Attachment Theory in Adult Mental Health - A Guide To Clinical Practice (PDFDrive)

Attachment Theory in Adult
Mental Health
In the ¿fty years since its inception, John Bowlby’s attachment theory has been a
powerful inÀuence on developmental psychology and, more recently, mental
health. Bringing together the experience of a diverse range of mental health
practitioners and researchers who routinely use attachment theory in their own
work, Attachment Theory in Adult Mental Health provides a guide to using
attachment theory in everyday practice.
Adam N. Danquah and Katherine Berry present a wide-ranging and practical
approach to the topic that includes studies on clinical practice, the provision of
mental health services and accommodating intercultural perspectives. Section
One covers the basics of attachment theory and practice. Section Two presents
clinical problems and presentations, including the treatment of depression, anxiety
disorders, psychosis, personality disorder and eating disorders. Section Three
addresses the needs of speci¿c populations, discussing the inÀuence of
sociocultural factors such as gender, ethnicity and age. Finally, Section Four
examines the organisation and the practitioner, including using the theory to
organise services and how individual therapists can integrate their own attachment
histories into their approach.
Including the most up-to-date theories and practice in the ¿eld, Attachment
Theory in Adult Mental Health is an ideal resource for psychologists and
psychological therapists, counsellors, psychiatrists, occupational therapists, social
workers and mental health service managers and commissioners.
Adam N. Danquah is a clinical psychologist in Pennine Care NHS Foundation

Trust, where he works in secondary care adult mental health with adults across the
age range with complex and longstanding mental health problems. He is co-
founder and associate editor of the Ghana International Journal of Mental Health.
Katherine Berry is a postdoctoral research fellow at the University of Manchester,

funded by the National Institute of Health Research, and a clinical psychologist.
Her main area of expertise is interpersonal relationships in people with a diagnosis
of psychosis.
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Attachment Theory in Adult
Mental Health
A guide to clinical practice
Edited by Adam N. Danquah and

Katherine Berry
First published 2014
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2014 Adam N. Danquah and Katherine Berry
The right of the editors to be identified as the authors of the
editorial material, and of the authors for their individual chapters, has
been asserted in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

Attachment theory in adult mental health : a guide to clinical
practice / edited by Adam N. Danquah and Katherine Berry.
p. ; cm.
Includes bibliographical references.
I. Danquah, Adam N. II. Berry, Katherine.
[DNLM: 1. Object Attachment. 2. Adult. 3. Mental Disorders--
therapy. 4. Psychotherapy--methods. WM 460.5.O2]
RC480.5
616.89’14--dc23
2013016224
ISBN: 978-0-415-68740-9 (hbk)

ISBN: 978-0-415-68741-6 (pbk)
ISBN: 978-1-315-88349-6 (ebk)
Typeset in Times and Gill Sans

by Saxon Graphics Ltd, Derby
Adam – For my family
Katherine – For Jacob and Ethan
Contents
List of ¿gures x
The editors xi
Contributors xii
Foreword by Brent Mallinckrodt xviii
Acknowledgements xxi
SECTION 1
Attachment theory and practice – the basics
1 Introduction 3
KATHERINE BERRY, ADAM N. DANQUAH AND DAVID WALLIN
2 Attachment theory in therapeutic practice 16

JEREMY HOLMES
SECTION 2
Clinical problems and presentations
3 Attachment theory and compassion focused therapy

for depression 35
PAUL GILBERT
4 Responding to threat: using attachment-related interventions in

cognitive behavioural therapy of anxiety disorders 48
GAIL MYHR
5 Attachment theory and psychosis 63

MATTHIAS SCHWANNAUER AND ANDREW GUMLEY
viii Contents
6 Understanding attachment, trauma and dissociation in

complex developmental trauma disorders 78
KATHY STEELE AND ONNO VAN DER HART
7 Attachment theory and personality disorders 95

KENNETH N. LEVY, KEVIN B. MEEHAN AND CHRISTINA M. TEMES
8 Disorganised attachment in the pathogenesis and the

psychotherapy of borderline personality disorder 113
GIOVANNI LIOTTI
9 Starving for affection: attachment narrative therapy

with eating disorders 129
RUDI DALLOS
10 An attachment perspective on understanding and

managing medically unexplained symptoms 145
ROBERT G. MAUNDER AND JONATHAN J. HUNTER
SECTION 3
Specific populations
11 Bringing a gendered perspective to attachment theory

in therapy 161
SUSIE ORBACH
12 Attachment in African Caribbean families 170

LENNOX K. THOMAS
13 Meeting the mental health needs of older adults using the

attachment perspective 183
CECILIA YEE MAN POON
SECTION 4
The organisation and the individual practitioner
14 Four pillars of security: attachment theory and practice in

forensic mental health care 199
GWEN ADSHEAD AND ANNE AIYEGBUSI
Contents ix
15 Using attachment theory to inform psychologically minded

care services, systems and environments 213
MARTIN SEAGER
16 We are the tools of our trade: the therapist’s attachment

history as a source of impasse, inspiration and change 225
DAVID WALLIN
Index 241
Figures
3.1 Three types of affect regulation system 39

3.2 Experiences associated with three major affect regulation
systems in depression 42
9.1 Corrective scripts and patterns of escalating distress 134
9.2 Kathy and her family – genogram 139
The editors
Adam N. Danquah is a clinical psychologist in Pennine Care NHS Foundation

Trust, where he works in secondary care adult mental health in Stockport, Greater
Manchester. Clinically he works with adults across the age range with complex
and usually longstanding mental health problems. His research interests include
attachment processes both in therapy and in mental health service provision more
generally. He is currently training in psychodynamic psychotherapy with the
Tavistock & Portman NHS Foundation Trust at the Northern School of Child and
Adolescent Psychotherapy, Leeds. He is associate editor of the Ghana International
Journal of Mental Health, which he co-founded whilst working as a clinical
psychologist and lecturer in Ghana.
Katherine Berry is a postdoctoral research fellow at the University of Manchester,

funded by the National Institute of Health Research, and a clinical psychologist.
Her main area of expertise is interpersonal relationships in people with a diagnosis
of psychosis. After completing her PhD, which explored the relevance of
attachment theory in psychosis, she obtained a fellowship to develop and evaluate
an intervention to improve staff–patient relationships in inpatient psychiatric
settings.
Contributors
Gwen Adshead is a forensic psychiatrist and psychotherapist. She trained at St

George’s Hospital, the Institute of Psychiatry and the Institute of Group Analysis.
For the last ten years she has worked as a consultant forensic psychotherapist at
Broadmoor Hospital, where she runs psychotherapeutic groups for offenders and
works with staff and organisational dynamics. Gwen also has a Master’s Degree
in Medical Law and Ethics and a research interest in moral reasoning and how this
links with ‘bad’ behaviour. Gwen has published a number of books and over 100
papers, book chapters and commissioned articles on forensic psychotherapy,
ethics in psychiatry and attachment theory as applied to medicine and forensic
psychiatry.
Anne Aiyegbusi is Interim Director of Nursing and Patient Experience at West

London Mental Health NHS Trust and visiting Fellow at Buckinghamshire New
University. She previously led and developed nursing practice within forensic
mental health services, with a particular focus on integrating forensic psychotherapy
with the nursing role. She has a special interest in psychological trauma and how
it can reverberate throughout mental health services. Anne is a strong advocate of
the clinical value of attachment theory as a framework for understanding and
supporting people with traumatic histories and complex mental health needs.
Rudi Dallos is Professor of Clinical Psychology and research director on the D

Clin Psychol training programme at the University of Plymouth. He is also a
family therapist and has utilised his research and clinical experience to incorporate
attachment theory into systemic therapy. He has published a number of books,
including Attachment Narrative Therapy and Systemic Therapy and Attachment
Narratives.
Paul Gilbert OBE is Professor of Clinical Psychology at the University of Derby

and consultant clinical psychologist at the Derbyshire Health Care Foundation
Trust. He has researched evolutionary approaches to psychopathology for over 35
years, with a special focus on shame and the treatment of shame-based dif¿culties
– for which compassion-focused therapy was developed. In 2003 he was president
Contributors xiii
of the BABCP and a member of the group that produced the ¿rst NICE guidelines
for depression. He has written or edited 20 books and over 150 papers. In 2006 he
established the Compassionate Mind Foundation, a charity with the mission
statement ‘To promote wellbeing through the scienti¿c understanding and
application of compassion’ (www.compassionatemind.co.uk). He was awarded
an OBE in March 2011.
Andrew Gumley is a clinical psychologist and Professor of Psychological

Therapy based in the Institute of Health and Wellbeing within the University of
Glasgow. Andrew’s research spans the trajectory of psychosis, from those at risk
to individuals with established psychosis that is unresponsive to existing
treatments. Andrew is interested in the application of psychological theory to the
understanding of mechanisms of recovery; the development and evaluation of
psychological therapies, from feasibility, through piloting, to de¿nitive randomised
controlled trials; and ¿nally, the design and evaluation of service systems to
promote engagement, autonomy and psychological wellbeing.
Jeremy Holmes worked for 35 years as a consultant psychiatrist and

psychotherapist in the NHS, ¿rst at University College London, and then providing
a district psychotherapy service in North Devon, focusing especially on people
with borderline personality disorder. He was Chair of the Psychotherapy Faculty
of the Royal College of Psychiatrists 1998–2002. Now partially retired, he has a
part-time private practice; has set up and co-runs a Masters and Doctoral
psychoanalytic psychotherapy training and research programme at Exeter
University, where he is visiting Professor; and lectures nationally and
internationally. He has written more than 150 peer reviewed papers and chapters
in the ¿eld of attachment theory and psychoanalytic psychotherapy. His many
books, translated into nine languages, include The Oxford Textbook of
Psychotherapy (2005, co-editors Glen Gabbard and Judy Beck), Storr’s The Art of
Psychotherapy (Taylor & Francis 2012) and Exploring in Security: Towards an
Attachment-informed Psychoanalytic Psychotherapy (Routledge), which won the
2010 Canadian Psychological Association Goethe Award. With Arietta Slade he
is currently preparing a six-volume compendium of the most important papers in
attachment theory (Benchmarks in Psychology: Attachment Theory, SAGE).
Literature and the Therapeutic Imagination and John Bowlby and Attachment
Theory, 2nd Edition (both Routledge) are due in 2013. He was the recipient of the
2009 New York Attachment Consortium Bowlby–Ainsworth Founders Award.
Jonathan J. Hunter is an associate professor at the University of Toronto, where

he heads the Division of Consultation-Liaison Psychiatry, which addresses the
psychiatric needs of medically and surgically ill patients. He is a founding member
of a network of Family Physicians, which links family practitioners in the
community with mental health care mentors for advice about managing psychiatric
concerns in a timely fashion. He participates in grants funded by NCIC, NIH,
xiv Contributors
CIHR, and the Change Foundation. His clinical practice centres on the psychiatric
and psychotherapeutic care of cancer patients. Research interests include
psychological management of chemotherapy side-effects, group psychotherapy in
women at high risk for breast cancer, the role of early life experience and
attachment in adaptation to disease, and the importance of mentalising in
treatment.
Kenneth N. Levy is a tenured associate professor in the Department of Psychology

at the Pennsylvania State University, where he directs the Laboratory for Research
on Personality, Psychopathology and Psychotherapy. He is also the Associate
Director of Research at the Personality Disorders Institute (PDI) at the Joan and
Sanford I. Weill Medical College of Cornell University. His main research
interests are attachment theory, borderline personality disorder, and psychotherapy
process and outcome. He was a founding member of the NIMH Think Tank on the
Treatment of Borderline Personality Disorder and is the associate editor of the
Journal of Psychotherapy Integration. He has published more than 150 articles
and chapters. He maintains a part-time private practice in State College, PA.
Giovanni Liotti is a psychiatrist and psychotherapist who currently teaches at the

APC Postgraduate School of Psychotherapy in Rome. His interest in the clinical
applications of attachment theory was ¿rst expressed in a book co-authored with
V.F. Guidano (Cognitive Processes and Emotional Disorders, Guilford Press,
1983). His work over the past 20 years has focused on the links between trauma,
dissociation and attachment disorganisation. In 2005 he received the Pierre Janet’s
Writing Award of The International Society for the Study of Trauma and
Dissociation, and in 2006 the International Mind and Brain Award of the
University of Turin. His latest book, co-authored with Benedetto Farina, is
Sviluppi traumatici: Eziopatogenesi, clinica e terapia della dimensione
dissociativa (Traumatic Development: etiology, clinical features and therapy of
the dissociative dimension, Cortina Editore, 2011).
Brent Mallinckrodt is a professor in the Department of Psychology at the

University of Tennessee. He is former editor of the Journal of Counseling
Psychology, and director of Graduate Studies in Counseling Psychology, where
he has helped develop the ¿rst programme accredited by the American
Psychological Association with a scientist–practitioner–advocate training model,
emphasising social justice advocacy. He is author of over 90 articles and book
chapters, many on the topics of adult attachment and the psychotherapy
relationship.
Robert G. Maunder is associate professor in the Department of Psychiatry at the

University of Toronto and Head of Research in the Department of Psychiatry at
Mount Sinai Hospital. His research, often done in collaboration with Jon Hunter,
focuses on issues at the interface of psychology, psychiatry and physical health,
Contributors xv
especially the impact of interpersonal relationships on health. Since the 2003

SARS outbreak, he has also studied the impact of extraordinary stress on healthcare
workers and how to build resilience.
Kevin B. Meehan is an assistant professor in the Department of Psychology and

the Clinical Psychology Doctoral Program at Long Island University, Brooklyn.
He is also an adjunct clinical assistant professor of psychology in the Department
of Psychiatry at Weill Cornell Medical College, where he collaborates with his
colleagues at the Personality Disorders Institute (PDI) in evaluating a manualised
treatment for borderline personality disorder called Transference Focused
Psychotherapy (TFP). His clinical research evaluates attachment and reÀective
functioning as mechanisms of change in psychodynamic and interpersonal
psychotherapies, as well as the process of change in patients with personality
disorders and post-traumatic stress disorder. His research also evaluates de¿cits in
social and regulatory processes in both college-age and personality disordered
populations. He also maintains a private practice in downtown Brooklyn.
Gail Myhr is an associate professor of psychiatry at McGill University, Canada.

She is a psychiatrist and a cognitive therapist and Director of the Cognitive
Behavioural Therapy Unit of the McGill University Health Centre, a university
research and teaching unit which trains mental health professionals in basic and
advanced cognitive behavioural therapy skills. Her clinical and research interests
include suitability for short-term CBT, CBT for psychosis, attachment-related
interventions in CBT, and the cost-effectiveness of CBT in the treatment of mental
disorders. She is a fellow of the Royal College of Physicians and Surgeons of
Canada, a diplomate of the Academy of Cognitive Therapy, and Membership
Chair and Founding Member of the Canadian Association of Cognitive and
Behavioural Therapies (l’Association Canadienne des Thérapies Cognitives et
Comportementales).
Susie Orbach is a psychoanalyst and writer whose interests have centred around
feminism and psychoanalysis, the construction of femininity and gender,
globalisation and body image, emotional literacy, and psychoanalysis and the
public sphere. She co-founded The Women’s Therapy Centre in London in 1976
and The Women’s Therapy Centre Institute, New York in 1981. Her numerous
publications include the classic Fat is a Feminist Issue, along with similarly
inÀuential texts such as Hunger Strike, What Do Women Want (with Luise
Eichenbaum), The Impossibility of Sex and her latest book, Bodies. Susie is
currently co-editing Fifty Shades of Feminism, which will be published in Spring
2013. Susie has been a consultant to the World Bank, the NHS and Unilever. She
is a founder member of ANTIDOTE (working for emotional literacy) and
Psychotherapists and Counsellors for Social Responsibility, and is convenor of
Endangered Bodies (www.london.endangeredbodies.org), the organisation
campaigning against body hatred. She is also an expert member of the steering
xvi Contributors
group of the British government’s Campaign for Body Con¿dence. Susie is

currently chair of the Relational School in the UK and has a clinical practice
seeing individuals and couples.
Cecilia Yee Man Poon is a postdoctoral fellow in clinical health psychology at

the Nebraska Medical Center. She grew up in Hong Kong and received her Ph.D.
in clinical psychology (ageing track) at the University of Southern California. Her
clinical and research interests are in ageing and mental health, particularly
caregiving and coping with chronic illness. Her published work has focused on
the inÀuence of adverse parent–child relationships on health and wellbeing across
the lifespan.
Matthias Schwannauer, MA, MSc, DPsych, Ph.D, CPsychol, AFBPsS, is a

professor of clinical psychology who graduated in clinical and applied psychology
from the University of Marburg in 1998. His ¿rst position as a clinical psychologist
was in the Adolescent Mental Health Services in Glasgow. He moved to NHS
Lothian and the University of Edinburgh in 2000. During this time he was able to
carry out his Ph.D research into psychological interventions for bipolar disorders.
This research involved the implementation of a randomised controlled trial of
Cognitive Interpersonal Therapy and an investigation of the role of interpersonal
and cognitive factors in the recovery process. He is currently Head of the Section
of Clinical and Health Psychology at the University of Edinburgh. He is a
consultant clinical psychologist in the Early Psychosis Support Service at CAMHS
Lothian. His current research interests include the application of attachment
theory and affect regulation to understanding the development, adaptation to and
recovery from psychosis and recurrent mood disorders.
Martin Seager is a clinician, lecturer, campaigner, broadcaster and activist on

mental health issues. He studied at Oxford University, Edinburgh University and
the Tavistock Clinic and has worked in the NHS for nearly 30 years. He had a
regular mental health slot on BBC Radio 5 Live from 2007–9. He is currently
working part-time with the South West Yorkshire Partnership NHS Foundation
Trust and in private practice. He is also an honorary consultant psychologist with
the Central London Samaritans and a member of the Mental Health Advisory
Board of the College of Medicine.
Kathy Steele, MN, CS, is clinical director of Metropolitan Counselling Services,

a psychotherapy and training centre. She is also a psychotherapist in private
practice in Atlanta, Georgia. She offers therapists training and consultation on
psychological trauma, dissociation, attachment issues and many other related
topics. Kathy has written extensively on the topics of trauma, dissociation,
attachment and stabilisation. Her publications include two award-winning books:
Coping with Trauma-related Dissociation: skills training for patients and
therapists and The Haunted Self: structural dissociation and the treatment of
Contributors xvii
chronic traumatization. She is past president of the International Society for the
Study of Trauma and Dissociation.
Christina M. Temes is a graduate student in clinical psychology at the

Pennsylvania State University, working with Dr Kenneth N. Levy. Her research
interests include the etiology and treatment of personality disorders and the
inÀuence of attachment on personality pathology, as well as psychotherapy
process and outcome.
Lennox K. Thomas trained in clinical social work, child and family psychotherapy
and psychoanalytic psychotherapy. He was clinical director of Nafsiyat
Intercultural Therapy Centre, and Co-Director of the University College London
MSc in Intercultural Psychotherapy. He is a consultant psychotherapist at the
Refugee Therapy Centre, a training therapist and supervisor. A member of
the British Psychoanalytic Council, he has been elected as an Honorary Fellow of
the United Kingdom Council for Psychotherapy. InÀuenced by his early work
with children and parents in hospitals, he has an interest in attachment and
relational psychotherapy.
Onno van der Hart is Emeritus Professor of the Psychopathology of Chronic

Traumatization at Utrecht University, and until recently a psychologist/
psychotherapist at the Sinai Center for Mental Health, Amstelveen, the
Netherlands.
David Wallin is a clinical psychologist in private practice in Albany and Mill

