himself and made the diagnosis of Affectionless Psychopathy. He knew whether the children were in the ‘theft group’ or the control group. Consequently, his findings may have been unconsciously influenced by his own expectations. This potentially undermines their validity.

Bowlby struggled to apply his new maladaptation model to retrospective research on adolescents with conduct problems, as such studies prejudice outcomes by selecting for problems and then looking backward.

Cautious of this, in 1950, Bowlby, Robertson, and new researcher Mary Ainsworth (1956) began a forward-looking “follow-up study” on whether preschoolers who were hospitalized long-term subsequently developed conduct issues.

Assessing 60 such children aged 6-13 and controls, contrary to maternal deprivation hypotheses, they found more emotional apathy, withdrawal, and poor control than criminality.

So, while early prolonged separation impacted some children’s later adjustment, outcomes proved far more varied than Bowlby’s theory initially predicted. The improved prospective methodology highlighted limitations in Bowlby’s previous retrospective approaches.

In the conclusions of the paper Bowlby admitted that his theory regarding the development of conduct problems may be wrong:

It is clear that some of the workers, including the present senior author, in their desire to call attention to dangers which can often be avoided have on occasion overstated their case. In particular, statements implying that children who are brought up in institutions or who suffer other forms of serious privation and deprivation in early life commonly develop psychopathic or affectionless characters (e.g., Bowlby, 1944) are seen to be mistaken. (Bowlby et al., 1956, p. 240)

Short-Term Separation

When WWII ended in 1945, Bowlby had to choose between completing child psychoanalysis training or researching parental separation’s impact on children. He chose the latter, joining colleagues at London’s Tavistock Clinic.

Robertson and Bowlby (1952) believe that short-term separation from an attachment figure leads to distress.

John Bowlby spent two years working alongside a social worker, James Robertson (1952), who observed that children experienced intense distress when separated from their mothers. Even when other caregivers fed such children, this did not diminish the child’s anxiety.

They found three progressive stages of distress:

• Protest : The child cries, screams, and protests angrily when the parent leaves. They will try to cling to their parents to stop them from leaving. Protest could last from a few hours to several days.
• Despair : The child’s protesting gradually stops, and they appear calmer, although still upset. The child refuses others’ attempts for comfort and often seems withdrawn and uninterested in anything. In the despair stage, children become increasingly withdrawn and hopeless.
• Detachment : If separation continues, the child will engage with other people again. All emotions are suppressed, and children live moment-to-moment by repressing feelings for their mother. On the surface, children were seen to be happy and content, but when the mother visited, they frequently ignored her and hardly cried when she left. If this state continues, children become so withdrawn as to seek no mothering at all – a sign of major psychological trauma.

Controversy arose between Bowlby and Robertson regarding the stages of separation, particularly the third stage, which Robertson termed denial, but Bowlby called detachment.

However, both powerfully influenced attitudes and practices around keeping mothers and children together. This led to advocacy for allowing parental presence and major reforms in hospital policies.

A Two-Year-Old Goes to Hospital

Though doctors saw the despair phase as adjustment, Bowlby felt it showed distress’s harm.

To demonstrate this, Robertson filmed two-year-old Laura’s distress when hospitalized for eight days for minor surgery in “ A Two-Year-Old Goes to Hospital ” (1952).

Time series photography showed the stages through which a small child, Laura, passed during her 8-day admission for umbilical hernia repair. The film graphically depicted Laura’s behavior while separated from her mother for a period of time in strange circumstances” (Alsop-Shields & Mohay, 2001).

Laura cries out for her mother from admission onward, pleading in anguish to go home when visited the second day. As the week progresses, her initial constant distress gives way to listlessness and detachment during the parents’ increasingly ambivalent visits.

However, when approached by hospital staff, Laura startles out of her trance to suddenly burst into tears and fruitlessly call for her mother once more.

The raw behaviors captured on film revealed the three-phase separation response of protest, despair, and detachment observed in Bowlby and Robertson’s prior research.

Laura’s suffering starkly contradicts expectations of childrens’ ready hospital adjustment, instead demonstrating their deep distress from both physical separation and the hospital environment itself.