Valley, California. A magna cum laude graduate of Harvard who received his
doctorate from the Wright Institute in Berkeley, he has been practising, teaching
and writing about psychotherapy for nearly three decades. Attachment in
Psychotherapy, his most recent book, is presently being translated into nine
languages. He is also co-author of Mapping the Terrain of the Heart: passion,
tenderness, and the capacity to love. He has lectured on attachment and
psychotherapy in Australia, Europe, Canada and throughout the United States.
For further information, please visit www.attachmentinpsychotherapy.com.
Foreword
In the preface to A Secure Base (1988), John Bowlby acknowledged the growing
body of research that attachment theory had prompted in developmental
psychology; but he also noted that despite the theory’s roots in his own experience
as a clinician, ‘it is none the less disappointing that clinicians have been so slow
to test its uses’. These words bring a little sorrow to me, because in this passage I
hear something of a lament. In this valedictory book, published just before his
death in 1990, I ¿nd myself wishing Bowlby had been able to gain a stronger
sense of satisfaction that his seminal theory had more completely ful¿lled its
promise for clinical practice. Ironically, because A Secure Base brought an
inÀuential series of Bowlby’s papers and lectures to a wider audience, the book
that began with this speci¿c regret sparked a new generation of researchers to
begin applying attachment theory to understand psychotherapy with adults.
I was a member of that wider audience in 1992, when I ¿rst read A Secure Base. I
had just become a tenured Associate Professor, a licensed psychologist, and director
of my programme’s research and training clinic. I was strongly inÀuenced by
Bowlby’s thinking about the psychotherapy working alliance as a secure attachment.
Fortunately, with so many adult outpatients available to me at the University of
Oregon’s DeBusk Center, I could observe the unfolding struggle of many therapists-
in-training and clients to forge a secure attachment – and thereby an effective
working alliance. I began a programme of research into how clients’ memories of
emotional bonds with parents were associated with the working alliances they were
able to develop. Fortunately, I was in the right place at the DeBusk Center clinic and
at the right time, inspired by the burgeoning research on adult attachment that
followed Bowlby’s A Secure Base from scholars like Shaver, Mikulincer, Fonagy,
Bartholomew, Holmes, Feeney, their colleagues and others. I also began a part-time
private practice in which I could directly test some of my developing ideas, and I was
able to gather a research team of very bright graduate students. Both became sources
of continuing inspiration. In 1995, this work led to development of the Client
Attachment to Therapist Scale (CATS), a 36-item self-report measure that has since
been translated into ¿ve languages and cited nearly 200 times.
More recently, our qualitative interviews with expert therapists who use
attachment theory to guide their work helped to re¿ne a model of managing
Foreword xix
therapeutic distance, which underscores the importance of creating different

corrective emotional experiences, depending on whether a client exhibits tendencies
toward attachment anxiety or avoidance. The optimal amount of distance versus
engagement appears to vary by type of client and phase of the work. Effective
therapists manage therapeutic distance in different ways to engage clients who tend
to be hyperactive versus deactivate in initial bids for attachment to the therapist;
and then therapists gradually alter this initial stance in the working and termination
phases, differently for each type of client, to foster a corrective psychotherapy
attachment. Our preliminary work with the Therapeutic Distance Scale suggests
that clients with anxious attachments bene¿t from a growing sense of autonomy,
and clients with avoidant attachments bene¿t from a growing sense of engagement
when their therapists skilfully manage distance in the psychotherapy relationship.
Dr Adam Danquah and Dr Katherine Berry have travelled a remarkably similar
path to combine clinical experience with research in the application of attachment
theory to understand patients and the psychotherapy process. Dr Berry has worked
as a clinical psychologist in the National Health Service and conducted research on
the role of attachment in the treatment of psychosis. Currently she has a postdoctoral
fellowship with the National Institute of Health Research, where she is working to
develop and evaluate an intervention to improve staff–patient relationships in
mental health services for people with schizophrenia and related psychoses. Dr
Danquah has worked as a clinician in a children’s hospital, and in West Africa
with former child soldiers. In Ghana he contributed to the continuing synthesis of
Western psychotherapy and traditional oral healing methods. After returning to the
UK, Adam accepted a position as a clinical psychologist in secondary care adult
mental health, where he works to broaden the application of attachment theory to
assessment and intervention. Both Dr Berry and Dr Danquah are accomplished
researchers with a growing list of publications to their credit. Given their solid
grounding, both as practising clinicians and as skilled researchers at the forefront
of applying attachment theory in clinical settings, perhaps it is not surprising that
they have edited a book so useful and so accessible for practising clinicians.
The editors’ rich personal and clinical experiences and perspectives have guided
them in assembling this superb and timely book. The chapters of Attachment
Theory in Adult Mental Health are authored by an international roster of expert
clinician-researchers. Thus readers will ¿nd a synthesis of the latest research in
adult attachment, thoughtfully considered from the perspective of direct
application to clinical work. For example, some chapters address attachment in
connection with speci¿c presenting problems such as anxiety, depression,
dissociation, eating disorders, psychosis, medically unexplained symptoms and
personality disorders. Clinicians working with these issues will ¿nd a wealth of
practical suggestions. Other chapters address speci¿c challenges from the
perspective of attachment theory, such as working in forensic settings, bridging
cultural and ethnic differences, working with older adults, or the impact of socially
proscribed concepts of gender and gender roles. Further chapters take a very broad
perspective, for example by considering how attachment theory can inform
xx Foreword
challenges in the delivery of mental health services. Finally, two chapters with
special relevance for psychotherapy process consider the impact of a therapist’s
own attachment history and the importance of attachment theory for understanding
the psychotherapy relationship.
Thus this book will appeal to a wide range of readers – graduate students in
training, researchers, and practising clinicians. I was especially impressed by the
wealth of practical advice, offered refreshingly unfettered by the ‘tyranny of the
.05 level’. I certainly do not mean to suggest that this book rejects the importance
of evidence based practice. Indeed, the chapters are informed by the best available
research ¿ndings. However, I write from the perspective of a former journal editor
who rejected 80 per cent of the psychotherapy manuscripts we received, and also
from the perspective of a psychologist faced with the necessity of making clinical
decisions in the moment. I fear that too many of the well-controlled studies I
accepted for publication in the Journal of Counseling Psychology were not
suf¿ciently helpful for practising therapists. The therapist who must decide
whether the speci¿c inpatient in her care is ready to be discharged, or whether the
speci¿c client he has just assessed is appropriate for referral to group therapy,
usually cannot wait for the jury of statistical signi¿cance to render a verdict
‘beyond a reasonable doubt’. Instead, clinical decisions must be made based on a
preponderance of the best evidence applied in that particular moment to a speci¿c
case. Of course, with time decisions like these are increasingly guided by clinical
wisdom. Readers seeking this type of hard-earned practical guidance will ¿nd this
book to be a superb contribution.
I am con¿dent that Bowlby would be quite pleased to see that, soon after
publication of A Secure Base, attachment theory expanded into such a wide range
of clinical applications with both children and adults, and that the theory he
developed is now a central foundation of work with a great variety of clients and
in many settings. In fact, given the disappointment that Bowlby expressed in his
last book on attachment, its title has now acquired a second, poignant meaning. In
addition to the secure base construct that is central to attachment theory, the theory
itself has now become an established ‘secure base’ for the application of clinical
practice – as exempli¿ed by Danquah and Berry’s wonderful contribution to this
developing literature.
Brent Mallinckrodt
Acknowledgements
First of all we would like to thank the authors, who somehow found time within
very busy schedules to write excellent chapters. We would like to thank the
editorial team at Routledge for their guidance and support over the course of the
book’s development. A number of people we know personally and professionally
helped us – usually indirectly and unknowingly – to get the book together with
their wisdom, ways of being and support. From among these, Adam would like to
give special mention to Mary Hopper for setting him the professional challenge
that played a part in the book’s conception, and to Joel Harvey for his
encouragement and generosity with insights gleaned from similar experience.
Katherine would also like to acknowledge the hard work of Isabelle Butcher,
Jasmine Elwheshi and Danielle Verity in helping us to polish the manuscript.
Figure from p. 24 of The Compassionate Mind by Paul Gilbert (Constable &
Robinson, London, 2010) is reproduced by kind permission of the author and
publisher.
The chapter entitled ‘Working from the inside out: the therapist’s attachment
history as a source of impasse, inspiration and change’ by David Wallin (original
title ‘From the inside out: the therapist’s attachment patterns as sources of insight
and impasse’) is reproduced from Clinical Pearls of Wisdom: 21 leading therapists
offer their key insights, edited by Michael Kerman. Copyright © 2010 by Michael
Kerman. Used by permission of W. W. Norton & Company, Inc.
Section 1
Attachment theory
and practice – the basics
Chapter 1
Introduction
Katherine Berry, Adam N. Danquah and David Wallin
Background
In the ¿fty years since its inception, John Bowlby’s attachment theory has become
‘the most powerful contemporary account of social and emotional development
available to science’ (Steele 2002: 518). Although the theory’s inÀuence has been
most obvious in developmental psychology, it was originally conceived in a
clinical context and the last 20 years have witnessed a dramatic surge of interest
in attachment from within the mental health ¿eld (Fonagy 2001; Holmes 2001;
Obegi and Berant 2009; Wallin 2007). A growing body of theory and research
now links attachment to adult psychopathology and interpersonal problems.
Meanwhile there is increasing consensus that attachment theory is well placed to
provide the overarching framework for interventions in mental health (see Obegi
and Berant 2009).
These developments notwithstanding, practitioners often ¿nd it dif¿cult to
know exactly how the concepts of attachment can be put to effective use in the
clinical setting. Those who would translate attachment theory into practice have
had to draw inferences from either the mainly nonclinical adult attachment
literature or from the comparatively sparse and narrowly focused literature on the
implications of attachment theory for single schools of psychotherapy (Obegi and
Berant 2009). The present volume aims to address this gap in the literature. By
inviting expert practitioners and researchers from a variety of therapeutic
backgrounds to spell out how they apply attachment theory to a range of mental
health problems and clinical issues we hope to make the theory an accessible
resource for the broad spectrum of mental health practitioners, including those in
training. We trust that the book will also be of use to service managers and
commissioners responsible for the design, delivery and organisation of mental
health services, as well as researchers testing key hypotheses relating to the
clinical applications of the theory. In this introductory chapter we review some of
the basic concepts of attachment theory, in order to provide a context for the
chapters that follow.
4 Katherine Berry, Adam N. Danquah and David Wallin
Basic concepts
John Bowlby was a psychoanalyst who drew on psychoanalysis, evolutionary
theory, ethology, developmental psychology and cognitive psychology to develop
attachment theory. The theory aimed to explain ‘the propensity of human beings
to make strong affectional bonds to particular others … and the many forms of
emotional distress and personality disturbance … to which unwilling separation
and loss give rise’ (Bowlby 1977a: 201). Attachment is de¿ned as an affectional
bond that a person forms with a ‘differentiated and preferred individual’ or
attachment ¿gure who is approached in times of distress (Bowlby 1979). The
attachment bond is conceptualised as persistent and emotionally signi¿cant, and is
associated with a desire for close proximity to, and distress following involuntary
separation from, the attachment ¿gure (Bowlby 1969, 1973, 1980). The attachment
¿gure is hypothesised to represent both a secure base around which the individual
is able to engage in exploration, developing and gaining independence (Ainsworth
et al. 1978), and a safe haven to which the individual can retreat, seeking
reassurance in situations of danger and moments of alarm (Bowlby 1969).
Attachment behaviours (crying, calling out, clinging, searching and the like)
are motivated by the urge to retain or regain contact with the attachment ¿gure in
the face of environmental threat, distress, illness or fatigue. As such, the
‘attachment behaviour system’ is not in constant operation, but rather only when
the individual senses threat. In evolutionary terms, caregiver proximity is vital
because it increases the infant’s chances of survival when confronted with danger.
That the development of attachment bonds during infancy is originally survival-
driven explains their ongoing and fundamental importance as well as their
inÀuence – not only during childhood but throughout the life cycle (Bowlby
1980). Whether in childhood or beyond, we turn when threatened to those upon
whom we depend. Moreover, because the internal representations of attachment
develop in a survival-critical context, their quality will largely be determined on
the basis of what does and does not ‘work’ in the infant’s relationship with the
attachment ¿gure. What works in that relationship can be integrated into the
developing self; what does not work – what threatens the survival-critical
relationship – will be defensively excluded (Bowlby 1980).
Bowlby (1969, 1973, 1980) asserted that as a result of their interactions with
caregivers during infancy individuals develop mental representations of the self in
relation to signi¿cant others and expectations about how others will behave in
social relationships. These internal working models are hypothesised to be largely
unconscious and to guide attention, interpretation, memory and predictions about
future interpersonal interactions (Maier et al. 2004; Pietromonaco and Feldman
Barrett 2000). They are characterised in terms of cognitive elements, which reÀect
beliefs about whether the individual is worthy of attention and whether other
people are reliable. They also represent emotions associated with interpersonal
experiences, such as happiness, fear and anger (Pietromonaco and Feldman
Introduction 5
Barrett 2000). An internal working model, then, is the mental representation of the
quality of an individual’s attachment.
Empirical support for Bowlby’s theory comes from laboratory-based
observations of the infant’s behavioural response to two brief separations from
his or her caregiver in the context of a procedure referred to as the ‘strange
situation’ (Ainsworth et al. 1978). Responses to the strange situation appeared to
take three distinct forms which are attributed to different underlying working
models and methods of regulating distress. Infants are classi¿ed as secure or
insecure, with the insecure category subdivided into ambivalent or avoidant
categories (Ainsworth et al. 1978). Infants classi¿ed as secure are able to use the
caregiver as a secure base, exploring the room in an interactive way; they are
distressed by the separation but willingly approach the caregiver and are easily
comforted upon reunion. Infants classi¿ed as ambivalent (or ‘resistant’) seem
less able to use the caregiver as a secure base for exploration, staying close by in
his or her presence. Upon separation they are likely to show much distress and to
be dif¿cult to soothe upon reunion, seeking contact with the caregiver while also
resisting angrily or with upset. Infants classi¿ed as avoidant are unlikely to show
affectional sharing with the caregiver during exploratory play and upon separation
they are unlikely to show distress. Upon reunion, despite some acknowledgement
of the caregiver’s return, they may ignore or even move away from the caregiver
(Ainsworth et al. 1978).
The three attachment patterns described above seem to arise largely in response
to the nature of the caregiver’s sensitivity to the infant’s nonverbal cues and
signals (Wein¿eld et al. 1999). A pattern of secure attachment is generally the
outcome when caregivers are sensitive and responsive to the infant’s needs. As
development proceeds beyond infancy, the secure pattern is associated with the
emergence of a positive self-image, a capacity to manage distress, comfort with
autonomy and in forming relationships with others. Conversely, when caregivers
are insensitive or unresponsive to the infant’s nonverbal signals, then he or she
must develop alternative means by which to elicit caregiving and regulate distress.
Infants classi¿ed as ambivalent are usually raised by caregivers who are
unpredictably responsive – at times they tune into the infant’s needs but more
often they do not. The offspring of such unpredictable attachment ¿gures appear
to adapt by escalating their displays of distress, as if to heighten the probability of
meeting attachment needs by making them too conspicuous for their caregivers to
ignore. This defensive strategy is referred to as hyperactivation and as development
proceeds is associated with a negative self-image, a fear of abandonment, an
inhibition of autonomy and a tendency to be overwhelmed by emotions. Infants
classi¿ed as avoidant tend to be the offspring of rejecting and/or controlling
caregivers who are predictably unresponsive. These infants learn to deactivate
their attachment system to avoid the pain and disappointment that have come to
be associated with their unsuccessful bids for physical and emotional closeness. In
the course of ongoing development, the deactivating strategy is associated with
compulsive self-reliance, an estrangement from emotion and an avoidance of

close relationships (Shaver and Mikulincer 2002).
Subsequent to the pioneering identi¿cation by Ainsworth, Blehar, Salter,
Waters and Wall (1978) of the three ‘organised’ attachment patterns of infancy, a
fourth, ‘disorganised’ pattern was recognised by Main and Solomon (1986, 1990).
These researchers saw that in the context of the strange situation there were infants
– whom they described as ‘disorganised-disoriented’ – who displayed behaviours
in response to separation and reunion that appeared bizarre, contradictory and/or
incomprehensible. Such behaviours have come to be understood as expressions of
fear. This fear has been seen to arise in response not only to frank maltreatment
and neglect, but also to what Hesse and Main (1999) call the ‘second generation
effects of trauma’. These effects occur when caregivers respond to their infants
not with explicit abuse, but rather with frightened withdrawal or dissociation. In
sum, disorganisation appears to be the outcome of interactions in which the infant
experiences the attachment ¿gure as frightening, frightened or dissociated. In all
three instances, the infant is thought to experience ‘fright without solution’ at
being placed in an untenable position – confronted with the biological paradox
that the attachment ¿gure is not only the genetically programmed ‘safe haven’ but
also the source of the infant’s alarm (Main and Hesse 1990). The bizarre or
contradictory behaviour of disorganised infants thus reÀects a breakdown in
attachment organisation, as a result of their profoundly disturbing and
fundamentally irresolvable conÀict about whether to approach or avoid the
attachment ¿gure (Fraley and Shaver 2000).
The initial research sparked by Bowlby’s theorising led to the identi¿cation of
the attachment classi¿cations of infancy, as summarised above. Subsequent
research has led to the classi¿cations of attachment in adulthood. This research
has been carried out by two distinct groups of investigators – developmental
psychologists (among whom the most prominent is Mary Main) and social
psychologists (including Phillip Shaver). The work of these two groups appears to
be organised by two related but distinct paradigms.
The approach of the ¿rst group – Main, Fonagy, Sroufe and others with a
developmental or psychoanalytic orientation – rests on ¿ndings that suggest that
individual differences in attachment relate to the organisation of mental
representations of earlier attachment ¿gures. The researchers in this tradition have
conducted longitudinal studies, focused on infant–parent interactions and their
sequelae, and investigated the development of ‘mentalising’ – the capacity that
permits us to ‘read’ our own minds and those of others on the basis of underlying
mental states. Main and colleagues developed the Adult Attachment Interview
(AAI), which measures adults’ ‘states of mind with respect to attachment’ on the
basis of the coherence of the narrative that emerges when they are asked to recall
and reÀect upon their own attachment relationships (Main, Kaplan and Cassidy
1985). The AAI classi¿es adults as secure-autonomous, dismissing (the adult
version of the infant’s avoidant attachment), or preoccupied (the adult version of
the infant’s ambivalent attachment). Corresponding to disorganised attachment in
Introduction 7
infancy is an unresolved state of mind in the adult. This category is associated

with reports of traumatic loss or abuse, as well as confusion and disorganisation
when discussing such traumas (Hesse 1999). Main (2010) has suggested that
secure parents tend to raise and resemble their secure offspring, that dismissing
parents raise and resemble their avoidant infants, that preoccupied parents raise
and resemble their ambivalent infants, and that unresolved parents raise and
resemble their disorganised infants.
The social psychological approach of the second group grew out of Hazan and
Shaver’s (1987) conceptualisation of romantic love as an attachment process.
Their fundamental assumption (and that of the social psychologists that followed
them) was that attachment patterns exert a profound and ongoing inÀuence on
multiple aspects of the adult’s psychology and behaviour. Hazan and Shaver
translated the attachment categories of Ainsworth and Main (secure, avoidant/
dismissing and ambivalent/preoccupied) into prototypical adult ‘attachment
styles’ (secure, avoidant and anxious, respectively). Their research methodology
classi¿ed adults on the basis of self-sort and self-report measures of attachment.
Later, Bartholomew (1990) argued that Main, Kaplan and Cassidy (1985) and
Hazan and Shaver (1987) were measuring different types of avoidance, which
were respectively motivated by defensive self-suf¿ciency and avoidance of
rejection. Bartholomew’s (1990, 1997) model incorporates both types of avoidance
and describes four attachment prototypes: secure, preoccupied, avoidant-
dismissing and avoidant-fearful – the latter, it has been suggested, maps onto
Main’s ‘unresolved’ state of mind with respect to attachment. Several multi-item
continuous self-report measures have been developed to measure attachment
styles in romantic and other relationships (Collins and Read 1990; Simpson and
Rholes 1998). Factor analyses have suggested that the two dimensions of
attachment anxiety and attachment avoidance underlie self-report measures,
which can also be conceptualised in terms of model of self and model of others
(Brennan, Clark and Shaver 1998). This dimensional approach to conceptualising
attachment avoids the inherent problem of categorising individuals into discrete
groups, although attachment prototypes are easier to formulate clinically (Slade
2000).
In the clinical context, attachment theory can contribute to our understanding of
the development of psychopathology and psychotherapy. According to attachment
theory, insecure attachment is originally an adaptation to suboptimal caregiving
environments. Insecure attachment per se is not pathological. However, it can
have an adverse effect on adjustment in later relationships and can increase the
risk of psychopathology by rendering the individual more vulnerable to the effects
of stress (Goodwin 2003). Research has found that among individuals diagnosed
with mental health problems or personality disorders a high proportion are
insecurely attached, while disorganised attachment is the classi¿cation most
strongly associated with later psychopathology – including borderline personality
disorder, dissociative disorders and PTSD (Dozier, Stovall and Albus 1999;
Goodwin 2003). Bowlby (1969, 1973, 1980) proposed that although internal
working models and the attachment patterns they encode tend to persist relatively
unchanged throughout the lifespan, due to their inÀuence on the quality of
engagement in new relationships, they may be revised under certain conditions
(Bowlby 1973). ‘History is not destiny’ (Fraiberg, Adelson and Shapiro 1975:
389) and there is evidence that individuals may become either more or less
securely attached, depending upon the life stressors they encounter and changes in
their key relationships (Waters et al. 2000; Wein¿eld et al. 2000). One such key
relationship, of course, is that which develops in psychotherapy. Bowlby held the
view that the therapeutic relationship had the potential to function as a new
attachment relationship that could repair early attachment failures. He saw the
therapist’s role as ‘analogous to that of a mother who provides her child with a
secure base from which to explore the world’ (Bowlby 1988: 140). For Bowlby,
the world to be explored was, in large part, that of attachment relationships, past
and present, internal and interpersonal. The aim of therapy was to foster the
patient’s ability to relate to others in new ways – and to engender, in the process,
what Bowlby called ‘earned security’ (Bowlby, 1977b, 1988).
Outline of the book

Bowlby (1977a) stated that the priorities for establishing attachment theory within
clinical practice were determining both the range of conditions to which the theory
applied and associated variations in intervention. This book continues and extends
this programme of work. In summary, the book will focus on how attachment
theory can inform psychological therapy and mental health practice. It will
demonstrate how attachment theory has particular relevance for understanding the
therapeutic relationship and describe the application of attachment theory to
assessment, formulation and intervention in therapy with adults with a range of
problems and presentations, including depression, anxiety, psychosis, dissociative
disorders, personality disorders, eating disorders and medically unexplained
symptoms. It will also show how the theory can accommodate gender and
intercultural perspectives and inform work with older adults. More broadly, it will
demonstrate how attachment principles can inform the organisation of mental
health services. More personally, it will be a resource for clinicians hoping to
understand and make use of their own attachment histories and patterns in service
of the work. Where relevant, we have asked contributors to provide case examples
from their own experience. Some details have been changed to protect the
con¿dentiality of the individual clients involved, but the details of the processes
have not been altered.
The contributors are clinicians and researchers from a range of professional
backgrounds, including psychology, psychiatry, nursing and psychotherapy. A
variety of therapeutic orientations are represented, including psychoanalytic/
psychodynamic, cognitive-behavioural, systemic and other more integrative
approaches. We believe that this diversity is a particular strength of the book,
demonstrating attachment theory’s relevance across the breadth of the mental
Introduction 9
health ¿eld. The chapters that follow are organised into four sections: (1)
attachment theory and practice – the basics; (2) clinical problems and presentations;
(3) speci¿c populations; and (4) the organisation and the individual practitioner.
In the ¿rst section, the foundation for the rest of the book is laid out in this
introductory chapter, which focuses on theory, and in the following one by Jeremy
Holmes that translates theory into practice. Holmes, Bowlby’s biographer and an
eminent proponent of the clinical application of attachment theory, argues that
although there are few speci¿cally and overtly attachment-based psychotherapies,
attachment theory as a whole has much to say about the procedural aspects of all
therapies, and that these are the factors that ultimately lead to therapeutic change.
Like Bowlby, he understands that therapeutic relationships are essentially
attachment relationships. Conceiving of them in this way, he highlights the
inÀuence on therapy of both the client’s and the therapist’s pre-existing attachment
patterns and explores the synergy of the therapist’s efforts to foster attachment
security in the client, to develop meaning and to promote change.
The second section comprises chapters focusing on clinical problems and
presentations that are commonly encountered in adult mental health settings. As
clinical psychologists, we do not routinely categorise people into discrete groups,
favouring individualised formulations. The breakdown of chapters in terms of
clinical problems reÀects the fact that contributors typically have expertise in
relation to speci¿c client groups. We hope that highlighting the relevance of
attachment theory to the development of, and therapy for, speci¿c problems will
provide the reader with a new perspective on problems that are anything but new.
Paul Gilbert’s chapter describes the theoretical underpinnings and practice of
compassion-focused therapy for depression. He describes an ‘attachment loss’
model of depression, arguing that disruptions in attachment and af¿liative
relationships are key to the development of shame, which is itself at the root not
only of depression but of other mental health problems as well. He also suggests
that cultivating attachment and af¿liative relationships is fundamental to the
treatment of shame and depression. Finally, he describes speci¿c intervention
strategies for encouraging clients’ capacity for self-compassion.
Gail Myhr, writing from a cognitive-behavioural perspective, focuses on using
attachment theory to inform our thinking about anxiety disorders and their
treatment. She describes the conceptualisation of anxiety disorders within a
cognitive framework, as well as the goals and processes that are commonly
identi¿ed by cognitive-behavioural therapists. She argues that integrating
attachment-informed interventions into the treatment of anxiety can not only
make dif¿cult therapeutic tasks easier, but may themselves be essential in
preventing remission and relapse. These interventions include the identi¿cation of
an individual’s attachment style to facilitate engagement and inform treatment,
and the development of a secure base to encourage both ‘inner’ and ‘outer’
exploration.
Matthias Schwannauer and Andrew Gumley present an attachment-based
understanding of the formulation of psychosis and psychotherapeutic approaches
that promote emotional recovery for clients in this group. They argue that
attachment theory aids our understanding of key processes in the development
and maintenance of psychosis. They focus on associations between attachment
and interpersonal functioning and coping and the individual’s capacity to seek and
utilise support in times of emotional distress, including engagement with services.
They describe how increasing the individual’s reÀective functioning (that is,
capacity for mentalisation) can enhance recovery.
Kathy Steele and Onno van der Hart apply attachment theory to the understanding
of dissociation in disorders involving complex developmental trauma. The chapter
begins with a description of how early secure attachment supports regulation and
integration in the child, and how abuse, neglect, and severe attachment disruptions
can adversely affect development and result in dissociation. The authors then
outline a phase-orientated treatment approach for dissociation and related
attachment problems. The treatment begins with an initial phase of stabilisation,
e.g. strengthening and skills-building, followed by the treatment of traumatic
memory and, in the ¿nal phase, a focus on the adaptive integration of the
individual’s functioning across all domains.
According to Kenneth Levy, Kevin Meehan and Christina Temes, attachment
theory and research provides a comprehensive framework within which personality
pathology can be understood. In their chapter they review the empirical literature
on attachment theory, with a focus on assessment and intervention for personality
disorders. Further, utilising clinical vignettes and examples, Levy and his
colleagues demonstrate the utility of attachment theory and research for
conceptualising personality pathology. Speci¿c attention is paid to explicating the
patient–therapist dynamics as a function of attachment patterns and dimensions.
In applying their knowledge of attachment dif¿culties to psychopathology and
psychotherapy, clinicians and researchers have paid particular heed to borderline
personality disorder. It is perhaps the prototypical disorder of attachment trauma,
yet those diagnosed are often the recipients of the most negative reactions from
mental health practitioners. We therefore asked Giovanni Liotti to write a separate
chapter dedicated to this personality disorder, which develops the more general
discussion of attachment and personality disorder presented by Kenneth Levy and
his colleagues. The ¿rst section of this chapter describes infant attachment
disorganisation and how it results from early relational trauma that triggers
dissociative processes. The second section describes how the presence of
disorganised internal working models may help to explain the fundamental aspects
of borderline personality disorder. The ¿nal section discusses helpful treatment
strategies for borderline personality disorder and how their success can be
understood on the basis of attachment theory and research.
Writing from a systemic family therapy perspective, Rudi Dallos highlights the
ways in which disruptions in attachment can inÀuence the development and
maintenance of eating disorders. He emphasises the importance of considering
‘triadic’ processes in both formulations of, and treatments for, eating disorders.
The chapter illustrates how attachment and systemic approaches can be combined
Introduction 11
by using attachment theory to help develop formulations about the parents’ own
childhood histories, and how these shape and maintain the present family
dynamics. Although the focus of this chapter is on eating disorders, the integration
of attachment theory into family therapy is also of relevance to the practice of this
therapy with other client groups.
Robert Maunder and Jonathan Hunter describe the application of attachment
theory to the understanding and management of medically unexplained symptoms,
which are commonly encountered not only in mental health settings but also in
general practice and other medical specialities. The authors argue that the best
evidence-based treatments available (cognitive-behavioural therapy and
antidepressant drugs) provide only modest bene¿ts and that attachment theory
provides a useful new window in understanding and treating the problem. They
provide evidence that both dimensions of attachment insecurity – anxiety-based
hyperactivation and avoidance-based deactivation – can be associated with
unexplained symptoms and they describe approaches for working with these
different types of attachment insecurity.
The third section of our book shows how attachment theory might be enlisted
to understand and work with some of the issues that arise in our efforts to be of
help with speci¿c demographic groups.
Susie Orbach argues that attachment theory presents a perspective that is gender
neutral. Missing as it is from Bowlby’s work, however, she contends that a focus
on gender is nonetheless resonant within an attachment paradigm. Conscious and
unconscious apprehensions of gender shape both a mother’s experience of herself
and the ways in which she relates and ‘attaches’ to children of different genders.
With these inÀuences in mind, Orbach then discusses how gender issues affect the
nature and focus of therapy.
Lennox Thomas describes how attachment theory informs intercultural therapy,
an approach to treatment that is responsive to the cultural and ethnic variables that
have impact on both patient and therapist. Such a therapeutic framework must
take into account how the signi¿cance and manifestations of attachment, separation
and loss are shaped by the culture(s) of each partner in the therapeutic couple. The
therapist may need to consider how the meanings of the collective journeys,
acculturation and patterns of child development in the patient’s original cultural
community are affected by the practices and injunctions of the dominant culture.
Though this chapter focuses on therapeutic work with people from the Caribbean,
the principles discussed are relevant to treatment across cultures. Because
attachment theory itself has been documented to have relevance across cultures, it
is well placed to frame intercultural work – so long as therapists take into account
the differing ways in which attachment is shaped by the different communities
that are its context.
Cecilia Poon applies attachment theory to work with older people. She argues
that clinical work with older adults may be informed by an attachment perspective
for several reasons. These include the enduring impact of attachment across the
lifespan, the fact that late adulthood is ¿lled with experiences of separation and
loss, and research showing that attachment security is associated with better
psychosocial adjustment among older adults. Through a synthesis of ¿ndings
from attachment research and the clinical setting, Poon shows how attachment
theory can help therapists to understand and more effectively respond to many of
the challenges commonly faced by older people and their families, including
physical decline, bereavement and dementia care.
The three chapters in the fourth section of the book explore the implications of
attachment, ¿rst at the institutional level – where the focus is on forensic mental
health and on the organisation and delivery of mental health services – and ¿nally
at the personal level (where the focus is on the attachment history and patterning
of the individual therapist). In different ways, all three chapters address how we
set ourselves up to offer attachment-informed services.
Gwen Adshead and Anne Aiyegbusi consider areas of attachment research and
practice that have particular relevance in the context of forensic mental health
care. Noting (as have Levy and Liotti in earlier chapters) the strikingly high
incidence of personality disorders diagnosed among populations in these settings,
the authors begin by explaining how personality disorder might be best understood
as the adult sequelae of profound attachment disorder in childhood. They then go
on to show how attachment theory can inform the assessment of risk, including
consideration of individuals who engage in high-risk behaviours. The ¿nal section
of this chapter emphasises the importance of attachment relationships within
institutional settings and describes how attachment security and insecurity are
manifest in the relationships between staff and patients.
Martin Seager’s chapter argues that attachment theory should inform the design
and delivery of mental health services in the most general sense. He suggests that
adult mental health services are run in ways that remain blind even to the basic
concept of attachment. However, as secure attachment is a core and universal
factor underlying well-being for all humans, organisations that exist to foster
mental health cannot afford to ignore the attachment needs of either their service
users or providers. Seager makes a number of speci¿c recommendations about
how services could move to being more ‘psychologically minded’ and attachment-
informed. These include suggestions for reducing the risk of attachment breakdown
among inpatients, personalising services, promoting psychological safety,
improving the availability and accessibility of the service system, de-stigmatising
the concept of dependency, creating a secure family atmosphere in mental health
organisations and ensuring that the attachment needs of staff members are
recognised and met.
The ¿nal chapter, by David Wallin, develops a theme initially introduced in
Jeremy Holmes’ chapter; namely the importance of considering the impact upon
treatment of the therapist’s own attachment history and patterning.Wallin suggests
that, as therapists, our ability to generate a secure attachment relationship will be
profoundly affected by the legacy of our own attachment relationships – a legacy
that is, for many of us who choose this work, marked by trauma. The chapter
opens by addressing the advantages and vulnerabilities that derive from the
Introduction 13
therapist’s characteristic career trajectory, with its roots in a history of trauma and
adaptation to trauma. This adaptation occurs through the ‘controlling–caregiving’
strategy identi¿ed by attachment researchers and also described in Giovanni
Liotti’s chapter on borderline personality disorder. Wallin explores the ways in
which clinicians can identify their own state(s) of mind with respect to attachment
and the implications that Àow from recognising that they are presently lodged in a
state of mind that is secure, dismissing, preoccupied or unresolved. He also
describes the uses of mindfulness and mentalising in recognising and working
with the enactments of transference and countertransference that arise when the
therapist’s attachment patterns interlock with those of the patient.
This book has been put together in such a way that it can be read in toto from
beginning to end. Alternatively, readers can select particular chapters that strike
them as especially relevant to their own work or interests. In synthesising and
summarising the chapters, we have noted that certain themes or motifs recur
throughout the volume – most strikingly, the high level of insecure attachment in
adults who present with mental health needs, the importance of the therapeutic
relationship, and the necessity to consider the attachment needs and patterns not
only of clients but also of the mental health practitioners who work with them. We
hope that the recurrence of such themes provides an opportunity to see parallels
across different presentations and that it highlights that the core, relational aspects
of individuals and their problems should constitute the primary focus of
intervention in adult mental health care and the organisation of services.
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Attachment in the Preschool years: theory, research, and intervention, pp. 161–82.
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Main, M. and Solomon, J. (1986). Discovery of an insecure-disorganized/disoriented
attachment pattern: Procedures, ¿ndings and implications for the classi¿cation of
behavior. In T. B. Brazelton and M. Yogman (eds), Affective Development in Infancy,
pp. 95–124. Norwood, New Jersey: Ablex.
——(1990). Procedures for identifying infants as disorganized/disoriented during the
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Attachment During the Preschool Years: Theory, research and intervention, pp. 121–60.
Chicago: University of Chicago Press.
Introduction 15
Main, M., Kaplan, N. and Cassidy, J. (1985). Security in infancy, childhood, and adulthood:
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Adults. New York: Guilford Press.
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Concept: What do we really know about the self in relation to others? Review of General
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and Human Development 4, 133–61.
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psychoanalysis. The Journal of the American Psychoanalytic Association 48, 1147–74.
Steele, H. (2002). State of the art: Attachment. The Psychologist 15, 518–22.
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Waters, E., Merrick, S., Treboux, D., Crowell, J. and Albersheim, L. (2000). Attachment
security in infancy and early adulthood: A twenty-year longitudinal study. Child
Wein¿eld, N. S., Sroufe, L.A. and Egeland, B. (2000). Attachment from infancy to early
adulthood in a high-risk sample: continuity, discontinuity, and their correlates. Child
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differences in infant–caregiver attachment. In J. Cassidy and P. Shaver (eds), Handbook
of Attachment: theory, research, and clinical application, pp. 68–88. New York:
Guilford Press.
Chapter 2
Attachment theory in
therapeutic practice
Jeremy Holmes
Evidence suggests that what happens in consulting rooms is at best tenuously

related to the avowed theoretical perspective of the practitioner. A good example
of this is to be found in the well-known study by Castonguay, Goldfried, Wiser,
Raue and Hayes (1996) of processes of change in Cognitive Behavioural Therapy
(CBT). They found that two key factors in predicting good outcomes were the
quality of the therapeutic alliance and the extent to which the client was able to
experience previously warded-off emotions in the course of therapy, and that
strict adherence to CBT protocol actually led to worse outcomes than where the
therapist applied techniques Àexibly. Thus ‘psychodynamic’ features seem to play
an important part in a ‘CBT’ therapy. This suggests that we need to distinguish
between the procedural/semantic aspects of psychotherapeutic work and the
declared or ‘episodic’ aspects of a particular theoretical position. My contention
in this chapter is that while there are relatively few overtly attachment-based
psychotherapies, attachment theory has much to say about the procedural aspects
of all therapies, and that it is these that lead to psychic change (Holmes 2001;
Slade 2008). Thus attachment ideas and research constitute a meta-position from
which to view psychotherapy practice (Holmes 2009). I argue that effective
practitioners are intuitively attachment-minded and guided, irrespective of their
therapeutic allegiance. I shall base the discussion around therapy’s three principal
components (Castonguay and Beutler 2006): the therapeutic relationship,
meaning-making and change promotion.
The therapeutic relationship

Attachment styles and therapeutic engagement
According to attachment theory, intimate relationships have speci¿c interactional
dynamics, prototypically between children and parents and between spouses;
sometimes amongst siblings and military or sporting ‘buddies’. Threat or illness
triggers attachment behaviours. Once activated, these override all other
motivations – exploratory, playful, sexual, gustatory, etc. Attachment behaviour
involves seeking proximity to a ¿gure able to assuage distress; in the case of
Attachment theory in therapeutic practice 17
children, one who is older and wiser. Once soothed and safe, and only then, is the
sufferer able to explore his or her world, inner or outer, in the context of
‘companionable interaction’ (Heard and Lake 1997) with a co-participant. This
model can usefully be applied to the therapist–client relationship.
An important feature of the basic attachment dynamic is that threat-triggered
attachment behaviour and exploration are mutually exclusive. In infants and
young children this is manifest in observable behaviours – pulling ‘in’ to the
secure base ¿gure when threatened, and turning ‘out’ into the world of play and
exploration when secure. Inhibitions and compromises of this pattern are to be
found in insecurely attached children. In adults these shifts are usually more
subtle, although most will have had the experience of ‘holding onto pain’, whether
physical or emotional, while in the public arena until the secure presence of a
loved one makes ‘letting go’ possible, usually with physical accompaniments
such as holding, hugging and tearfulness.
Thus, the basic interpersonal architecture of therapy is: (a) a person in distress
seeking a safe haven, in search of a secure base; (b) a care-giver with the capacity
to offer security, soothing and exploratory companionship; and (c) the resulting
relationship, with its own unique qualities. This process applies to the initiation of
therapy itself, to the start of ongoing sessions, and to moments of emotional
arousal as they occur within a session. Since a central therapeutic aim is eliciting
and identifying buried feelings (Malan and Della Selva 2006), there will, in the
course of a session, be an iteration between affect arousal, activation of attachment
behaviours, and their assuagement; companionable exploration of the triggering
feelings; further affective arousal and so on.
This process is inevitably coloured by past experience, especially expectations
about how a care-giver will respond to expressed distress. This can be construed
as ‘transference’ in that the client brings to the relationship largely unconscious
schemata, or internal working models, based on, but not identical with, previous
experiences of care-seeking.
Classifying attachment styles in adults, Shaver and Mikulincer (2008) see
insecure attachment as a spectrum ranging from deactivation of attachment needs
(corresponding to avoidance in children) at one pole, to hyperactivation
(corresponding to ambivalent attachment) at the other. This hyperactivation/
deactivation dichotomy captures the relational expectations clients typically bring
into the consulting room. Some seem ‘switched-off’, describing their dif¿culties
in clichéd, minimalist ways, resistant to therapists’ probes for feelings. Others
overwhelm the therapist and themselves with emotion, seemingly confusing
present and past, leaving little space for the therapist to stem the tide of emotion
or assuage distress so that dif¿culties can be reÀectively considered. This can be
conceptualised as the unassuaged activation of the attachment dynamic.
Real-life therapists are far from passive observers, neutral elicitors of ‘material’,
or objective commentators on their clients’ dif¿culties. A proportion of them will
themselves have insecure attachment styles, commonly towards the hyper-
activating pole (Diamond et al. 2003). Therapist and patient actively engage in an
18 Jeremy Holmes
attachment/exploration cycle, in which the actuality of what the therapist offers,

and the client seeks, is counterpoised with deeply ingrained expectations
potentially threatening that very process of productive engagement.
Mallinckrodt and his co-workers (Mallinckrodt, Porter and Kivlighan 2005)
illustrate how skilful therapists accommodate to, and gradually modify, the
presenting stance of the client vis-à-vis attachment. They suggest that successful
therapy requires initial ‘concordance’ (cf. Racker 1968) on the part of the therapist.
This means partial acceptance by the therapist of the role allocated by the patient’s
unconscious expectations and procedures. This might entail allowing for a degree
of intellectualising with deactivating clients, waiting patiently for the client to
begin to allow feelings to surface, for example in relation to breaks – ‘I used to
take gaps in my stride, just telling myself that you were a hard-working professional
and were entitled to holidays; now I really resent your going away, and wonder
who you are going away with’. Conversely, with hyperactivating clients, a degree
of boundary Àexibility and grati¿cation might be allowable, accepting inter-
session letters and text-messages and occasionally offering extra sessions. Later
the therapist will move to a ‘complementary’ (as opposed to ‘concordant’, Racker
1968), more challenging role, thereby discon¿rming maladaptive client
expectations and opening the way for psychological reorganisation.
From an attachment perspective, the therapeutic relationship can be seen as the
result of two opposing sets of forces. On the one hand the analyst attempts within
the limited framework of therapy to provide a secure attachment experience – to
identify and assuage attachment needs and to facilitate exploration; on the other,
the patient approaches the relationship with prior expectations of sub-optimal
care-giving, unconsciously assumes an unloving and/or untrustworthy, or
narcissistically self-gratifying care-giver and aims mainly for a measure of
security. The attachment viewpoint suggests that the therapeutic relationship is
shaped both by the dynamic of its actuality and the distorting effects of transference.
Secure therapists redress their clients’ attachment insecurities, while insecure
ones are more likely to reinforce them. As therapy proceeds, the soothing presence
of the analyst enables the client to expose themselves to, tolerate, and learn from
increasing levels of anxiety.
Susan, 46, a single parent who had had recurrent major depressive episodes,
sought therapy when she developed depression following the break-up of a
five-year relationship with a married man. She herself had been brought up by
her lone parent mother, a narcissistic woman who had numerous affairs
throughout Susan’s childhood. In the initial interview Susan described how she
longed for closeness, but at the same time felt intruded on whenever she did
get close to a man, and how she felt this had contributed to the breakdown of
her relationship. She had mentioned at the outset that her funds were limited
and that she could only afford infrequent sessions. The therapist suggested that
she had learned as a child to keep her distance from her attachment figure,
thereby achieving a modicum of security, albeit by protecting herself from her
mother’s narcissistic intrusions by sacrificing the need for intimacy and
understanding. It was likely that she had then reproduced this pattern in her
relationships, and that her declaration that she could only manage infrequent
sessions suggested that she was setting herself up for a similar experience in
therapy. The therapist stated that once a week would normally be a minimum,
but that he would be prepared to see her fortnightly but not less often than
that, as that would then perpetuate her difficulties rather than helping to
overcome them.
Emotional connectedness
What makes a potential secure base ‘secure’? How does an infant ‘know’ to whom
to turn when attachment behaviours are activated? How does an attachment
hierarchy, normally with mother at the apex, followed by other kin such as aunts,
older siblings, father, grandparents and non-kin ‘alloparents’ (Hrdy 1999) such as
child-minders, become established? For adults, at what point does friendship and
companionship become ‘love’, and what is the relationship between this and the
establishment of a secure base? (Attempting to tap into this vector, I routinely ask
clients at assessment ‘Who would you contact ¿rst if there were an emergency or
crisis in your life?’). When does a therapist move from being a helpful professional
to the role of an indispensable attachment ¿gure? Attachment research suggests at
least partial answers to some of these questions.
Ongoing intimate proximity, availability, together with the ‘knowing’ – the
holding in mind through absence and interruption that is integral to parental (and
spousal) love – are some of the essential ingredients of a secure base. The mother–
infant literature suggests that, among other characteristics, a secure base parent
also provides responsiveness and ‘mastery’ (Slade 2005); reliability and
consistency; ‘mind-mindedness’ (Meins 1999); and the ability to repair disruptions
of parent–infant emotional connectedness (Tronick 1998). All of these are threads
that also run through the fabric of successful therapeutic relationships.
Overall, care-seeker/care-giver emotional connectedness is the key feature of a
secure base (Farber and Metzger 2008). The restriction, exaggeration, or uncoupling
of such connectedness is what leads to the three varieties of insecure attachment.
No less than in secure relationships, in insecure attachments the attachment ¿gure
is present in the mind of the care-seeker as a sought target for attachment behaviours,
but there is a discrepancy between what is desired and what is available. In analytic
psychotherapy, transference analysis attempts to place the minutiae of this
disjunction under the therapeutic microscope. Thus in Susan’s case the therapist
offered the client a chance to look at her insecure attachment pattern within the
safety of the therapeutic relationship.
20 Jeremy Holmes
Contingency and marking