These findings contradicted the dominant behavioral theory of attachment (Dollard and Miller, 1950), which was shown to underestimate the child’s bond with their mother.  The behavioral theory of attachment states that the child becomes attached to the mother because she feeds the infant.

Implications for nursing include the development of family-centered care models keeping parents integral to a child’s hospital care in order to minimize trauma, principles now widely implemented as a result of this pioneering work on attachment.

Internal Working Model

The child’s attachment relationship with their primary caregiver leads to the development of an internal working model (Bowlby, 1969).

This internal working model is a cognitive framework comprising mental representations for understanding the world, self, and others.

The social and emotional responses of the primary caregiver provide the infant with information about the world and other people, and also how they view themselves as individuals.

For example, the extent to which an individual perceives himself/herself as worthy of love and care, and information regarding the availability and reliability of others (Bowlby, 1969).

Bowlby referred to this knowledge as an internal working model (IWM), which begins as a mental and emotional representation of the infant’s first attachment relationship and forms the basis of an individual’s attachment style.

A person’s interaction with others is guided by memories and expectations from their internal model which influence and help evaluate their contact with others (Bretherton & Munholland, 1999).

Working models also comprise cognitions of how to behave and regulate affect when a person’s attachment behavioral system is activated, and notions regarding the availability of attachment figures when called upon.

Bowlby (1969) suggested that the first five years of life were crucial to developing the IWM, although he viewed this as more of a sensitive period rather than a critical one.

Around the age of three, these seem to become part of a child’s personality and thus affect their understanding of the world and future interactions with others (Schore, 2000).

According to Bowlby (1969), the primary caregiver acts as a prototype for future relationships via the internal working model.

There are three main features of the internal working model: (1) a model of others as being trustworthy, (2) a model of the self as valuable, and (3) a model of the self as effective when interacting with others.

It is this mental representation that guides future social and emotional behavior as the child’s internal working model guides their responsiveness to others in general.

The concept of an internal model can be used to show how prior experience is retained over time and to guide perceptions of the social world and future interactions with others.

Early models are typically reinforced via interactions with others over time, and become strengthened and resistant to change, operating mostly at an unconscious level of awareness.

Although working models are generally stable over time they are not impervious to change and as such remain open to modification and revision.  This change could occur due to new experiences with attachment figures or through a reconceptualization of past experiences.

Although Bowlby (1969, 1988) believed attachment to be monotropic, he did acknowledge that rather than being a bond with one person, multiple attachments can occur arranged in the form of a hierarchy.

A person can have many internal models, each tied to different relationships and different memory systems, such as semantic and episodic (Bowlby, 1980).

Collins and Read (1994) suggest a hierarchical model of attachment representations whereby general attachment styles and working models appear on the highest level, while relationship-specific models appear on the lowest level.

General models of attachment are thought to originate from early relationships during childhood, and are carried forward to adulthood where they shape perception and behavior in close relationships.

Attachment & Loss Trilogy

The attachment books trilogy developed key concepts regarding attachment, separation distress, loss responses, and clinical implications over the course of the three volumes.

Attachment (1969/1982)

• Provided evidence for the importance of early parent-child relationships.
• Analyzed the systemic and “goal-corrected” nature of behavior.
• Introduced the concept of an “environment of adaptedness” that organisms inherit a potential to develop systems suited for.
• Discussed how attachment behaviors in infants are components of an attachment system designed to achieve security.
• Explained how attachment behaviors change via feedback from caregivers, becoming oriented toward discriminated figures.
• Posited attachment as a foundational system for survival that interacts with other systems like exploration.

Separation (1973)

• Focused on the negative impacts of separation from attachment figures.
• Outlined phases of separation responses in infants and children.
• Analyzed short- and long-term pathological effects of loss or deprivation.
• Studied how mourning progresses in relation to attachment bonds.
• Linked separation distress and avoidance to later issues of delinquency.

Loss (1980)

• Explored the concept of “loss” in relation to attachment theory.
• Proposed stages of the mourning process.
• Studied outcomes following the loss of an attachment figure.
• Examined detachment and defense processes resulting from loss.
• Applied attachment theory understanding to treatment approaches.

Critical Evaluation

Implications for children’s nursing.