There are analogues of therapeutic intimacy in developmental studies of parent–
child interaction. Gergely and Watson’s landmark paper (Gergely and Watson
1996; see Gergely 2007) focuses on affective sequencing between parents and
infants. They identify ‘contingency’ and ‘marking’, in the context of intense
mutual gaze, as the basis of mirroring sequences in which, to use Winnicott’s
(1971: 51) phrase, the ‘mother’s face is the mirror in which the child ¿rst begins
to ¿nd himself’.
‘Contingency’ describes the way in which the care-giver waits (her response is
‘contingent upon’) for the infant to initiate affective expression. Her response is
then ‘marked’ by an exaggerated simulacrum of the infant’s facial and verbal
affective expression. For example, the child might be slightly down-at-mouth; the
mother might then, while maintaining intense eye contact with her child, twist her
face into a caricature of abject misery, saying, in high-pitched ‘motherese’, ‘Oh,
we are feeling miserable today, aren’t we…’. She thereby offers the child a visual/
auditory representation of his own internal affective state. This sets in motion the
child’s capacity to ‘see’ and ‘own’ his feelings.
Contingency gives the child the message that s/he is an actor, a person who can
initiate and make a difference to the interpersonal world in which he or she ¿nds
himself, and introduces him to the dialogic nature of human meanings. Marking
links representation (initially in the mother’s face, then re-represented in his own
mind) to the child’s own actions and internal feelings, while ‘tagging’ that these
are his/her feelings, not the mother’s. This proto-linguistic envelope has a
soothing, affect-regulating quality.
When mothers mirror their infant’s feelings, ‘marking’, which is a form of
exaggeration or elaboration, means that the image that the infant sees is never an
exact match of his or her facial expression. It is partial, not complete, contingency,
a rhyme, not a replica. Fonagy and colleagues (2002) placed infants in high chairs
in front of two reÀective video-screens. One acted like a conventional mirror, the
other was able to copy the child’s movements but with a time lag so that there was
a discrepancy between what the child could see and his or her actions. Up to 3
months, infants selectively chose total contingency when offered a choice of
visual feedback (Fonagy et al. 2002). At this stage the child is still mapping the
body representation, where total contingency, e.g. between hand movements and
the movement of an image across the visual ¿eld, is the rule. But over the age of
3 months, when offered a choice between watching a conventional (‘total
contingency’) mirror, or one that subjects their movements to a time lag, infants
tend to select the latter (Fonagy et al. 2002), presumably because it represents
novelty and interest.
In a comparable auditory mirroring study of 4 month olds (Koulomzin et al.
2002), Beebe and her colleagues showed that both high and low contingency were
more likely to lead to insecure attachment classi¿cation at 1 year than mid-range
or partial contingency. Mothers, who could play comfortably with their children’s
vocalisations in jazz-like improvisation around them, were more security-

producing than those that mirrored them exactly or, at the other end of the
spectrum, were incapable of getting on their child’s wavelength. Similarly,
psychotherapy, however empathic, that merely reÀects back what the patient
brings without challenge or alteration, may fail to precipitate change, which
depends on the continuous interplay of sameness and difference (Holmes 2009).
Gergely and Watson’s interactive sequences (see Gergely 2007) thus involve:
(a) affect expression by the child; (b) empathic resonance on the part of the
mother, able to put herself into the shoes of the child; (c) affect regulation in that
the parent tends to up-regulate or down-regulate depending on what emotion is
communicated (stimulating a bored child, soothing a distressed one); resultant (d)
mutual pleasure and playfulness or, to use Stern’s (1985) phrase, the evocation of
‘vitality affects’, enlivenment, leading to (e) exploratory play/companionable
interaction (Heard and Lake 1997).
Similar sequences characterise in-session therapist–client interactions.
McCluskey (2005) has shown that initial attunement – a mirroring affect-
identifying response on the part of the therapist – in itself is insuf¿cient to make
up a satisfactory therapeutic interaction. Further steps are needed in order to
release exploration and companionable interaction. Step two is affect-regulatory,
as the therapist ‘takes’ the communicated feeling and, through facial expression,
tone of voice and emphasis, modi¿es or ‘regulates’ it: softly expressed sad feelings
are ampli¿ed, perhaps with a more aggressive edge added; manic excitement
soothed; vagueness of tone sharpened. Mirroring here becomes dialogic.
In Susan’s case she became very tearful and her face distorted with expressed
suffering and misery. Without saying much or indeed consciously being aware
of any more than adopting a ‘witnessing’ stance, the therapist mirrored this
distress with his physical posture, facial expression and non-verbal murmurings
of sympathy. Susan responded to this by, as it were, ‘seeing’ her own affects
through the therapist’s eyes and ears – and therefore to an extent objectifying
them – by saying with a wry smile, ‘By the way, I don’t think I’m depressed – just
distressed’. One can hypothesise that it is precisely this kind of responsiveness
that her self-preoccupied mother would have found very difficult to achieve.
More typically, the therapist makes comments comparable to the ‘marking’ of the
Gergely and Watson schema (see Gergely 2007). The therapist might say: ‘You
did what?!’; ‘That sounds painful’; ‘Ouch!!’; ‘It sounds as though you might be
feeling pretty sad right now’; ‘I wonder if there isn’t a lot of rage underneath all
this’. The therapist communicates to the patient that he has heard and felt her
feelings, regulates their intensity, and implicitly or explicitly adds something, e.g.
the sadness that underlies mania, the anger that can be an unacknowledged feature
of depression. The security associated with being understood leads to enlivenment
22 Jeremy Holmes
on the part of the patient. This in turn opens the way for companionable exploration
of the content or meaning of the topic under discussion. McCluskey (2005) dubs
this sequence Goal Corrected Empathic Attunement (GCEA), in which there is a
continuous process of mutual adjustment or ‘goal-correction’ between client and
therapist as they attempt, emotionally and thematically, to entrain the client’s
affective states and imagine the contexts which engender them. Mentalising
(Holmes 2009), see below, can be thought of as an umbrella term covering all
aspects of this process.
Triangulation
At the Gergely stage, looking/mirroring is dyadic. ‘Marking’ signals to the child
the message ‘mirror’, rather than ‘reality’ – i.e. ‘It’s a reÀection of your feelings
you are looking at, not mine’. The mother’s face is a reÀective surface for the
child, but not, under normal circumstances, vice versa. But as development
proceeds, visual referencing and elaboration of meaning come to encompass the
outer as well as the inner world. Mother and child look together at what is ‘over
there’. Initially this may take the form of pointing – the child points, perhaps
randomly, the mother says, ‘Yes, that’s … Daddy, doggie, Àower, tree’ etc. Thus
the mother gradually brings order and meaning, ‘thirdness’ and the beginnings of
simple narrative, to the child’s ‘buzzing booming’ world of sensation.
Cavell (2006), a philosopher and psychoanalyst, theorises this process using the
concept of ‘triangulation’. From a Kantian perspective, ‘reality’ is ineffable; it can
never be directly apprehended but is always ¿ltered through the mind. Nevertheless,
as development proceeds, the child acquires a sense of quiddity – ‘thing-ness’ –
via ‘triangulated referencing’. The child reaches out to a cup. The mother says
encouragingly, ‘Yes, cup’. She lets the child hold and feel and smell it. She
‘references’ it – they are both looking at the ‘same’ cup – albeit not quite the same
since they both have their unique point of view. The child looks at the mother
looking at her looking at the cup. A triangle is formed: mother–child–cup. The
child ‘triangulates’ the reality of the cup, ¿xed via language, and the overlap of
her own experience with that offered by the mother’s imaginative identi¿cation.
The security-inducing care-giver gives the message to the child that he or she has
a mind, different from, but similar to, hers, and that despite differing perspectives,
the cup exists ‘out there’. In psychotherapy, the ‘cup’ analogue are the patient’s
feelings and the connections between them and his life-experience. The triangle
now is patient, therapist, and the patient’s story. Patient and therapist together
look at fragments of experience and mentalise them: ‘What did you make of that?’
‘Looking back, how does that seem to you today?’ etc.
This metaphorical mutual gaze helps validate and bring the patient’s experience
to life. Most therapists (and patients) have an inherent sense of what it feels like
to have a ‘good session’, however painful it may seem at the time. One aspect of
this is the strengthened sense of consensual reality that comes from triangulation:
‘Yes, that’s just how it was’, ‘That really hits the nail on the head’ etc.
Rupture and repair

Like parents and spouses, and indeed anyone whose goal is intimate understanding
of another person, therapists regularly ‘get it wrong’. Tuckett and his co-authors’
category of therapist actions (Tuckett et al. 2008: 29), which they de¿ne as
‘sudden and glaring reactions not easy to relate to the analyst’s normal method’,
can be seen as ruptures comparable to the normal and expectable ruptures in
parent–infant connectedness, which in well-functioning parent–infant couples are
‘repaired’ as the parent responds to the child’s signals of distress.
The GCEA framework tells us that being understood reduces anxiety, liberates
vitality affects and initiates exploration. Conversely, being misunderstood is
anxiety-augmenting and aversive, triggering withdrawal and avoidance and/or
defensiveness and anger. But just as security-providing mothers are able to repair
lapses in attunement with their infants, so the capacity to repair therapeutic
‘ruptures’, a concept developed by Safran and Muran (2000), is associated with
good outcomes in therapy.
Using the ‘still face’ paradigm, attachment researchers have looked at
attachment styles in relation to the capacity of mother–infant dyads to resume
affective contact following a brief one-minute affective withdrawal on the part of
the mother in which she is asked to ‘freeze’ her expression (Crandell, Patrick and
Hopson 2003; Tronick 1998). Securely attached children are least disrupted by
this procedure. Children with organised insecurity resort to temporary self-
soothing via looking at their own faces in the mirror when the link with mother is
broken, but can generally resume contact once the break is terminated. Disorganised
children are least likely to get back on track with their mothers on resumption, and
likely to resort to more entrenched self-soothing, failing to link up again with the
security of the mother’s gaze even when it becomes once more available.
Extrapolating from these ¿ndings to adult psychotherapy, therapists need to be
highly sensitive to client reactions to ‘freezing’ or discontinuities of contact both
within sessions and in relation to the normal interruptions of holidays and illness.
Even though psychoanalytic psychotherapists are trained to focus on manifestations
of ‘negative transference’, the evidence suggests that clients hold back negative
feelings from their analysts no less than in other modalities of therapy (Safran and
Muran 2000). An attachment perspective suggests that: (a) in any intimate
relationship quotidian misunderstandings are the norm; (b) the implications of
these depend in part on prior expectations and attachment styles of both
participants; and (c) the therapeutic issue is not so much to eliminate
misunderstandings as to focus on the feelings associated with them and ¿nd ways
to talk about them. Therapist ‘enactments’ (e.g. starting a session late, drowsiness,
inattention or intrusiveness, etc.) need to be non-defensively acknowledged.
ReÀexive thinking about them by therapist and client together strengthens the
therapeutic bond and is itself a change-promoting manoeuvre, enhancing the
client’s capacity for self-awareness and negotiating skills in intimate relationships.
24 Jeremy Holmes
‘Paternal’ aspects of the attachment/therapeutic relationship

A key early ¿nding in attachment research was that attachment classi¿cation in
the Strange Situation was a relational not a temperamental feature, since at 1 year
old children could be secure with mother and insecure with father or vice versa,
although by 30 months the maternal pattern tends to dominate (Ainsworth et al.
1978). Nevertheless, the role of fathers in attachment has been relatively neglected,
disorganised attachment because, sadly, most of the children studied, as in Susan’s
case, come from mother-only families (Lyons-Ruth and Jacobvitz 1999). The
Grossman’s longitudinal studies (Grossman, Grossman and Waters 2005) are an
exception, showing that paternal contributions in childhood to eventual security in
early adulthood are as important as those of the mother, and that their combined
parental impact is greater than the sum of each alone.
The Grossmans delineate the ‘paternal’ role as somewhat different from the
‘maternal’. (The sexist implications of this dichotomy are acknowledged, perhaps
better reframed as ‘security-providing’ and ‘empowering’ parental functions.)
When asked to perform a brick-building or sporting task (e.g. teaching a child to
swim), security-providing fathers offer their offspring a ‘You can do it’ message,
creating a zone of protection within which sensory-motor development can
proceed. In the Strange Situation, as compared with mothers, fathers tend to use
short bursts of intense distraction and activity as comforting manoeuvres, in
contrast to the more gentle crescendo and diminuendo of hugging and soothing
that characterises female care-givers.
Comparing parent–child relationships in disorganised and secure children,
measures of maternal sensitivity are insuf¿cient to capture security-providing
functions. A dimension of ‘mastery’ also contributes to the variance,
communicating not just intimate protectiveness but also the presence of a
competent adult in charge of the play-space (Slade 2005). The importance of
space – physical and metaphorical – links with the Vygotskian notion of the ‘zone
of proximal development’ where the child is directed to tasks that are neither too
easy nor too hard (Leiman 1995), and the ‘defensible space’ surrounding the child
whose security it is the parent’s responsibility to guarantee. Similarly, therapists
provide for their clients therapeutic space, which is also a ‘space of time’.
Effective psychotherapy is both soothing and empowering. In the Western
world, ‘naming’ is construed as a ‘paternal’/masculine function. The famous
Lacanian pun – ‘le no(m) de père’ (the name of the father; the no of the father) –
encapsulates the ‘negative’ paternal prohibition that severs the infant’s fantasy of
merging with the mother, but also the ‘positive’ liberating, linguistic function that
enables one to stand outside, think about and manipulate experience and,
ultimately, to understand oneself (expressed in the patronymic). In order to
alleviate client anxiety, the therapist needs not just to be empathic, but also to
communicate ‘mastery’ (with its ‘paternal’ resonance) – a sense that she knows
what she is doing, is in control of the therapy and its boundaries (without being
controlling), and is relaxed enough to mentalise her own feelings. Mastery and
empathy are not mutually exclusive, but denote a good ‘primal marriage’ of
sensitivity and power from which the client can begin to tackle his dif¿culties.
Meaning
Meaning-making is intrinsic to all therapies. An explanatory framework brings
order to the intrinsically inchoate experience of illness, whether physical or mental
(Holmes and Bateman 2002). A ‘formulation’ is both anxiety-reducing in itself
and provides a scaffolding for the mutual exploration that follows once attachment
anxiety has been assuaged. A symptom or troublesome experience is ‘reframed’
via an explanatory system that helps make sense of the sufferer’s mental (or
physical) pain. The use of the word ‘sense’ here acknowledges that meaning
transcends mere cognition and ultimately derives from bodily experiences.
Language
New meanings emerge in the cut and thrust of psychoanalytic work in part through
the analyst’s close attention to language. Freud saw the inherent ambiguity of
language as an entrée to the unconscious, viewing words as ‘switches’ or junction
points between conscious and unconscious thoughts, or, to use a contemporary
metaphor, nodal points in neural networks.
In the attempt of Tuckett et al. (2008) to categorise psychoanalytic interventions,
one group of comments is described as ‘polysemic’, i.e. having ‘many meanings’.
As the literary critic Eagleton (2007: 22) puts it: ‘language is always what there is
more of’. Therapist and patient co-create a space from which to look at feelings,
behaviours and speech-acts from all possible perspectives and angles – concrete,
metaphorical, sexual, adult, child-like, coercive, intimidated, anxiety-inÀuenced
and so on.
Susan came into therapy with the idea that there was something ‘wrong’ with
her that drove people away – her intolerance of closeness, ‘bad temper’, etc.
The therapist offered a new set of meanings: her fear of intimacy linked with
her mother’s neglectfulness (better to be self-sufficient than get close to
another and then be abandoned); her choice of partner as a continuation of this
pattern; her angry outbursts representing the protest of the abandoned child;
the underlying fear that if she gave up her fragile self-sufficiency all would fall
apart.
In the consulting room, sensitivity to the ebb and Àow of attachment and
exploration is the hallmark of the skilful therapist. As discussed, GCEA entails
‘secure base’ responses to client distress. This is in part a matter of timing and
tone of voice, but accurate verbal identi¿cation of feelings – i.e. the emergence of
26 Jeremy Holmes
shared meanings – is in itself soothing. As in any intimate relationship – spousal,

parent–child, sibling, close friendship – highly speci¿c meanings derived from the
minutiae of a person’s life are co-created by therapist and client. Elaborating this
personal vernacular or ‘ideolect’ (Lear 1993; 2009) is a crucial aspect of psycho-
therapeutic work. In Bollas’ (2007) terminology, the ‘receptive unconscious’ of
the analyst is tuned into the ‘expressive unconscious’ of the client; the task of the
analyst’s conscious ego, like that of the good-enough mother in Winnicott’s
(1971) model of the child playing ‘alone in the presence of the mother’, is to guard
the therapeutic space in a non-intrusive way.
The meaning-making function of therapy picks out signi¿cance from this
unending Àux and free play of the imagination, or stream of consciousness. Once
verbally ‘¿xed’, meanings can be considered, by therapist and patient together
from all possible angles: tested, re¿ned, held onto, modi¿ed, or discarded as
appropriate.
Main is credited with attachment theory’s decisive ‘move to the level of
representation’ (Main 1999) – i.e. the instantiation in the mind of attachment
relationships. Clearly ‘representation’ is not exclusively nor necessarily verbal.
‘Teleological’ thinking, characteristic of pre-verbal, ‘pre-mentalising’ toddlers
(Holmes 2009) is both representational and meaningful in the sense that the infant
begins to develop a mental map of the interpersonal world based on ‘if this, then
that’ logic. However, the capacity to represent the Self and Others and their
relationship verbally is a vital developmental step, enabling children to negotiate
the interpersonal world that will be a matrix of all future existence once the
physical ‘matrix’ (i.e. mother) is relinquished. Language underpins a ‘self’ that
becomes both a centre of experience and an object in the world that can be
described and discussed and ‘worked on’ through the vicissitudes of everyday life
and, when necessary, in psychotherapy.
Narrative styles and the meaning of meaning

The Adult Attachment Interview suggests that how we talk about ourselves and
our lives, as much as what we talk about, reveals the architecture of the inner
world. Like the ‘Àuid attentional gaze’ (Main 1995) of the secure infant who
seamlessly negotiates transitions between secure base-seeking, social referencing
and exploratory play, Main characterises secure narratives as ‘Àuid autonomous’
– neither over- nor under-elaborated and able to balance affect and cognition in
ways appropriate to the topic discussed.
In the context of therapy, secure narrative styles are ‘meaningful’ in the sense
that they facilitate an open-ended ‘language game’ (Wittgenstein 1958) between
therapist and client. ‘Meaning’ is inherent in the interactive mutuality of a
language game. Clearly it is possible to have a private language, as for example in
psychosis, but it is only when it can be shared that it becomes meaningful in the
sense used here. Therapy can be seen as continuously helping the client to move
from private to shared meanings. Insecure attachment styles lead to therapeutic
conversations that are under- or over-saturated with meaning (dismissive or

enmeshed respectively), or with breaks in meaning (incoherent), depending
whether they represent deactivating, hyperactivating or unresolved attachments.
A key part of therapeutic work is moving the client towards the exploration of
mutual meanings, based on a more secure narrative style. ‘Can you elaborate on
that?’; ‘What exactly did you mean then?’; ‘I can’t quite visualise what you are
talking about here; can you help?’; ‘What did that feel like to you?’; ‘I’m getting a
bit confused here, can you slow down a bit?’; ‘There seems to be something
missing in what you’re saying; I wonder if there is some part of the story we
haven’t quite heard about?’. In this kind of dialogue the therapist is probing for
speci¿city, visual imagery and metaphor that enable her to conjure up, in her
mind’s eye and ear, aspects of the patient’s experience. This then becomes a shared
object or ‘third’ (Benjamin 2004; Ogden 1987) that can be ‘companionably
explored’ (Heard and Lake 1997), often a metaphor to be played with and extended.
There is evidence to support the idea that successful therapy is associated with
the replacement of insecure by more secure narrative styles (Avdi and Georgaca
2007), towards the acquisition of what I have called ‘autobiographical competence’
(Holmes 2001). Main’s schema describes the Àuidity of secure styles, always
subject to further ‘vision and revision’ (Eliot 1986), in contrast to the ¿xed,
overwhelming, or inchoate narratives of insecure attachment.
Finding the right meaning

As therapists we are continuously struggling to ¿nd the ‘real’, ‘right’, or ‘true’
meaning of our client’s communications, verbal and non-verbal. The client will in
turn respond by telling us whether a particular comment on the part of the analyst, or
idea they have generated themselves, ‘feels right’. In his neurophysiological critique
of Cartesian dualism, Damasio (1994) suggests that mind and body work in tandem
to let us know when our cognitive and intellectual faculties are on track. Implicit in
Cavell’s (2006) notion of ‘triangulation’ is the idea that a child cross-checks the
veracity and validity of their perceptions of the outside world with those of the care-
giver, and so begins to build up a picture of the real world distinct from his or her
perception of it. The Winnicottian ideas of mirroring, contingency/marking and
empathic attunement suggest that we learn about our inner world in a comparable
way, using the care-giver’s understanding to develop our own self-knowledge. In
psychotherapy sessions the analyst makes guesses or suggestions about how clients
may be feeling; clients then compare this proffered empathic understanding with
what their introspection tells them. Exploring whether there is a near-match or a
misalignment, therapy helps the client to gradually know him or herself better.
Attachment and empathy, apparently abstract concepts, are ultimately psycho-
physical phenomena. Proximity is sought – tactile (hugging, sitting on a lap),
auditory (via a telephone) or visual (a picture, which may be in the ‘mind’s eye’).
This lowers arousal – slowed heart rate, less sweating – and releases oxytocin
(Zeki 2009). A mentalising conversation (e.g. a therapy session) may also be seen
28 Jeremy Holmes
in those terms. The physical posture and tone of voice of the client reveals his or
her emotional state. The therapist imaginatively or even actually (via contingently
marking and so altering their own physical posture) mirrors this state, which in
turn, via ‘mirror neurones’, triggers a version of the client’s emotional state in the
therapist’s receptive apparatus (Hobson 2002). This can then be introspected,
identi¿ed, verbalised. In doing so, change is set in train.
Attachment theory’s contribution to meaning-making underpins a meta-
theoretical perspective in which it is not so much speci¿c interpretations that
count, as the restoration or fostering of the capacity to ¿nd/make shared meanings,
irrespective of their content. Therapist and client come together in a meaningful,
shared ‘present moment’ (Stern 2004). Meaning in itself is not mutative; it is the
mutuality of meaning-making that matters. This brings us to the third leg of the
psychotherapy tripod – promoting change.
Promoting change
Exposure
An integrative approach to psychotherapeutic work sees a crucial component in
psychic change as the exposure to previously avoided/warded off mental pain and
trauma. In the safety of the consulting room, past pain is revived and relived.
Focusing on this in safety enables sufferers to experience, process, name and gain
perspective on the unexpressed feelings that bedevil their relationship to
themselves and their intimates. In that it is based on trauma, avoidance and
exposure, psychoanalytic approaches here are consistent with cognitive/
behavioural theory, even if the methods – spontaneous free association and
transference interpretation as opposed to pen-and-paper self-observation and
directed homework exposure tasks – are radically different.
In a series of attachment-inÀuenced studies, Mikulincer and colleagues
(reviewed Mikulincer and Shaver 2008; Mikulincer et al. 2008) show how the
experience of security, even if subliminal, enables insecurely attached people to
confront rather than defensively deactivate or hyperactivate mental pain. In one
study, participants who had completed a questionnaire tapping into attachment
styles were asked to write a description of an incident in which a close partner had
hurt their feelings. They were then exposed to security-enhancing subliminal
‘primes’ (words like ‘love’, ‘secure’, ‘affection’) or neutral ones (‘lamp’,
‘building’ etc). Next they were asked to reconsider the hurtful event and to
describe how they would feel if it were to occur again. In the neutral priming
condition, deactivators reported less, and hyperactivators more, pain than in the
initial task. This would be expected if, with the passage of time, pre-existing
defences were reinforced. However, in those exposed to the positive prime, both
anxiety and avoidance were greatly reduced and the insecurely attached subjects’
responses were indistinguishable from those of the securely attached. As
Mikulincer and his colleagues (Mikulincer et al. 2008: 318) put it:
protective armour can at least temporarily [be] softened by an infusion of felt

security … even a small security boost can allow an avoidant person to be
more open to inner pain … which can then be addressed clinically.
Transposing this into the consulting room, the benign presence of the therapist
offers a validating, encouraging environment, helping clients to face, bear,
process, live with, master, transcend and incorporate pain and trauma. Positive
priming, via the implicit validating presence of the analyst, is a precondition for
meaningful exposure to negative emotions. Conversely, support without challenge
can be collusive rather than mutative.
Mentalising
According to Gustafson (1986; drawing on Bateson 1972), who based his ideas on
Bertrand Russell’s ‘theory of logical types’, psychic change invariably entails
taking a perspective at a meta-level, or ‘higher logical type’, from the problematic
behaviours or experience that had led the sufferer to seek help. Attachment
research established more than 20 years ago (Fonagy 2008) that the ‘ReÀective
Function’ subscale of the Adult Attachment Interview predicted sensitive
parenting, irrespective of the trauma history of the individual. ReÀective
Functioning has now mutated into the concept of mentalising, both as a general
mark of psychological social maturity and as a treatment objective in people
suffering from Borderline Personality Disorder (Fonagy 2008; Holmes 2009).
‘Mentalising’, which can be de¿ned as the capacity to see oneself and others as
sentient beings with desires, hopes and aims, or ‘mind-mindedness’ (Meins 1999),
clearly ful¿ls the Gustafson criterion in that it is a species of ‘meta-thinking’.
Moving from action and impulse to reÀecting on one’s own and others’ mental
states is crucial to therapeutic action in psychoanalytic psychotherapy, and perhaps
the psychotherapies generally (Allen 2003).
Bleiberg (2006) suggests that mentalising is an essential social skill for group
living. Being able to mentalise or to read the intentions of the ‘Other’ became a
vital ‘friend-or-foe’ appraisal as small groups of hominids learned to collaborate
and to cope with competition. However, once the ‘Other’ is identi¿ed as
unthreatening, mentalising is inhibited. With the appraiser’s guard down, psychic
energy is available for other uses. Extreme instances of this are seen in intimate
relationships between infants and their mothers, and the mothers and their romantic
partners. Brain patterns in both are similar, with inhibition of the neuroanatomical
pathways subsuming mentalisation (Zeki 2009). This releases psychic energy
from the appraisal task, and perhaps explains the necessary idealisation inherent in
such relationships (‘my baby/lover/mum is the best baby/lover/mum in the whole
world’), in which negative features are ignored or discounted.
A similar sequence may apply in psychotherapy, as the client begins to imbue
the therapist and therapeutic situation with secure base properties and to relax into
a comfortable state of held intimacy. However, while encouraging the development
30 Jeremy Holmes
of trust, the therapist will simultaneously insist that clients examine their feelings
about the therapist and the therapeutic relationship – aiming to help clients acquire,
activate and extend mentalising skills. A psychotherapy session is recursive in the
sense that it loops back on itself in ways that normal relationships tend not to,
except perhaps when repair (which can be thought of as an everyday form of
‘therapy’) is needed. To take a commonplace example, there is often a tussle
between therapist and client – especially if a deactivating one – about reactions to
breaks. The client may insist that it is perfectly all right for the therapist to have a
holiday (‘everyone needs time off, especially in your sort of work’), while the
therapist relentlessly probes for signs of disappointment, rejection and anger,
sometimes much to the client’s irritation. The client is encouraged to mentalise
the avoided negative affect in the service of therapeutic change. Therapy thus puts
the client in a paradoxical ‘change/no change’, ‘inhibit mentalising/mentalise’
bind, forcing the emergence of new structures and extending clients’ range of
interpersonal skills and resources. Clients have no choice but to think about their
feelings and identity in ways that would normally be dealt with by repression,
avoidance, acting out or projection.
Conclusions
The main argument of this chapter is that psychotherapy process may best be
understood by theoretical perspectives – in this case Attachment Theory –
orthogonal to those espoused by its practitioners. Attending to the pull and push
of the attachment dynamic and freeing oneself from dogma (including dogmatic
views on Attachment!) may lead to better therapy, productive research questions
and a focus on the mutative ingredients of psychotherapeutic process.
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Section 2
Clinical problems and

presentations
Chapter 3
Attachment theory and

compassion focused therapy
for depression
Paul Gilbert
Compassion focused therapy (CFT) emerged from a number of major but disparate
inÀuences, including clinical observation, evolution theory, attachment theory
and Buddhist practices (Gilbert 2000a, 2009a, 2012). Firstly, when working with
Cognitive Behaviour Therapy (CBT) for chronic depression in the 1980s, it
became clear that some people could generate impressive alternative thoughts to
their depressive ones but still said: ‘I can see the logic but I don’t feel any better’
or ‘I know logically I am not a failure but I still feel a failure’. This is now well
recognised as a dif¿culty in CBT (Stott 2007). Exploring the emotional textures
by which people experienced their alternative thoughts revealed that they were
often somewhat harsh and aggressive, rather than kind, understanding and
supportive. Attachment theory gave important insights into how we generate such
‘kind’ emotional textures (Cozolino 2007) and that shame is one of the biggest
blocks to feeling af¿liative emotions for the self (Gilbert 2010).
The attachment model focuses on the emotional and behavioural mechanisms
that enable parent and child to stay in close proximity to each other and that
regulate the child’s physiological systems, especially emotions. The evolution of
attachment is the basis for the experience of early warmth, af¿liation and emotional
soothing. Attachment loss impacts on these emotion systems, giving rise to
anxiety and depression (Bowlby 1969, 1973, 1980; Harlow and Mears 1979;
Mikulincer and Shaver 2007). The evolved defensive strategies to disruptions in
attachment and af¿liation are protest (anger, anxiety and crying) and despair
(retardation, loss of positive emotions and hiding). Separated and thus uncared
for, mammalian juveniles do not generally survive. The ¿rst defensive response to
separation, called protest-distress, is therefore to lose interest in any other
considerations and attend fully to distress – seeking and calling to the parent.
However, if this continues without resolution then the infant attracts predators and
is at risk of becoming exhausted and lost. At some point the protest-distress
strategy becomes a liability and needs to be ‘turned off’ and a totally different
strategy of conserving resources and minimising signalling is required. The
despair defences reduce explorative and distress calling and down-regulate
positive affect, inhibiting explorative and resource seeking behaviour (Gilbert
1992, 2007b). There is some evidence for genetic differences in the susceptibility
36 Paul Gilbert
to the intensity of protest and despair responses (Suomi 1997, 1999) that give rise
to phenotypic differences arising from variations in af¿liative or hostile early
environments (Belsky and Pluess 2009).
As Bowlby was articulating the link between attachment and mood, Price
(1972) was developing a model that suggested that a down-regulation of positive
emotion was defensive when confronted with a more powerful, hostile other.
There were many descriptions in the literature of animals who had lost status or
were subject to constant down rank aggression, who then went into submissive
states of high social avoidance, reduced explorative behaviour, became passive
with low drive and took on the appearance of depression (Gilbert 2000b; Price and
Sloman 1987).
Rank, attachment and af¿liation have very complex interactions (Liotti 2000;
Sloman, Gilbert and Hasey 2003). For example, perceptions of low social rank
(feeling inferior, shame, being fearful of assertiveness, and vulnerability to social
rejection) seem a route into adult depression and other forms of psychopathology
(Gilbert 1992, 2000b; Sturman 2011), but those routes are sensitised in early life,
particularly by the lack of appropriate attachment relationships. Moreover, shame
(the sense of being undesirable to others, bad, unworthy, or inadequate) often
underpins depression (Gilbert, 2013). Not only does shame carry a sense of inferiority,
but it is one of the biggest blocks to the experience of af¿liative emotion. Healing
shame requires some experience of connectedness with others, such as kindness,
understanding, support, and validation (Gilbert 2007a, 2011). Indeed, even in
monkeys who have been rendered subordinate or defeated, their abilities to engage
in supportive relationships with other primates has a huge impact on their recovery,
including cardiovascular and cortisol indicators of stress (Abbott et al. 2003).
From attachment to affiliation and shame

Bowlby (see also Harlow and Mears 1979) argued that the experience of
attachment acted as a template by which individuals come to choreograph their
perceptions and feelings about other relationships and themselves. Recent
researchers have pointed out that attachment inÀuences capacities for empathising,
mentalising (Allen and Fonagy 2007; Liotti and Gilbert 2011), and compassion
(Gillath, Shaver and Mikulincer 2005). Thus our early experiences of another
human being (as loving, available and trustworthy) come to inÀuence (though not
determine) our ways of engaging in different types of relationships as we grow up,
such as co-operation, friendship formation, sexual and social rank (Cozolino
2007). Belonging to, and taking identity from, groups can also be inÀuenced by
attachment history (Baumeister and Leary 1995). Indeed the neurophysiology
would indicate that the attachment system is linked to wider systems for the
development of af¿liative relationships in general, and not just attachment ones
(Dunbar 2010; Gilbert 1989; Porges 2007). For example, although the
neurohormone oxytocin is known to be important in the evolution and onset of
attachment behaviour (Carter 1998), it also plays a role in a range of social and
Attachment theory and compassion focused therapy 37
af¿liative behaviours including trust, conspeci¿c recognition, empathy and mind

reading, and the ability to be soothed by a trusted friend in the face of threat
(Carter 1998; MacDonald and MacDonald 2010). So while attachment is key to
our beginning of feeling safe or threatened in relationships, we need to think about
the wider contexts of social relationships in terms of the af¿liative qualities that
can be shared between friends and groups in general (Cacioppo and Patrick 2008),
which is the basis of social neuroscience (Cacioppo et al. 2000).
Gilbert (1989) suggested that as infants move through childhood and into
adulthood, the attachment system links with more complex forms of relating. This
is because different social (archetypal) tasks await the child on their maturational
journey, such as forming alliances, identifying with groups, working in teams,
developing sexual interest and relating, becoming a parent and developing
authority (and adapting/accommodating to higher authority) within a group. Many
of these tasks and goal orientations will focus the growing child-to-adult on their
social reputation and how they (think they) exist in the minds of others; on the
competitive dynamics of life but also caring and supporting others; the processes
of ‘getting along’ and ‘getting on’. Key for humans is that social competition and
social rank have evolved to become increasingly less focused on aggression and
more focused on winning approval or being liked by others. This aspect became
known as our social attention holding potential, SAHP (Gilbert 1989, 1997).
There is, for example, evidence that people ground their self-esteem by believing
they have traits that others will value (Santor and Walker 1999). The dimension of
being valued is a different dimension to being cared for. Some people (especially
in the older populations) can get depressed not because they feel uncared for but
because they feel they have nothing to contribute; no-one needs or wants them. It
is the feeling that one cannot contribute that can therefore be a major issue for
some depressed people (Gilbert 1984).
SAHP can be positive and negative – when it is negative, individuals have
issues of shame and stigma. When SAHP is ¿rst experienced positively in the
loving gaze and embrace of an affectionate parent, we have the emotional
experience of existing positively in the mind of another. The positive emotion in
the face of the mother leads to positive emotion in the infant (Schore 1994, 2010;
Trevarthen and Aitken 2001). In fact, the evolution of being interested in and
monitoring our attractiveness in the minds of others is linked to humans being
sensitive to multiple caregivers (aunts and grandmothers) and carries on throughout
life (Hrdy 2009). Indeed, even our competitive behaviour now is orientated around
attractiveness and wanting ‘to be chosen’ (Barkow 1989; Gilbert 1992). Shame is
an experience of feeling undesired and unattractive to others, vulnerable to
criticism, rejection or even persecution (Gilbert 1998). It is useful, therefore, for
therapists to understand the evolutionary roots of dynamics of shame and how
shame can be one of the most important disruptors of af¿liative capacities in
therapy, increasing risk of concealments, dropout and acting out (Dearing and
Tangney 2011; Gilbert 2007a, 2011). Shame and af¿liation therefore share
complex, dynamic and reciprocal relationships. Shame can arise from disruptions
in af¿liation and af¿liation can heal shame.
38 Paul Gilbert
Neurophysiology of attachment and affiliation

It is now understood that basic motivational systems such as ¿nding food, sexual
partners, seeking status, and the various human derivatives, are linked to actions
by emotion. Take any motive, and if we are successful we get a buzz of positive
emotion, but when it is blocked, thwarted or we fail, we experience negative
emotion. In this respect, emotions are motive trackers. There is evidence that
depressed people are motivated (they want to achieve certain things) but they lack
feeling/emotion in being able to do it or anticipate a negative emotion in trying
(Dalgleish et al. 2011). Lack of interest may come from repeated efforts of failing
to experience positive emotion in the context of trying or as a result of high levels
of threat (White, Laithwait and Gilbert, in press). Key to understanding the link
between motivational systems like attachment and af¿liation, then, is how
different types of emotion are regulated by them.
To answer this we ¿rst need to recognise that we are now able to identify three
types of affect regulation systems, all of which play fundamental roles in
attachment and af¿liative psychology (Depue and Morrone-Strupinsky 2005).
These are the:
• Threat and self-protection focused system, which enables detecting, attending,

processing and responding to threats. There is a menu of threat-based
emotions such as anger, anxiety and disgust, and a menu of defensive
behaviours, such as ¿ght, Àight, submission and freeze.
• Drive, seeking and acquisition focused system, which enables the paying of
attention to advantageous resources and, with some degree of ‘activation’, an
experience of pleasure in pursuing and securing them.
• Contentment, soothing and af¿liative focused system, which enables a state of
peacefulness and openness when individuals are no longer threat focused or
seeking resources, but are satis¿ed and experience positive well-being. Over
evolutionary time, this system of calming has been adapted for many functions
of attachment and af¿liative behaviour. The system is linked to the endorphin-
oxytocin systems which function to promote trust and af¿liative behaviour.
Recipients of af¿liation experience calming of the threat system (MacDonald
and Macdonald 2010).
These three systems are depicted in Figure 3.1.