• During Robertson and Bowlby’s research, the British government established a parliamentary committee investigating children’s hospital conditions. This resulted in the 1959 Platt Report, containing 55 recommendations, including allowing parental presence and provisions for their accommodation and children’s education/recreation (Alsop-Shields & Mohay, 2001).
• Robertson also specifically critiqued task-oriented nursing and childcare institutions (Robertson, 1955, 1968, 1970) as emotionally neglectful. He and Bowlby suggested dysfunctional families be kept together but supported (Robertson & Bowlby, 1952) – principles now accepted but decades ahead of their time.
• Robertson and Bowlby’s work has greatly influenced the development of family-centered pediatric nursing models like partnership-in-care and family-centered care in the 1990s. By planning care around the whole family unit rather than just the hospitalized child, and involving parents closely in care, these models aim to reduce emotional trauma for children.

Bifulco et al. (1992) support the maternal deprivation hypothesis. They studied 250 women who had lost mothers, through separation or death, before they were 17.

They found that the loss of their mother through separation or death doubles the risk of depressive and anxiety disorders in adult women. The rate of depression was the highest in women whose mothers had died before the child reached 6 years.

Mary Ainsworth’s (1971, 1978) Strange Situation study provides evidence for the existence of the internal working model. A secure child will develop a positive internal working model because it has received sensitive, emotional care from its primary attachment figure.

An insecure-avoidant child will develop an internal working model in which it sees itself as unworthy because its primary attachment figure has reacted negatively to it during the sensitive period for attachment formation.

Bowlby’s Maternal Deprivation is supported by Harlow’s (1958) research with monkeys .  Harlow showed that monkeys reared in isolation from their mother suffered emotional and social problems in older age.  The monkey’s never formed an attachment (privation) and, as such grew up to be aggressive and had problems interacting with other monkeys.

Konrad Lorenz (1935) supports Bowlby’s maternal deprivation hypothesis as the attachment process of imprinting is an innate process.

Bowlby’s (1944, 1956) ideas had a significant influence on the way researchers thought about attachment, and much of the discussion of his theory has focused on his belief in monotropy.

Although Bowlby may not dispute that young children form multiple attachments, he still contends that the attachment to the mother is unique in that it is the first to appear and remains the strongest.  However, the evidence seems to suggest otherwise on both of these counts.

• Schaffer & Emerson (1964) noted that specific attachments started at about eight months, and very shortly thereafter, the infants became attached to other people. By 18 months, very few (13%) were attached to only one person; some had five or more attachments.
• Rutter (1972) points out that several indicators of attachment (such as protest or distress when an attached person leaves) have been shown for various attachment figures – fathers, siblings, peers, and even inanimate objects.

Critics such as Rutter have also accused Bowlby of not distinguishing between deprivation and privation – the complete lack of an attachment bond, rather than its loss.  Rutter stresses that the quality of the attachment bond is the most important factor, rather than just deprivation in the critical period.

Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as the failure to develop an attachment.  Are the effects of maternal deprivation as dire as Bowlby suggested?

Michael Rutter (1972) wrote a book called Maternal Deprivation Re-assessed .  In the book, he suggested that Bowlby may have oversimplified the concept of maternal deprivation.

Bowlby used the term “maternal deprivation” to refer to separation from an attached figure, loss of an attached figure and failure to develop an attachment to any figure.  These each have different effects, argued Rutter.  In particular, Rutter distinguished between privation and deprivation.

Michael Rutter (1981) argued that if a child fails to develop an emotional bond , this is privation, whereas deprivation refers to the loss of or damage to an attachment.

Deprivation might be defined as losing something that a person once had, whereas privation might be defined as never having something in the first place.

From his survey of research on privation, Rutter proposed that it is likely to lead initially to clinging, dependent behavior, attention-seeking, and indiscriminate friendliness, then as the child matures, an inability to keep rules, form lasting relationships, or feel guilt.

He also found evidence of anti-social behavior, affectionless psychopathy, and disorders of language, intellectual development and physical growth.

Rutter argues that these problems are not due solely to the lack of attachment to a mother figure, as Bowlby claimed, but to factors such as the lack of intellectual stimulation and social experiences that attachments normally provide.  In addition, such problems can be overcome later in the child’s development, with the right kind of care.

Bowlby assumed that physical separation on its own could lead to deprivation, but Rutter (1972) argues that it is the disruption of the attachment rather than the physical separation.