One of the most important developments in the last 10 years has been the
understanding that positive emotion is of (at least) two fundamental types. The
¿rst is linked to drives and is associated with feelings of excitement, social
dominance, pleasure and anticipation of reward. The second is a positive affect
system that is associated with soothing/af¿liative affects, neither seeking positives
nor responding to the threat, which creates feelings of calming, soothing and well-
being. These emotions are especially linked to the endorphins and to some degree
oxytocin (Dunbar 2010). This type of positive affect, linked with well-being, is
associated with parasympathetic arousal, calm mind and ease of sleeping.
Driven, excited, vitality Content, safe, connected
Incentive/resource- Non-wanting/
focused Affiliative-focused
Wanting, pursuing, Safeness-kindness

achieving, consuming
Soothing
Activating
Threat-focused
Protection and
safety-seeking
Activating/inhibiting
Anger, anxiety, disgust
Figure 3.1 Three types of affect regulation system

From Gilbert, The Compassionate Mind (2009b), reprinted with permission from Constable and
Robinson Ltd.
Therefore, attachment and af¿liative relationships down-regulate the threat

system (e.g. Guerra et al. 2012) and provides suf¿cient safeness for people to be
able to engage in explorative behaviour (Gilbert 1989), mentalise, reÀect and
change (Allen and Fonagy 2007; Liotti and Gilbert 2011; Wallin 2007).
The point is that, without recognition of the distinction between these two very
different types of positive emotion, it can be dif¿cult to think about which type of
positive emotion (or both) has gone off-line in depression and what needs to be done
to bring it on-line. There are many theories that focus on drive emotions, and indeed
the neuropharmacology of depression tends to focus on the monoamines and drive
and threat systems. While the focus on drive emotions, achievement and doing can
be helpful (Dimidjian et al. 2006), as can unconscious threat emotions such as anger
(Wachtel 2011), we should also focus on the importance of the attachment,
af¿liation, endorphin and oxytocin systems, which are about slowing, calming and
creating a sense of safeness from which exploration can occur. It is this safeness (or
what Bowlby called a ‘secure base’) that provides a platform to go out, seek and
have the con¿dence to try things. In addition the concept of ‘safe haven’ refers to
how the child can return to a secure base, for calming and reassurance, if they
become threatened or distressed. So there are both encouraging and soothing
qualities to attachment. Indeed, self-report measures that distinguish drive emotions
(feeling energised, active) from soothing affect (warm, secure) suggest that it is the
latter which are particularly (negatively) linked to depression and anxiety (Gilbert
et al. 2008). Kelly, Zuroff, Leybman and Gilbert (2012) found that a measure of
40 Paul Gilbert
general social safeness and capacities for feeling connected to others were a better
predictor of vulnerability psychopathology than negative affect, positive affect or
needs for social support. So it is possible that the general day-to-day tone of the
af¿liative (endorphin-oxytocin) system plays a role in resilience.
Disruptions of this affect system are associated with feelings of separation,
disconnection and aloneness. Indeed, for many people who have psychopathology,
including depression, the experience of aloneness, especially when they are feeling
at their worst, is very common (Cacioppo and Patrick 2008). The experience of
aloneness and disconnectedness or ‘shut off-ness’, as part of the emotional complex
a person is feeling is actually a focus for compassion focused therapy (Gilbert 2010).
So, using the three circle model, we can see that depression involves disruption
in all three systems – and should not be seen as only a disturbance of positive affect
(Gilbert 2007a, b, in press). This can be depicted in diagram form in Figure 3.2.
Attachment and affiliative disruption

Many problems in psychopathology, and especially depression, are linked to the
dif¿culties of attachment and soothing/af¿liation systems to regulate the drive and
threat system (Gilbert 1993, 2009). One reason this occurs is because the parent
could have been a source both of comfort and also of fear, producing approach
avoidance conÀicts (Liotti and Gumley 2008). So, for example, if parents have
frightened the child, the child can hardly turn to them for comfort, or if they do,
he or she must behave in a highly submissive way (Gilbert 1992, 2007). This is
commonly seen as creating in the child a state of ‘fright without resolution’ in that
there is no-one to act as a soothing caring other (Liotti 2009).
Shame can also create ‘fright without resolution or solution’ because the very
thing that will heal shame is the af¿liative validating experience, or even a
forgiving experience from another. Shame is, however, the fear that one will lose
whatever af¿liation and care there is if one reveals ‘the shameful’. It is a Catch-22
situation. In this sense, shame creates avoidance or sometimes aggressive counter-
defences – all of which completely disrupt the capacity for connective, af¿liative
relationships. The management of shame within therapy therefore becomes central
(Dearing and Tangney 2011).
Logically it might seem that the best thing for shame-prone individuals to do is
to engage in more af¿liation – which is true up to a point. However, this is
problematic. Some years ago I saw a recorded lecture by John Bowlby in which he
noted that the kindness and support of the therapist can activate the attachment
system. When this happens the ‘system’ will open up whatever memories have
been encoded there. Sometimes the emotional memories coded in the attachment
system are ones of neglect, abuse, yearning, aloneness and shame and reactivating
those could be traumatic. This can also be understood in conditioning terms (Gilbert
1992). For example, normally one’s own sexual arousal, or imagining a holiday, is
pleasant. However, if one has been raped on holiday then having memories of
holidays or sexual feelings triggered will be not pleasant but deeply traumatic. This
is just one of a number of ways in which stimulating the attachment and af¿liative
system can at ¿rst be aversive. The therapist needs to work through this, of course,
because not to do so leaves the patient without a major affect regulating system.
They can again get stuck in a kind of ‘threat without resolution’.
People can have a fear of af¿liative feelings for many reasons (Gilbert et al.
2011). Whatever the reasons, one of the consequences is that the movement
towards af¿liation actually produces intense approach–avoidance conÀicts (Liotti
2000, 2009). When shame is involved as a block to af¿liative feelings, the most
common problem is the person’s ability to deal with overwhelming sadness and
grief (Gilbert and Irons 2005), which not uncommonly they block. There are
many therapies that recognise the fear of af¿liative emotion but do not necessarily
make that the focus of therapy – nor do they suggest that practising af¿liative
motives and emotions should be central to therapy itself. Sometimes they rely on
the therapeutic relationship being the key focus for compassion development.
Compassion focused therapy

Compassion focused therapy (CFT) suggests that one of the key dif¿culties for
many people with depression and other emotion regulation dif¿culties is that for
various reasons the three affect regulation systems are out of balance, this type of
pattern of change in affect systems is shown in Figure 3.2. Given the enormous
importance of the soothing af¿liative system in affect regulation, this is a central
(but not the only) focus of CFT.
Drive, excite, vitality Content, safe, connected
Separated
Can’t look forward Alone
Feeling of inner Disconnected

deadness
No-one understands
Despair
Unsafe
Trapped
Dread
Angry
Anxious
Anger, anxiety, disgust
Figure 3.2 Experiences associated with three major affect regulation systems in
depression
42 Paul Gilbert
In addition to using standard therapeutic interventions, such as building an

appropriate safe and validating therapeutic relationship, Socratic questioning,
teaching people how to monitor their thoughts and feelings, using inference chains
and behavioural experiments, a good deal of the work for depression in CFT focuses
on building compassionate capacity (Gilbert 2007b, 2010; Gilbert and Choden
2013). In CFT it is like basic muscles: unless some degree of compassion (strength,
a kind of inner secure base and safe haven) is available to the patient, it can be
dif¿cult to engage with threat-based experiences.
The model of compassion is also quite speci¿c in CFT (Gilbert 2005, 2009).
We make a distinction between the ability to compassionately approach and
engage suffering and the compassionate capacity for alleviation, holding and
softening suffering. This is often represented as two interacting ‘psychologies’ of
attributes (engagement abilities) and skills (alleviation) (Gilbert 2010, 2012).
The engagement aspect of compassion involves motivation to engage and
learning how to be attentionally sensitive to suffering (including what is happening
in one’s body and emotions). It also involves the ability to be emotionally moved
by what one attends to or experiences ‘sympathy for’ (for example, if you attend
to another person in distress, are you left cold by it or do you attune into it and feel
connected, emotionally moved); and distress tolerance (sometimes when people
become distressed they engage in avoidance, dissociation and denial). It further
involves empathy, which links with mentalising, the ability to think about and
reÀect on what is happening and the potential sources of suffering (clearly one
cannot do that if one is not motivated or able to tolerate distress); and non-
judgement (which means we do not criticise or ¿ght with what comes up in us as
we explore the nature of our own or other people’s suffering).
These two psychologies of ‘engagement and alleviation’ can guide the therapist
almost like walking – ¿rst one foot/aspect, then the next – and show him or her
how to explore where key problems lie. For example, some patients with
depression can engage with their suffering but do not know how to do anything
about it, or do so in very critical, hostile ways. In contrast, some individuals are
very reluctant to engage with the source of their suffering, such as early trauma or
the implications of the need to change lifestyle. Some individuals struggle with
mentalising and empathy competencies and these can compromise motivation. So
CFT does not engage too much with suffering (e.g. trauma memories) until there
is suf¿cient capacity for compassionate holding, alleviation and soothing – one
foot should not get too far ahead of the other.
CFT therefore seeks to build motivation and these abilities, skills and
competencies to address suffering and the causes of suffering in compassionate,
containing ways. The concepts of a secure base and safe haven is very important,
because this is the point to return to if the threat system gets too highly activated
(Holmes 2001). While CFT can proceed in very standard ways through guided
discovery, validation, encouragement and creating a secure base and safe haven in
the therapeutic relationship, CFT suggests that we need to go beyond this and
teach patients how to actually cultivate and practise generating patterns of
compassionate activity inside themselves (Dalai Lama 1995, 2001); so that they
can create their own inner secure base and safe haven. Hence compassionate mind
training becomes a part of the overall structure of the therapy. There are therefore
a number of unique aspects to CFT which have some overlap with Buddhist
concepts of compassion cultivation (Gilbert 2009a; Gilbert and Choden 2013).
These involve sharing the evolutionary model, helping people to understand the
nature of depression as an evolved potential and the importance of social shaping
of our identities and sense of self (e.g. if I had been adopted as a baby into a
violent drug gang then this version of Paul Gilbert would not exist, but rather one
who is more violent and even murderous). These are key to de-shaming processes.
In addition we build compassionate capacity by focusing on the generating
experience of practising compassionate behaviours, being open to compassion
from others, and developing self compassion. The therapist uses a mixture of
building the therapeutic relationship and a range of imagery and sensory body-
focused exercises (Gilbert and Choden 2013). In addition, we focus on developing
compassionate attention, compassionate thinking, compassionate behaviour and
compassionate feeling. All these are designed to help balance the three affect
regulation systems and to develop a particular kind of self-identity.
There is good evidence that imagery can work better than verbal interventions
(Stopa 2009), and that guided positive imagery can be helpful for depression
(Holmes, Lang and Shah 2009). CFT uses a series of imagery tasks, some of
which are adaptations from Buddhist imagery practices (Leighton 2003), whereas
others were developed with patients themselves (Gilbert 2009; Gilbert and Choden
2013). There is evidence that practising imagining one’s ‘best possible self’ is
related to increased optimism (Meevissen, Peters and Alberts 2011), and practising
positive self-imagery by recalling a time when one felt relaxed and positive is
related to higher levels of self-esteem and reduced anxiety in response to anxiety-
provoking vignettes (Stopa, Brown and Hirsch 2012). There is also growing
evidence, based on an increasing number of outcome studies, that compassion
focused practices have a major role to play in the treatment of psychopathology
(Gilbert 2011; Hofmann, Grossman and Hinton 2011).
CFT for depression, and other conditions, builds on many other therapies but its
central focus is that the attachment and af¿liative systems often require more
attention and cultivation. CFT suggests that in the context of a supportive
relationship we can literally teach people with depression to cultivate
compassionate ways of thinking and being in the world that will have major
impacts on their attention, thinking, behaviour and feeling and the very essence of
the sense of self these will then re-orientate motivations and balance emotion
regulation systems.
Conclusion
Evolutionary insights have illuminated some of the reasons we and other animals
are vulnerable to reduced positive affect and increased negative affect which is the
44 Paul Gilbert
basis of depression (Gilbert 2013). It also reveals how attachment became the
major regulator of threat, with huge impacts on a range of physiological processes.
However, it was not just attachment between child and parent that was vital in
human evolution, but the evolution of general af¿liative relationships that
supported pair bonding and alliance formation (Dunbar 2010). Within these
contexts we live not only in the physical world but in the world of the minds of
others when we seek to be valued and respected and wanted. Shame is the
experience of living negatively in the minds of others and this has an impact on
blocking us from af¿liative connections and af¿liative emotions, processes that
are so vital for emotion regulation and well-being. In addition, shame is commonly
linked to self-criticism, which blocks the capacity for self kindness support and
encouragement. Compassion focused therapy explicitly addresses these issues. If
our internal self-with-self relationship is hostile then there is no source for joy,
love and soothing – and the world turns dark and empty.
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Chapter 4
Responding to threat
Using attachment-related
interventions in cognitive behavioural
therapy of anxiety disorders
Gail Myhr
Introduction
The natural goal of the attachment system is to increase a person’s sense of
security in the world (Bowlby 1982). Early attachment relationships affect not
only the perceived level of threat and safety in the person’s world (Liotti 2007),
but also the strategies the person uses to attenuate that sense of threat (Main 2000).
The conceptualisation of attachment security as an important determinant of
human thinking, emotional processing and behaviour, both in times of distress
and in novel situations, dovetails with the cognitive behavioural model of anxiety
disorders.
Central to the cognitive behavioural model of anxiety is the notion of perceived
personal vulnerability to threat (Beck, Emery and Greenberg 1985). Individuals
with anxiety disorders exaggerate threats from both external and internal sources,
and underestimate their capacity to cope with these threats. They respond to their
fears with behavioural avoidance and the employment of ‘safety behaviours’ or
strategies to reduce anxiety in threatening situations (Abramowitz, Deacon and
Whiteside 2011). Not surprisingly, insecure attachment has been associated with
anxiety in both clinical and non-clinical populations (Bifulco et al. 2006;
Mikulincer and Shaver 2007). Greater attachment insecurity, compared to
controls, has been measured in individuals with speci¿c phobia (Mikulincer and
Shaver 2007), social anxiety disorder (Eng et al. 2001), obsessive compulsive
disorder (Myhr, Sookman and Pinard 2004), generalised anxiety disorder (Cassidy
et al. 2009), and post traumatic stress disorder (Kanninen, Punamaki and Qouta
2003). Furthermore, the extent of attachment insecurity is directly related to
symptom severity (Bifulco et al. 2006).
While the pattern of attachment behaviour (or attachment ‘style’) and extent of
attachment security are considered to be relatively stable across the lifespan
(Fraley et al. 2011; Waters et al. 2000), psychotherapy has been found to alter
both in the direction of greater attachment security (Levy et al. 2006; Travis et al.
2001). In the cognitive behavioural therapy (CBT) literature, Guidano and Liotti
(1983) were the ¿rst to advance the notion that attachment-related beliefs, feelings
and behaviour, activated within the therapeutic relationship, could be examined
Responding to threat 49
using a CBT approach, leading to healthy changes in patients’ internal working

models (IWMs) of attachment (Guidano and Liotti 1983; Liotti 2007). IWMs
refer to those internalised representations, derived from early experiences with
caregivers, that affect one’s view of oneself as competent and worthy of attention,
and one’s expectations of others as responsive and available in times of need
(Bowlby 1982).
This chapter draws on Guidano and Liotti’s early work and speci¿es how the
knowledge of patients’ attachment styles and IWMs can inform not only the
management of the therapeutic relationship, but also the speci¿c targets and
interventions in CBT for anxiety disorders.
Insecure attachment and the cognitive model of anxiety

The cognitive behavioural model of emotional distress posits that, in any given
situation, a person’s thoughts, feelings, and behaviour are inter-related.
Consequently, insecure attachment can impact a person’s thoughts and behaviours
in such a way as to increase anxiety.
Thinking
In the cognitive model, anxious individuals suffer from a heightened sense of
personal vulnerability to threat, fuelled by their thought content as well as by
characteristic thinking patterns, known as cognitive biases (Beck, Emery and
Greenberg 1985). Important cognitive biases in anxiety include attentional biases
(Bar-Haim et al. 2007) – the tendency to scan the environment for threats – and
interpretative biases such as overestimating the probability of a negative event
and exaggerating the dire consequences should it happen (catastrophisation)
(Allen, McHugh and Barlow 2008).
These thought processes are fuelled by the content of underlying beliefs.
Themes important in anxiety includes assumptions related to control (‘If I don’t
prepare for the worst, bad things will happen’), perfectionism (‘Mistakes lead to
disaster’), inÀated responsibility (‘If something bad happens, it will be my fault so
I must do what I can to prevent it’), intolerance of uncertainty (‘I can’t take a
chance…’) and personal vulnerability (‘If something goes wrong, I won’t be able
to handle it’) (Casey et al. 2004; Taylor et al. 2010).
Many of these content areas directly relate to IWMs (Bowlby 1982), i.e. beliefs
about one’s capacity to cope with adversity and whether attachment ¿gures will
be available or helpful in times of stress (Doron and Kyrios 2005). Derived from
early interactions with caregivers, these attachment-related expectations of the
self and others are crucial determinants of anxiety in exploring novel situations
and in dealing with stress.
If early attachment ¿gures are reliable and consistent sources of soothing and
help, the child learns that their attachment-related emotions are legitimate and that
the attachment ¿gure can be called upon for comfort and soothing, even when the
50 Gail Myhr
attachment ¿gure is not present during the distressing episode (Liotti 2007). This
is a feature of secure attachment (Main 2000).The securely attached child explores
his environment more readily, safe in the knowledge that he can rely on his
attachment ¿gure in the case of dif¿culty (Main 2000).
If, however, the attachment ¿gures of childhood respond intermittently to the
child’s distress, at times proving helpful and at other times proving intrusive or
inept, the child learns to increase the intensity of requests for emotional soothing.
This is a feature of insecure attachment characterised by ‘hyperactivating’
attachment strategies and overly dependent behaviour. Through this organised
strategy, the child’s ‘clinginess’ within the attachment relationship ensures that he
does not miss any sporadic soothing which might come his way (Main 2000).
On the other hand, if early attachment ¿gures respond with impatience or
ridicule or neglect to the young child’s requests for comfort and help, the child
learns to suppress their attachment-related emotions and to become more self-
reliant. This is a feature of an avoidant insecure attachment style, with the use of
‘deactivating attachment strategies’ and compulsive self-reliance. Through this
strategy, the avoidant child manages his attachment relationships to minimise the
likelihood of rejection and abandonment (Bartholomew 1990; Main 2000).
IWMs and attachment strategies, originating in childhood, are thought to
underlie adult attachment representations, with research indicating stability in
these over time (Fraley et al. 2011; Waters et al. 2000). Prototypes of adult
attachment typically measure two dimensions: attachment anxiety and attachment
avoidance (Fraley and Waller 1998). The attachment anxiety dimension refers to
an increased sensitivity to abandonment and has been associated with
‘hyperactivating’ attachment strategies characterised by heightened vigilance to
threats, increased expressiveness of fears and needs, worry about attachment
¿gures’ availability and excessively dependent, clingy behaviour. Individuals
scoring high on this dimension can be called ‘preoccupied’ or ‘anxiously attached’
individuals.
By contrast, the attachment avoidance dimension refers to avoidance of
emotional closeness with attachment ¿gures and has been associated with
‘deactivating attachment strategies’ such as dismissal of emotional threats, denial
of personal needs, exaggerated self-reliance and downplaying needs of support
from attachment ¿gures. Individuals scoring highly on this dimension can be
considered to have an ‘avoidant’ attachment style.
‘Secure’ individuals are conceptualised as having low attachment anxiety and
low avoidance. They are independent, but also comfortable with intimacy and
depending on others in times of stress (Fraley and Waller 1998).
Bowlby’s IWM (1982) – representing beliefs, emotions and behavioural
tendencies of self and other within attachment relationships – resemble the CBT
construct of ‘schemas’ (Beck 1979). Schemas refer to underlying organising
structures consisting of a person’s core beliefs about themselves, others and the
world around them, with emotional and behavioural components. Schemas guide
a person’s attention towards certain aspects of the world around him and mould
data to ¿t with the schema-related beliefs (con¿rmation bias). While schema can
encompass many themes (e.g. competence, entitlement, alienation), schema
related to expectations about attachment ¿gures, attachment-related emotions and
behavioural strategies to maintain attachment relationships can be seen as
equivalent to IWMs (McBride and Atkinson 2009) and worked on in an explicit
fashion in therapy.
These patterns of attachment reÀect not only beliefs about the self and others,
but also inÀuence cognitive domains relevant to anxiety. People with avoidant
attachment styles, who believe that they are alone to solve their problems and
must do all they can to prevent things from going awry, may have related beliefs
about perfectionism, responsibility and control. Preoccupied patients, who believe
that they can’t cope alone and must guarantee the availability of others, may have
related beliefs about the subjugation of one’s personal needs to those of others, the
dangerousness of anger and the catastrophisation of emotional distress.
Behaviour
Two behaviours which serve as key maintaining factors in anxiety are avoidance
and safety behaviours (Salkovskis 1991). Avoidance can range from the obvious,
such as an OCD patient who crosses the street to avoid a potentially contaminated
garbage can, to the more subtle, such as a panic disorder patient who avoids
arguments with his spouse to prevent increasing his heart rate and bringing on a
panic attack. Safety signals/behaviours are those behaviours that allow the anxious
person to endure a dif¿cult situation with a sense of safety. These may include a
wide variety of actions such as carrying medication in case of a panic attack,
attending social situations only if accompanied, or seeking excessive reassurance
about medical issues from the internet. Avoidance and safety behaviours prevent
the person from learning that what they fear may not happen or that, whatever
does happen, they can cope.
Secure individuals, with internalised attuned and responsive attachment ¿gures,
will display skilful ‘secure base’ behaviour in order to explore the world and elicit
comfort in times of stress (Waters and Cummings 2000). They will be comfortable
taking risks and facing challenging new situations, and will seek comfort or
instrumental help from attachment ¿gures when the going gets rough. Conversely,
insecurely attached individuals use the ‘secure base’ less skilfully, perceiving
attachment ¿gures as unresponsive, unavailable or unhelpful. The deactivating or
hyperactivating attachment strategies used by insecure individuals, while
originally effective in optimising early inadequate attachment relationships, now
lead to greater anxiety, greater avoidance and efforts to minimise risk of all kinds.
Attachment and case conceptualisation in CBT

CBT of anxiety involves facing what is feared (exposure), eliminating safety
behaviours, changing anxiogenic thinking and increasing emotional awareness
52 Gail Myhr
and self-regulation. Therapy begins with case conceptualisation, integrating

information about habitual ways of thinking and behaving in anxiety-provoking
situations, with empirically supported models of the anxiety disorder in question.
Attachment-informed CBT incorporates information about attachment styles
and related schemas into case conceptualisation (Liotti 2007; McBride and
Atkinson 2009; Tasca et al. 2004). This requires assessment of thoughts, emotions
and behaviours within attachment relationships – past and present. Typical
questions include:
• When you were young, to whom did you go for help when you had a problem
or were upset?
• After you went to X, what would be the usual result of this?
• If the answer was ‘no one, I had to solve my own problems’: Why was this so?
• Suppose you had expressed your distress to your parents, what might have
happened?
• How were disagreements dealt with?
• How did they deal with emotions in general?
• How do these past experiences inÀuence you today?
• Who do you go to if you have a problem in your life now? What is the usual
result?
• If you are comfortable asking help from others, does this ever pose a problem
for you? Is it hard for you to do things independently?
• If you tend to solve things on your own, what keeps you from asking for help?
• Are you satis¿ed with the level of intimacy with X?
• How do you and X deal with disagreements?
From these questions can be derived underlying assumptions about the self,
expectations about attachment ¿gures and typical behaviour within attachment
relationships used to attenuate stress and regulate emotion. Pertinent assumptions
have stems like: ‘If I am upset, then…’, ‘If I get close to X, then…’, ‘If I ask for
help, then X will…’ etc. Self-report questionnaires, such as the Experiences in
Close Relationships scale (Brennan, Clark and Shaver 1998), can aid clinicians in
identifying their patients’ attachment styles.
The CBT therapist as a ‘secure base’

Patients enter CBT for anxiety disorders because something is inordinately
threatening for them and they have not been able to manage it using their habitual
strategies. These conditions activate the attachment system; inviting therapists to
serve as ‘secure bases’ from which help can be sought (Bowlby 1988; Waters and
Cummings 2000). CBT’s ‘collaborative empiricism’ highlights one secure base
function: the exploration of patients’ internal and external worlds. The ‘felt safety’
of an engaged and responsive therapist allows patients to articulate hypotheses
about what is feared and facilitates the testing of these hypotheses, through the
joint process of guided discovery. Changes in thinking and behaviour, whether

through exposure exercises, acting more assertively at work, or examining painful
beliefs in session, engender increased anxiety in the short-term, requiring
therapists to ful¿l the second secure base function, that of ‘safe haven’ providing
soothing and comfort in times of threat (Bowlby 1988). Asking patients to face
what they fear most requires therapists to convey something like: ‘I know this is
hard, but I have con¿dence in you and in this therapy. You are not alone in this – I
am beside you’.
Recognising attachment system activation in the

therapeutic alliance
CBT begins with patients and therapists interacting on equal ground, working
towards shared therapeutic goals in what can be called the ‘joint, goal-oriented
mode’ (Liotti 2007). Over time, a deepening emotional bond in the alliance
reÀects the activation of the attachment system and the use of the therapist as
secure base. This signals a shift from the ‘joint goal-oriented mode’ to an
‘attachment-caregiving’ mode. Liotti has suggested that there are three signs that
this has happened (Liotti 2007). First, patients become increasingly emotionally
vulnerable in session and express, explicitly or implicitly, the wish for soothing by
their therapists. Second, therapists become aware of an increased sense of
protectiveness towards their patients. Moments occur in therapy where therapists
have an acute sense that ‘something else is required of me’ that is not necessarily
geared towards the stated goals of therapy. Third, patients’ attachment-related
schemas may become apparent in their dialogue, especially with the notion that
the therapist is a kind of rescuer from suffering.
A 46 year-old businessman began CBT for panic disorder and agoraphobia. Mr.
A was an independent man who functioned well at home and at work, but was
unable to drive on the highway or take a plane for fear of having a panic attack.
Family vacation plans suffered and there were business trips he could not
attend because of his fears. When his oldest daughter planned her wedding on
a Caribbean island, he consulted in a desperate bid to be able to attend.
After several sessions of exploring avoided situations, safety behaviours and
pertinent beliefs, a plan was made to begin exposure. When asked to choose a
starting point, he looked at his list of avoided situations for a moment, then burst
into tears. The therapist became aware of an acute sense of tenderness towards
him, and inquired gently whether he could explain what was going on inside of
him. He blew his nose and said ‘No, I’m ok, let’s go on’. When she commented
that this was not easy work they were doing together and that she could see it
was upsetting to him, he answered tearfully: ‘You must think I’m so pathetic. A
grown man, afraid of driving his wife to the shopping mall! This is hopeless’.
54 Gail Myhr
The therapist remarked: ‘You have been struggling with these fears alone for
many years and it might be uncomfortable for you to share them with me. Are
you interested in what I am really thinking?’ When he looked up at her, she went
on to say: ‘I am just getting to know you, but I know you well enough to recognise
the courage and determination it took for you to come and discuss your fears
with me. I am so glad you did. I, for one, am extremely hopeful that with your
courage and determination, and my help, you will achieve your goals’. He was
silent in response to this. When she pressed him for a response, he said that if
she felt that way, he could allow himself to hope things would get better too.
In the above vignette, the therapist recognised the three signs of attachment system
activation. First, she saw in his emotional vulnerability activation of the attachment
system and an implicit request for comfort in a usually avoidant individual.
Second, she noticed her own feeling of tenderness in response to his distress,
which led her to respond to him in a highly personal, attachment-related way.
Rather than giving information about the likelihood of improvement with CBT,
she reassured him that she would be his ‘secure base’ – that he was not alone, that
she was interested in his emotional state, that she was committed to helping him,
and that she was not critical of him but rather appreciative of his qualities. Third,
having recognised his avoidant attachment style in the initial assessment, and
having assessed his expectation of attachment ¿gures as being ‘critical’ or
unhelpful, she deliberately disclosed her own true feelings and welcomed his need
for her, so he could begin the process of changing attachment-related schema.
Therapists’ recognition of attachment system activation, validation of
attachment-related emotions and establishing oneself as a helpful, consistent and
non-critical ‘secure base’ leads to a reduction of anxiety in their patients and a
resumption of the joint therapy venture, once again focused on the tasks of therapy
(Liotti 2007). Effective CBT is characterised by Àuid shifts between the joint
goal-oriented mode and the intensely personal attachment-caregiving mode at
times of stress or dismay. In the process, patients’ expectations of attachment
¿gures may undergo transformation, ideally leading to greater attachment security.
Therapeutic stance with respect to

attachment-related schema
Emotionally charged moments in session are golden opportunities to elicit
pertinent thoughts, underlying assumptions, emotions and behavioural responses
in an attachment-related situation. How these situations are dealt with by therapists
may, over time, modify attachment-related expectations and behaviours.
For example, patients whose childhood caregivers were experienced as
incessantly critical may view benign comments by their therapists as criticisms
and withdraw in silent protest. The task-oriented approach and the use of
homework in CBT provide many potential situations where patients may feel their
performance is being evaluated. Therapists should elicit their patients’ thoughts
and feelings during such moments and explore the observed behavioural responses
(e.g. withdrawal). By welcoming their patients’ articulation of the true feelings
underlying the withdrawal, acknowledging their own contribution to the
therapeutic ‘strain’, and perhaps by disclosing their actual non-critical feelings
towards their patients (Safran and Muran 2000), therapists can help their patients
consider new attachment-related schema in which attachment ¿gures are interested
in their true feelings, appreciative of their efforts and genuinely welcoming self-
expression.
Closely related to patients’ expectations of attachment ¿gures are the strategies
patients employ to get their attachment needs met – whether secure, deactivating
or hyperactivating. Secure patients Àexibly move between dependence on the
therapist (attachment-caregiving mode) and work on the problem at hand (joint
goal-oriented mode). Avoidant patients, having learned to ignore or minimise
emotions, overvalue cognition and devalue the importance of connection and
dependence on others, will be more comfortable in the joint goal-oriented mode
and may resist discussion of attachment related issues (Dozier et al. 2001).
Conversely, preoccupied patients, utilising hyperactivating attachment strategies,
pull for more time to be spent in the attachment-caregiving mode with their
therapists and less time in moving towards non-attachment related therapy goals
(Liotti 2007).
According to Bowlby, therapists must challenge the usual strategies patients
use to process emotion in the context of attachment relationships by acting in
ways opposite to the patient’s expectations (Bowlby 1982). These ‘non-
complementary’ actions on the part of the therapist vary by attachment style
(Dozier and Tyrrell 1998).
The avoidant patient

With avoidant patients, therapists should recognise emotional avoidance, validate
unarticulated feelings, draw attention to the attachment-related needs, and
underline the importance of the therapeutic and other attachment relationships.
The therapist must non-defensively normalise dependency and deepen intimacy,
even in the face of sarcasm or dismissal.
Mr. B was in treatment for Obsessive Compulsive Disorder (OCD) featuring

pathological doubt. His attachment style was avoidant, with extensive use of
deactivating strategies. His condition reduced his efficacy at work and made
everyday actions fraught with anxiety over doing the wrong thing.
56 Gail Myhr
During therapy, Mr. B’s father entered the hospital in the terminal stages of
cancer. While visiting him, Mr. B attempted to express thanks to his father for
having provided him with many good opportunities in life. Mr. B’s father
responded in a gruff dismissive way and changed the subject. A nurse,
overhearing this, intervened, saying to Mr. B’s father that what his son was
saying was important and that he should hear him out. But Mr. B’s father
turned his head and appeared not to hear.
As Mr. B recounted this poignant scene is his dry, matter-of-fact way, his
therapist found herself becoming tearful. She recognised the effort it must have
taken Mr. B to overcome his usual emotional avoidance to communicate with
his dying father, and how ultimately disappointing this interaction must have
been. This prompted her to ask what he was feeling as he was telling her this
story. He replied with apparent irritation that he felt nothing: ‘I said what I had
to say to my father, and one can’t expect more than that’. While it would have
been easier to simply agree with this rationalisation and move on, the therapist
persisted: ‘Well, I am proud of what you did to express yourself to your father,
and I find myself feeling sad that he didn’t respond to you differently’.
Mr. B quickly replied: ‘The problem with you psychologists is that you have
no lives of your own and you rely on other people’s feelings to have a life’. The
therapist replied gently: ‘Well, any way you want to look at it, it must have
been a tough night for you.’ Mr. B looked at her for a long moment, then he
appeared uncertain. ‘I’m confused. What are we talking about here?’ She
repeated her earlier comments and he grew pensive for several long minutes.
Then he began to speak again of this episode with greater emotional depth.
In this vignette, the therapist, knowing Mr. B’s avoidant attachment style,
recognised the courage it took to attempt an emotional connection with his father,
and was privy to the kind of rebuff that had probably played itself out many times
in Mr. B’s childhood. She responded in a ‘non-complementary’ way by bringing
her own emotional reaction into the story, and empathising with what she imagines
he might have felt. She ignored Mr. B’s attempt to derail the conversation with a
personal attack by sticking to her goal of validating his attachment-related
emotions and trying to foster a sense of connection in the therapeutic relationship.
The anxiously attached patient

Non-complementary interventions for anxiously attached patients include
resisting patient requests for excessive reassurance and stressing the therapist’s
con¿dence that other ways exist to reduce the patient’s suffering. Here the message
is that ‘I am here for you’, but also, ‘I have con¿dence that there are things you
can do on your own to reduce your suffering’. Skilful use of cognitive behavioural
techniques can give patients concrete tools to reduce their anxiety and model
attachment ¿gures who are consistent and helpful (Liotti 2007).
Ms C suffered from hypochondriasis. She had attachment anxiety and had

employed hyperactive attachment strategies with her husband and previous
therapists over the years. Recently she had become convinced that she had
symptoms of multiple sclerosis. She had consulted many medical doctors and
had been finally sent for CBT by her exasperated GP. Despite her therapist’s
attempts to structure her sessions and methodically tackle her tendency to
catastrophise minor physical sensations, she would frequently derail the agenda
by describing her symptoms in detail, crying intensely and asking her therapist
whether he thought she had a serious illness. While she attended sessions
faithfully, she didn’t do her homework, which consisted of simple monitoring
of her symptoms, triggers and underlying thoughts and behavioural responses.
Finally, the therapist said to her: ‘I get the feeling that you and I are working
at cross purposes; that we’re almost not on the same team! I know there are
practical ways of dealing with these kinds of worries that are very effective, and
I am eager to show you. I am confident that you could learn them. But as long
as you continue to seek my reassurance about your symptoms, we don’t have
the time to try them. So why don’t we do an experiment? How many hours of
pure reassurance do you think it will take to make you feel better? I will book
them in, and we can try that and see what effect that has on how you feel. We
can write down right now what you predict will happen to your anxiety with
this plan, and what alternate predictions could be’.
Ms C was delighted with the idea of being able to ask for as much reassurance
as she wanted. After four sessions of straight reassurance, her anxiety was
worse than ever. She noticed that she experienced temporary relief during the
session, but that shortly after she found herself worrying about details of the
reassuring comments. At the beginning of the fifth session, she asked her
therapist about those other treatment options. The experiment had brought
home to her how reassurance was making her anxiety worse.
In this vignette, the therapist demonstrated to Ms C his con¿dence that he could help
her, not by being a source of reassurance, but by speci¿c techniques that she could
eventually do on her own. Aware of his role as an attachment ¿gure, he was careful
to act quietly con¿dent and unexasperated by her clinginess. ‘Concrete, consistent
help’ was offered (Liotti 2007) and was eventually requested by the patient through
the process of guided discovery. In this way, the patient started taking charge of her
own life and moved towards a more secure relationship with her therapist.
58 Gail Myhr
Using attachment-related schema to inform behavioural

interventions: ‘external exploration’
Cognitive behavioural therapy of anxiety involves confronting what is feared,
either through an exposure exercise or a behavioural experiment to test a relevant
belief. Both the anticipation and execution of these interventions will augment
anxiety and activate the attachment system. An individual’s predominant
attachment style may play a role in such technical parameters as the choice of
therapist-assisted versus independently conducted exposure. Avoidant patients, in
their efforts to minimise felt distress, may not pay attention to the full exposure
experience. Subsequent lack of progress may lead to self-recrimination for being
unable to do this independently. Anticipating this, therapists should avoid joining
in the minimisation of these tasks and encourage attention to the emotional aspects
of the exposure (‘This exercise would be tough for anyone. How can you and I
make it easier for you? Shall we do it together ¿rst?’). The choice of therapy-
assisted exposure (with the advantage of detecting subtle safety behaviours and
efforts at neutralisation) may result in learning not only about the confronted
danger, but also the helpfulness of others in dealing with threat and the relief that
comes with emotional connection.
For anxiously attached patients, therapist-assisted exposure may be less
desirable: the tendency to be more mindful of the therapist’s presence than the
confronted fear may diminish the results of exposure. Thus the preference may be
for independent exposure, with early exercises easy enough to accomplish alone.
Patients will learn that not only is what they fear not as dangerous as they thought,
but also that they can actually cope with the threat alone.
‘External exploration’ may include testing other kinds of behaviour in the
world. Insecure individuals with anxiety disorders have managed their attachment
relationships in characteristic ways to minimise their anxiety. Anxiously attached
individuals, who feel they cannot cope alone, may ¿nd it dif¿cult to disagree with
signi¿cant others for fear of being abandoned. Conversely, avoidant individuals,
who expect no soothing or help from family members, may cause conÀict by
having to have things ‘just so’ in their efforts to stave off catastrophic outcomes
for which they will feel solely responsible. Thus behavioural targets in attachment-
informed treatment of anxiety disorders may include conÀict resolution, self-
assertion and emotionally authentic interpersonal communication.
Using attachment-related schema to inform cognitive

interventions: ‘internal exploration’
Cognitive strategies involve the exploration of patients’ internal worlds – their
deepest beliefs, their expectations of others and of themselves. Cognitive strategies
emphasise the articulation and re-evaluation of these beliefs through the
exploration of automatic thoughts in problematic situations, or as they emerge in
behavioural experiments. Targeting cognitions that maintain anxiety will often
simultaneously target attachment-related cognitions, especially in the insecurely

attached individual.
Ms D, with an anxious attachment style, was in treatment for social anxiety.

She was clingy with her husband and unable to attend social situations or do
grocery shopping without him. As therapy progressed and she became more
confident in dealing with strangers alone, she subtly expressed dissatisfaction
with this man on whom she had so heavily relied. While he was generally good
to her, she felt hurt at the way he referred to her, when irritated, as ‘a mental
case’. When her therapist asked if she had ever protested such treatment, she
replied: ‘Oh I couldn’t’. When the therapist gently persisted, wondering what
would happen if she did express herself to him, she said: ‘I’m sure he would be
furious’. ‘And if he were furious?’ ‘Well, probably nothing, but I would feel bad,
as if I had done something wrong. And I hate feeling that way.’ This example
permitted her therapist to explore pertinent underlying beliefs related to anger
(‘anger is to be avoided at all costs’), and her own perceived fragility in the face
of negative affect (‘I can’t handle feeling bad’). In the context of the therapeutic
relationship, the patient considered an alternate belief about anger as a valuable
source of information and re-evaluated her inability to tolerate short-term
emotional discomfort, in the interest of attaining greater emotional authenticity
with her partner.
Implicit versus explicit attachment-related interventions

Many attachment-related interventions are implicit, such as decisions to self-
disclose in order to offer a contrast to expectations of attachment ¿gures. At the
same time, CBT is highly collaborative, with case conceptualisations and targets
of therapy elaborated jointly. Habitual beliefs and behaviours – including
attachment-related ones – are described in patients’ own words, and are explicitly
referred to throughout therapy as they are modi¿ed. Attachment-related
interventions can be made explicit through drawing attention to particular in-
session interactions of emotional salience. Patients can be asked what they
expected their therapists to say or do, to articulate what actually happened and
how that made them feel. Through careful examination of felt experience, patients
can consider new attachment-related schema and how to test these with current
attachment ¿gures.
Summary
Attachment-related schema inÀuence the sense of personal vulnerability to threat
and behavioural avoidance characterising individuals with anxiety disorders, as
60 Gail Myhr
well as their use of attachment relationships in the attenuation of this threat.

Attachment-informed CBT involves the use of interventions to augment felt
security in the service of facing what is feared. This involves recognisng the
activation of the attachment system, managing the therapeutic alliance to counter
attachment-related schemas, and choosing cognitive and behavioural targets that
may underlie both the anxiety disorder and attachment security.
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62 Gail Myhr
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security in infancy and early adulthood: A twenty-year longitudinal study. Child
Chapter 5

psychosis
Matthias Schwannauer and Andrew Gumley
Introduction
Psychosis is characterised by severe and distressing changes in self experience.
The individual experiences a pervasive sense of interpersonal threat combined
with a sense of vulnerability that undermines basic assumptions of safety, security,
intimacy and attachment. Psychosis signi¿es stigmatising negative life trajectories
generating feelings of hopelessness or triggering defensive denial and sealing
over. Emotional recovery from psychosis is governed by an integration of affective
experience, interpersonal adaptation and constructive help-seeking in the face of
crisis. A central theory that has been developed to explain the link between
emotional distress, adaptation and help-seeking is attachment theory. Attachment
theory has been one of the most inÀuential concepts in psychology, informing
developmental models of human behaviour and interaction as well as approaches
to psychopathology and psychotherapy. We argue that attachment theory also has
the potential to aid our understanding of key processes in the development and
maintenance of psychosis (Liotti and Gumley 2009). Following a brief description
of attachment classi¿cation in infancy and adulthood, this chapter will describe
the way in which attachment theory can inform our understanding of psychosis.
This will be followed by a description of how concepts and ideas from attachment
theory can be used to help facilitate recovery.
Attachment classification and psychopathology

Insecure attachment strategies are adaptive and develop throughout childhood in
order to help the individual cope with a sub-ideal attachment context (Bowlby
1988). From an attachment perspective, there are two key interpersonal strategies
available to help the infant in such an environment to regulate affect and distress:
deactivating affect (dismissive strategies) or hyperactivating affect (preoccupied
strategies). Disorganised (or unresolved) attachment status is not an attachment
pattern as such. It refers to the absence or the collapse of organised attachment
strategies due to exposure to trauma and/or loss. The description refers to infants
most often parented by carers who are either frightening, frightened or both. In
this context, the infant’s source of security is also a source of fear. The infant’s
64 Matthias Schwannauer and Andrew Gumley
conÀict between approach (safeness) and avoidance (fear) strategies is temporarily

resolved by dissociative responding.
Bowlby (1973) proposed that the experience of interactions with attachment
¿gures in childhood becomes internalised and carried forward into adulthood as
mental models that he termed ‘Internal Working Models’ (IWMs). These implicit
structures embedded in procedural memory systems regulate cognitive, affective
and behavioural responses during subsequent interpersonal interactions. Through
IWMs, therefore, early attachment relationships form the prototype for
interpersonal relationships throughout life, and indeed serve to shape the nature
and functioning of individuals’ interpersonal networks. It is generally well
established that early adverse experiences such as early loss and trauma are
strongly linked to emotional and psychological problems in adulthood (Brown et
al. 1986; Hofstra, van der Ende and Verhulst, 2002; Rutter 2000) and psychosis in
particular (Read et al. 2005). However, this association between early loss and/or
trauma and later adult psychopathology is no longer understood as arising from a
direct relationship between early adverse events and later psychopathology. A
signi¿cant number of those who experience adverse events in childhood do not
develop problems in adulthood. The association between earlier life experiences
and later psychopathology is seen as being inÀuenced by a range of different
factors, including how experiences are processed and incorporated into
autobiographical narratives: a core function of the attachment system.
There have been numerous studies describing the impact of early attachment
experiences on individuals’ interpersonal functioning and emotional regulation
(summarised in Fonagy 1998; Fonagy et al. 2002). Theories describing causal
mechanisms linking attachment experiences with later interpersonal functioning
and emotional regulation highlight the centrality of concepts of mentalisation and
reÀective function (Fonagy 1998; Fonagy et al. 2002). Mentalisation refers to
‘mind mindedness’, which is the ability or willingness to identify and understand
thoughts and feelings, including the thoughts and feelings of others. ReÀective
function describes the process by which ‘mind mindedness’ is acquired. For
example, in infancy this function is provided by the caregiver’s appropriate
attunement to, and reÀecting (or mirroring) of, the infant’s intentional and
emotional expressions. This social biofeedback assists the infant in developing a
second order symbolic representational system for organising their affective and
mental states and thus the ability to regulate negative and unwanted emotions. The
mirrored expression and response of the caregiver moderates affect in such a way
that it is different and separate from the primary experience. The infant starts to
associate positive changes in their emotions with the control they have over this
process, leading to an understanding of having the ability to self-regulate. In
adults reÀective functioning is evidenced by an awareness of the nature of mental
states and how they underpin the behaviour of the self and others (Fonagy 1998).
An inÀuential framework for understanding attachment states of mind in
adulthood has been provided by Mary Main’s work (Main, Kaplan and Cassidy
1985; Main 1990, 1999). This conceptualisation of adult states of mind with
Attachment theory and psychosis 65
regard to attachment provides analogous categories to infant attachment behaviour.