This is supported by Radke-Yarrow (1985), who found that 52% of children whose mothers suffered from depression were insecurely attached. This figure raised to 80% when this occurred in a context of poverty (Lyons-Ruth,1988). This shows the influence of social factors. Bowlby did not take into account the quality of the substitute care. Deprivation can be avoided if there is good emotional care after separation.

Is attachment theory sexist?

Feminist critics argue Bowlby’s attachment theory is sexist for overly emphasizing mothers as ideal caregivers while neglecting other influences like fathers (e.g., Vicedo, 2017).

His popular 1950s parenting articles reinforced gender roles by proclaiming mothers uniquely important and always available. Critics also attacked his concept “monotropy” – instincts focused on one caregiver, presumably the mother.

However, Bowlby’s academic writings use phrases like “mothers or foster-mothers,” adoptive mothers, and “mother substitutes,” acknowledging many can serve as primary caregiver.

He never scientifically stated only biological mothers suffice. While “monotropy” poorly implies a singular caregiver, Bowlby meant children form one main attachment, not only to mothers. So academically, Bowlby did not limit caregivers to mothers, though his public emphasis on maternal deprivation and parenting did reinforce gender biases.

There are implications arising from Bowlby’s work.  He reinforced the idea that a mother should be the most central caregiver and that this care should be given continuously. An obvious implication is that mothers should not go out to work.  There have been many attacks on this claim:

• Mothers are the exclusive carers in only a very small percentage of human societies; often there are a number of people involved in the care of children, such as relations and friends (Weisner, & Gallimore, 1977).
• Van Ijzendoorn, & Tavecchio (1987) argue that a stable network of adults can provide adequate care and that this care may even have advantages over a system where a mother has to meet all a child’s needs.
• There is evidence that children develop better with a mother who is happy in her work, than a mother who is frustrated by staying at home (Schaffer, 1990).

Ainsworth, M. D. S., Bell, S. M., & Stayton, D. J. (1971) Individual differences in strange- situation behavior of one-year-olds. In H. R. Schaffer (Ed.)  The origins of human social relations . London and New York: Academic Press. Pp. 17-58.

Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978).  Patterns of attachment: A psychological study of the strange situation . Hillsdale, NJ: Erlbaum.

Alsop‐Shields, L., & Mohay, H. (2001). John Bowlby and James Robertson: theorists, scientists and crusaders for improvements in the care of children in hospital.  Journal of advanced nursing ,  35 (1), 50-58.

Bifulco, A., Harris, T., & Brown, G. W. (1992). Mourning or early inadequate care? Reexamining the relationship of maternal loss in childhood with adult depression and anxiety. Development and Psychopathology, 4(03) , 433-449.

Bowlby, J. (1944). Forty-four juvenile thieves: Their characters and home life. International Journal of Psychoanalysis, 25(19-52) , 107-127.

Bowlby, J. (1951). Maternal care and mental health . World Health Organization Monograph.

Bowlby, J. (1952). Maternal care and mental health. Journal of Consulting Psychology, 16(3) , 232.

Bowlby, J. (1953). Child care and the growth of love . London: Penguin Books.

Bowlby, J. (1956). Mother-child separation. Mental Health and Infant Development, 1, 117-122.

Bowlby, J. (1957). Symposium on the contribution of current theories to an understanding of child development. British Journal of Medical Psychology, 30(4) , 230-240.

Bowlby, J. (1969). Attachment. Attachment and loss: Vol. 1. Loss . New York: Basic Books.

Bowlby, J. (1980). Loss: Sadness & depression. Attachment and loss (vol. 3); (International psycho-analytical library no.109). London: Hogarth Press.

Bowlby, J. (1988). Attachment, communication, and the therapeutic process. A secure base: Parent-child attachment and healthy human development , 137-157.

Bowlby, J., Ainsworth, M., Boston, M., & Rosenbluth, D. (1956). The effects of mother‐child separation: a follow‐up study .  British Journal of Medical Psychology ,  29 (3‐4), 211-247.

Bowlby, J., and Robertson, J. (1952). A two-year-old goes to hospital. Proceedings of the Royal Society of Medicine, 46, 425–427.

Bretherton, I., & Munholland, K.A. (1999). Internal working models revisited. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 89– 111) . New York: Guilford Press.

Collins, N. L., & Read, S. J. (1994). Cognitive representations of adult attachment: The structure and function of working models. In K. Bartholomew & D. Perlman (Eds.) Advances in personal relationships, Vol. 5: Attachment processes in adulthood  (pp. 53-90). London: Jessica Kingsley.

Harlow, H. F., & Zimmermann, R. R. (1958). The development of affective responsiveness in infant monkeys. Proceedings of the American Philosophical Society, 102 ,501 -509.

Hodges, J., & Tizard, B. (1989). Social and family relationships of ex‐institutional adolescents. Journal of Child Psychology and Psychiatry, 30(1) , 77-97.

Lorenz, K. (1935). Der Kumpan in der Umwelt des Vogels. Der Artgenosse als auslösendes Moment sozialer Verhaltensweisen. Journal für Ornithologie 83, 137–215.

Lyons-Ruth, K., Zoll, D., Connell, D., & Grunebaum, H. E. (1986). The depressed mother and her one-year-old infant: Environment, interaction, attachment, and infant development. In E. Tronick & T. Field (Eds.), Maternal depression and infant disturbance (pp. 61-82). San Francisco: Jossey-Bass.

Ministry of Health (1959). The Welfare of Children in Hospital, Platt Report . London: Her Majesty’s Stationery Office.

Radke-Yarrow, M., Cummings, E. M., Kuczynski, L., & Chapman, M. (1985). Patterns of attachment in two-and three-year-olds in normal families and families with parental depression. Child development , 884-893.

Robertson J. (1953). A Two-Year-Old Goes to Hospital: A Scientific Film Record (Film) . Concord Film Council, Nacton.

Robertson, J. (1955). Young children in long-term hospitals.  Nursing Times ,  23 (9).

Robertson, J. (1958).  Going to Hospital with Mother: A Guide to the Documentary Film . Tavistock Child Development Research Unit.

Robertson, J. (1968). The long-stay child in hospital.  Maternal Child Care ,  4 (40), 161-6.

Robertson, J., & Robertson, J. (1968). Jane 17 months; in fostercare for 10 days.  London: Tavistock Institute of Human Relations. Film .

Robertson, J., & Robertson, J. (1971). Young children in brief separation: A fresh look.  The psychoanalytic study of the child ,  26 (1), 264-315.

Rutter, M. (1972). Maternal deprivation reassessed. Harmondsworth: Penguin.

Rutter, M. (1979). Maternal deprivation, 1972-1978: New findings, new concepts, new approaches. Child Development , 283-305.

Rutter, M. (1981). Stress, coping and development: Some issues and some questions. Journal of Child Psychology and Psychiatry, 22(4) , 323-356.

Schaffer, H. R. & Emerson, P. E. (1964). The development of social attachments in infancy. Monographs of the Society for Research in Child Development , 29 (3), serial number 94.

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment & Human Development, 2(1) , 23-47.

Tavecchio, L. W., & Van Ijzendoorn, M. H. (Eds.). (1987). Attachment in social networks: Contributions to the Bowlby-Ainsworth attachment theory . Elsevier.

Vicedo, M. (2020). Attachment Theory from Ethology to the Strange Situation. In  Oxford Research Encyclopedia of Psychology .

Weisner, T. S., & Gallimore, R. (1977). My brother’s keeper: Child and sibling caretaking. Current Anthropology, 18(2) , 169.

Further Reading

• The Internal Working Models Concept: What Do We Really Know About the Self in Relation to Others?
• The Effects of Maternal Deprivation
• Davies, R. (2010). Marking the 50th anniversary of the Platt Report: from exclusion, to toleration and parental participation in the care of the hospitalized child .  Journal of Child Health Care ,  14 (1), 6-23.
• Bowlby, J. (1963). Pathological mourning and childhood mourning .  Journal of the American Psychoanalytic Association ,  11 (3), 500-541.

Related Articles

Child Psychology

Vygotsky vs. Piaget: A Paradigm Shift

Interactional Synchrony

Internal Working Models of Attachment

Learning Theory of Attachment

Stages of Attachment Identified by John Bowlby And Schaffer & Emerson (1964)

Attachment Theory In Psychology