Secure attachment in infancy is mirrored by a ‘freely autonomous’ adult attachment
state of mind. Secure adults are able to behave with Àexibility and openness in
relationships. They are able to reÀect openly on, and communicate information
about, their own state of mind without excessive distortions or censorship. They
are also more able to reÀect on and attune to the mental states of others.
Autonomous adults communicate an autobiographical narrative that is free-
Àowing, fresh, reÀective, sensitive to context and collaborative with another
person. They respond to painful experiences in self and others with expressions of
compassion, forgiveness and warmth.
Avoidant infant attachment associates with an adult stance that is ‘dismissing’ of
attachment. ‘Dismissing’ adults minimise and avoid attachment-related experiences
and therefore autobiographical memories related to attachment experiences tend to
be under elaborated. The ‘dismissing’ adult’s ability to reÀect on his or her own
affective experience, and attune to the minds, intentions and mental states of others,
is diminished. Anxious/ambivalent infant attachment is paralleled by ‘preoccupied/
enmeshed’ adult attachment. In a preoccupied state of mind with respect to
attachment, adults are valuing of attachment but are insecure, ruminative and
distressed. Often adults with preoccupied states of mind are concerned with themes
of abandonment and rejection. Finally, disorganised infant attachment behaviour
predicates an unresolved subcategory in adulthood, reÀecting trauma with regard to
loss and abuse. Adults with disorganised and unresolved attachments will
characteristically show disorganisation of affect regulation and behaviour and
problems in monitoring the coherence of discourse. This is characteristic of the
approach–avoidance conÀict that we often see in adults seeking help for past
trauma and abuse. It is, however, important to note that, to a greater or lesser degree,
we all have unresolved attachment-related issues and therefore elements of
dysregulation. It is just that some people’s interpersonal experience – as a result of
extensive childhood trauma – is dominated by these issues (Wallin 2007).
Attachment and psychosis

A growing number of studies have investigated attachment theory and its relevance
for psychological models of psychosis (Berry, Barrowclough and Wearden 2007;
Read and Gumley 2008). Generally, samples of individuals with psychosis tend to
have higher levels of insecure attachment than control groups (Couture, Lecomte
and Leclerc 2007; Dozier 1990; Ponizovsky, Nechamkin and Rosca 2007) and
there is some evidence to suggest that insecure attachment may be associated with
an earlier onset of psychosis and longer periods of hospitalisation (Ponizovsky,
Nechamkin and Rosca 2007). Studies have also found higher levels of insecure-
dismissing attachment in people with a diagnosis of psychosis (Dozier et al.1991;
Mickelson, Kessler and Shaver 1997; MacBeth et al. 2011). High levels of
insecure attachment, and insecure-dismissing attachment in particular, have been
replicated using different methods of assessing attachment and in ¿rst episode and
multiple episode samples.
A number of studies have examined individual symptoms of psychosis and their

association with attachment. In line with ¿ndings of high levels of dismissing
attachment in psychosis, there is consistent evidence of associations between
attachment avoidance, assessed using self-report measures of attachment and
positive symptoms of psychosis (Berry, Barrowclough and Wearden 2007; Kvrgic
et al. 2012; Ponizovsky, Nechamkin and Rosca 2007). Ponizovsky, Nechamkin
and Rosca (2007) also found associations between attachment anxiety, which is
similar to preoccupied attachment, and positive symptoms, but this was not
replicated by the two later studies, suggesting that associations between preoccupied
attachment and psychosis might not be as robust. Individuals with dismissive
attachment styles may employ minimising and dismissive affect regulation
strategies to cope and adapt to the dysregulated affect that accompanies psychosis.
Externalising strategies, such as paranoid delusions or positive psychotic symptoms,
may also be conceptualised as an attempt to externalise emotional arousal whilst
minimising its impact. Furthermore, this pattern of attachment avoidance and down
regulation of interpersonal and emotional distress may contribute to our
understanding of the development of negative symptoms in psychosis. Studies
using self-report measures of attachment have also found evidence of associations
between attachment avoidance and negative symptoms (Berry, Barrowclough and
Wearden 2007; Ponizovsky, Nechamkin and Rosca 2007).
The growing body of research into attachment theory and psychosis has not only
investigated relationships between attachment and symptoms, but has also
investigated associations between insecure attachments and factors that are likely
to facilitate or impede recovery. The quality of the individual’s social relationships
is a key factor in inÀuencing the course of psychosis (Penn et al. 2004) and there is
evidence of associations between insecure attachment and dif¿culties in forming
relationships with others in this group (Couture, Lecomte and Leclerc 2007; Berry,
Barrowclough and Wearden 2007). The majority of studies investigating attachment
and interpersonal relationships in psychosis have studied the impact of insecure
attachment on therapeutic relationships, possibly because attachment theory is in
part a theory of help-seeking behaviour and also because of the well established
effect of the quality of therapeutic relationships on outcomes (Horvath and Symonds
1991). Studies have used different methods to assess therapeutic relationships,
including engagement with services, adherence to treatment, therapeutic
interactions, therapeutic alliance and attachment to services (Berry et al. 2008;
Blackburn, Berry and Cohen 2010; Dozier 1990; Dozier et al. 2001; Kvrgic et al.
2011; MacBeth et al. 2011). Across all these studies, there is evidence that insecure
attachments are associated with more dif¿culties in therapeutic relationships and,
in line with associations between dismissing attachment and more severe symptoms,
some studies have found that dismissing attachment may have a particularly
negative inÀuence on engagement and therapeutic alliance (Dozier 1990; Dozier et
al. 2001; Berry, Barrowclough and Wearden 2007; Kvrgic et al. 2011; MacBeth et
al. 2011). If individuals with a dismissing pattern of attachment do not seek help in
the context of the onset or relapse of psychosis, this narrows the opportunity for
early detection and intervention. The impact of this avoidance on families and
mental health teams can lead to more coercive strategies of intervention, such as
involuntary hospital admissions. These coercive strategies are likely to reinforce
avoidance of help-seeking and impede emotional recovery (Gumley et al. 2010).
It may be easier to form therapeutic relationships with individuals with
preoccupied attachment compared to individuals with dismissing attachment and
there is evidence of more symptom reporting and treatment adherence in this
group (Dozier 1990; Kvrgic et al. 2011). Nonetheless, as preoccupied attachment
is typi¿ed by sensitivity to rejection, it might be associated with more ruptures in
alliance or over-dependence in therapeutic relationships (Daniel 2006). There is
also evidence to suggest that it is important to consider interactions between
therapists and clients’ attachment patterns. For example, one study of case
managers and patients with severe and enduring mental health problems found
that dyads of case managers and patients who differed in terms of their attachment
strategies reported better therapeutic alliance and outcomes than dyads with
similar attachment strategies (Tyrell et al.1999).
Bowlby’s (1980) theory of loss and grief has also been used as a framework to
understand emotional adjustment to psychosis. Responses to bereavement that are
atypical fall into two distinct areas, on a continuum ranging from chronic mourning
to prolonged absence of mourning (Middleton et al. 1993). In attachment terms,
the chronically mourning individual mirrors the preoccupied/anxious individual
who makes persistent attempts to retain proximity or attention of any attachment
¿gure as part of a pervasive and enduring interpersonal schema. This attenuates
the feelings of anxiety, distress and disorganisation associated with any loss or
separation. In contrast, the absence of grief mirrors the dismissing/avoidant
individual. Bowlby (1980) saw this as indicative of ‘defensive exclusion’, an
internal mechanism of downplaying the emotional impact to minimise distress to
the self. This strategy was hypothesised to leave fragmented shards of ‘raw’
memories and feelings about the loved one. Individuals who attempt to block off,
minimise and deny the occurrence of psychosis have been described as having a
‘sealing over’ recovery style.
McGlashan (1987) argues that in recovering from psychosis, individuals adopt
either a ‘sealing over’ or an ‘integrative’ recovery coping style. The former is
characterised by a dif¿culty in recognising and understanding psychotic
experiences and the latter is characterised by recognising the links between
previous psychotic and present experiences. Individuals with a diagnosis of
psychosis tend to use avoidant coping strategies like ‘sealing over’ more often
than ‘integrative’ styles, although integrative styles have been related to less
frequent relapse and better social functioning (McGlashan 1987). Individuals who
‘seal over’ their experiences of psychosis isolate these experiences from other
domains of their life and thus may not experience explicit memories of previous
episodes. In this case the associations may be more implicit. Therefore internal
events reminiscent of relapse may cue feelings of fear and dread (Gumley and
MacBeth 2006; Gumley, White and Power 1999). Similar to ¿ndings in the trauma
literature (Ehlers and Clark 2000; Schacter, Israel and Racine 1999), individuals
are likely to struggle to source the origins of these feelings (‘affect without
recollection’) and therefore they may become vigilant for other forms of threat,
for example scanning for interpersonal danger.
Birchwood (2003) argues that individuals need an internal secure base to
integrate and explore experiences of psychosis. Earlier dif¿culties in attachment
relationships can adversely affect the development of this internal secure base and
thus result in a ‘sealing over’ recovery style. In support of this theory, studies have
found evidence of associations between insecure attachment and/or reports of
dif¿culties in earlier relationships with parents and a ‘sealing over’ recovery style
in response to psychosis (Drayton, Birchwood and Trower 1998; Tait et al. 2004;
Mulligan and Lavender 2009). This sealing over recovery style has also been
associated with less engagement with services (Tait et al. 2004).
As outlined above, attachment patterns and psychosis have largely been linked
on a theoretical level in an attempt to enhance and develop current conceptualisations
of symptoms, social relationships, engagement with services and recovery style.
By contrast, the impact of mentalisation and reÀective function on the experience
of, adaptation to, and recovery from psychosis is largely unexplored. De¿cits in the
related concept of ‘Theory of Mind’ have, however, been implicated in schizophrenia
(Frith 1992). There is now robust evidence to show that ‘Theory of Mind’ is
impaired among persons with a diagnosis of schizophrenia compared to non-
clinical controls and that this impairment exists in patients in remission, indicating
that it is not merely a consequence of acute symptoms and may reÀect a more stable
vulnerability factor (Sprong et al. 2007). Indeed, ‘Theory of Mind’ de¿cits have
been found in persons at high genetic risk of developing schizophrenia (Schiffman
et al. 2004; Marjoram et al. 2006) and among those with schizotypy (Pickup 2006).
Conceptualisations of the ‘Theory of Mind’ as a form of cognitive capacity tend to
be exclusively focused on cognitive and rational aspects, understanding and insight,
whereas related concepts of reÀective function and mentalisation include a strong
emphasis on affective and relational components of behaviours and social
interactions and have been less well researched. ReÀective function and
mentalisation stem from the interaction of affect mirroring, the reÀection of the
individual’s own mental and emotional state in that of others. Well developed
reÀective function is associated with the ability to form and revise thoughts about
beliefs and feelings and the ability to understand the perspective of others. This
capacity allows individuals to successfully adapt to signi¿cant life events and
changing contexts. It is important to note that the discussed concepts of ‘theory of
mind’, reÀective function, metacognition and mentalisation describe overlapping
and related areas of cognitive, emotional and relational ability and awareness, and
place differentiating emphasis on cognitive, interpersonal and affective aspects, but
are at times used interchangeably. There is a strong need for further research to
clarify how these concepts relate to each other and their associated mechanisms.
The only study that has directly investigated attachment states of mind and
mentalisation in psychosis to date is a study by MacBeth, Gumley, Schwannauer
and Fisher (2011). In a small sample of 34 ¿rst episode psychosis patients, the
authors established a clear association between AAI-based attachment states of
mind and reÀective function. Participants with an insecure dismissive classi¿cation
had lower mentalisation skills than the secure and preoccupied classi¿cation
groups. The study also found that reÀective function was associated with social
functioning. This study did not ¿nd a direct association between reÀective function
and psychotic symptoms, which may indicate that although individuals experience
dif¿culties in mentalisation, this dif¿culty is not reducible to a single cognitive
de¿cit or symptom. Rather, dif¿culties in understanding one’s own thoughts and
feelings and those of others may inÀuence the affective experience of psychosis
and social functioning. We argue that processes of mentalisation are therefore
important targets in therapeutic work.
Implications for psychological treatment

Early developmental experiences characterised by attachment disruptions and/or
traumatic experience lead to the evolution of IWMs that may be impoverished,
overly rigid or disorganised. This results in dif¿culties in self-reÀection, affect
regulation and understanding the mental states of self and others. Psychological
therapy provides the opportunity for a corrective attachment-related experience
that has the potential to re-orientate attachment-related behaviours, enhance
emotional containment and consequentially update IWMs. The therapist’s
orientation throughout therapy is the collaborative development of a coherent
client narrative that optimises the evolution of self-reÀectiveness, the crafting of
alternative helpful beliefs and appraisals, and the development of adaptive coping
and interpersonal behaviours. Underpinning this process, the therapist carefully
nurtures the therapeutic alliance and provides the client with a safe haven and
secure base from which to explore dif¿cult issues. For this reason there is a strong
emphasis on interpersonal functioning as it unfolds in the patient’s external
context and internal representations, and their unfolding in the context of the
therapeutic relationship. Siegel (1999) proposes ¿ve basic elements of how
caregivers can foster a secure attachment in the children under their care. These
elements are: collaboration, reÀective dialogue, repair, coherent narratives, and
emotional communication. We argue that these elements are also key in therapeutic
work with people with a diagnosis of psychosis.
Collaboration
Secure relationships are based on collaborative and carefully attuned
communication. The therapeutic relationship is central to therapy in people with
psychosis. The collaborative working alliance becomes an important scaffold to
facilitate the development of clients’ understandings of their own experience and
their understanding of the beliefs and intentions of others. In terms of fostering
collaboration, a number of authors, including Jeremy Holmes (2003), Harris
(2004) and Robert Leahy (2008), have emphasised the importance of tailoring
therapy style to attachment style in the ¿rst few months of therapy. Our clinical
experiences have led us to feel that such an approach is extremely helpful in
supporting recovery from psychosis. In this context, there are two central
therapeutic processes: these involve the development of ‘safe haven’ to enable the
experience of safeness, the expression of distress and help-seeking in context of
crisis; and the promotion of ‘secure base’, involving the promotion of autonomy,
choice, freedom, curiosity, courage and compassion. Collaboration relies on
balancing these fundamental components of attachment security. For example,
during the initial stages formulation is used to strengthen therapeutic bonding,
whereas later, formulation and reformulation of problem understanding and shared
goals might be used to highlight important therapeutic tasks or to identify the
relationship between historical events and current problems, which is also evident
in the therapeutic relationship itself. In formulating the client’s dif¿culties it is
important to attend to the quality of the client’s narrative and to notice their ability
to openly reÀect and consider past experiences as important in the current context.
Susan, a 19-year-old service user following her second episode of psychosis,

found it difficult to make best use of vocational opportunities offered through
the service and to engage in peer-based groups and activities. Following an
episode of inpatient stay she lost contact with her old friends and people she
knew at her college. When she was talking about her experience of psychosis
she was also reluctant to explore how this had affected her and to consider the
impact on her as a young person. Given Susan’s initial reluctance to explore
experiences, the initial engagement focused on development of the therapeutic
frame as a safe haven to express problems in relation to valued goals, and the
use of formulation as a means of mapping problem areas to goals and specifying
the activities of therapy. Using a timeline which provided a map linking key life
events, their impact and her use of social supports enabled Susan to consider
the advantages and disadvantages of withdrawal from others and minimisation
of their influence on her. The unintended consequence of this ‘safe haven’
strategy was to block access to feelings of support and social connectedness
and thus ultimately to undermine safeness and security by increasing loneliness
and isolation. Therefore, Susan was able to formulate the ‘secure base’
treatment goal to consider new social situations as different from past events,
to attend to interactions as they unfolded; a linked goal was to use these new
opportunities of interactions with peers to share some of her experiences and
to be open about her reluctance to talk about herself. She found that others on
the whole responded positively to her, giving her the experience and
understanding that her own appraisal of herself and her experience was not
necessarily that of others.
Reflective dialogue
‘Secure base’ relationships are characterised by attuned communication; openness
to both positive and negative aspects of experience; an acceptance of pain and
suffering in relation to experiences of loss, separation, threat and abuse; a valuing
of relationships as inÀuential; and a curiosity about the nature of relationships and
their inÀuence on mental states and behaviour. ReÀective discourse provides a
framework within which individuals are able to consider the inÀuence of their
experiences and construct new or altered meanings. There is a focus on the person’s
internal experience, where the therapist attempts to make sense of client narratives
and then communicate their understanding in a way that helps the client create new
meanings and perspectives on their emotions, perceptions, thoughts, intentions,
memories and beliefs. An example in relation to the use of the client’s narrative as
a means to understand their internal experiences and their capacity to reÀect is to
draw attention to the emotional context and to other, comparable emotional
experiences, in order to facilitate a re- or co-construction of the experience from
another perspective, including their current feelings when thinking about the event.
Questions like ‘Can you think of other situations in which you felt similar?’,
‘Looking back how do you think X felt when you...’, or ‘What do you think may
have happened if you...’ can be used to elicit thoughts and emotions in relation to
past experiences that are reÀective of current feelings about the events, and
to consider the importance of their emotional experience now in responding to
similarly challenging or distressing situations. ReÀective dialogue can only take
place in the context of safe haven and thus moving to a more reÀective mode of
discourse is permitted by the necessary establishment of collaboration.
Repair
When attuned communication is disrupted there is a focus on collaborative repair,
allowing the client to reÀect upon misunderstandings and disconnections in their
interpersonal experiences. Disrupted communication threatens safe haven, and the
focus on repair enables a refocusing on problems, goals and change strategies.
Within the structure of safe haven, interpersonal problems and ruptures can be
detected and explored that might not otherwise be volunteered or raised by the
client. This is important when considering that the client may be highly avoidant
and unaware of possible problems. Process factors within therapy, such as those
expressed in concepts derived from psychodynamic therapies (e.g. transference
and counter-transference), can be utilised within therapy as a means to enable the
therapist’s reÀective functioning, particularly with respect to how their own
responses within therapy may facilitate or interfere with recovery. The establishment
of a containing and reÀective therapeutic relationship will enable therapeutic
change to take place within an interpersonal context that can in itself provide an
essential and corrective emotional experience. In this context it can be helpful to
think about possible ruptures and ‘stuckness’ in therapy in attachment terms. For
example, a client with a disorganised or unresolved attachment state of mind may

draw the therapist into very strong but fragmented and contradictory narratives
about past experiences. They may also have a ready tendency to identify the
therapist with other important people in their past lives and assume that the therapist
will feel similarly about them as people in the past did. It is vitally important in
these instances to be able to take a mentalising stance and maintain an ‘observing
distance’ by identifying and verbalising what is currently happening between client
and therapist, including the identi¿cation of feelings of both. In the context of an
unresolved attachment state of mind, the therapist may notice herself being tempted
to provide solutions or to act by reformulating the client’s narrative prematurely,
rather than noticing her urge to resolve the client’s distress through action and thus
mirror the client’s inability to tolerate distress in the moment. By verbalising the
affect felt at the time and highlighting its importance for their shared ability to think
about the impact of the experience, the therapist is more likely to progress the
session than by focusing on the detail or content of the narrative.
Coherent narratives
The connection of past, present and future is central to the development of a
person’s autobiographical self-awareness. The development of coherent narratives
within therapy aims to help foster the Àexible capacity to integrate both internal
and external experiences over time. This can be achieved by focusing on the
speci¿c details of autobiographical memory in a client’s description of a particular
event, resisting the tendency to abstract or generalise from the experience, and by
carefully separating feelings at the time from the feelings triggered by the
remembering and verbalising of these memories. Coherence in the co-construction
of the narrative can further be achieved by focusing on the client’s perspective at
the time, so, for example, aligning the guilt felt now in relation to interpersonal
trauma with the possibilities of having been able to understand what was happening
at the time they were much younger. The therapeutic narrative gives an indication
of the levels of processing and understanding achieved by the client and can be
used to focus therapeutic discourse. For example, when discussing trauma, it is not
unusual for narrative to become fragmented, dif¿cult to follow and impoverished.
This acts as a signal to the therapist of the presence of problematic or unresolved
experiences. Trauma and loss can disrupt the development of a coherent narrative
and care should be taken in accessing strong negative affect. The therapist needs to
work with the client and carefully consider the client’s ability to regulate strong
negative affect in the context of the therapeutic relationship.
Emotional communication
The therapist maintains close awareness not only of the cognitive contents of
narrative but also of clients’ emotional communications. In focusing on negative
or painful emotions within sessions, the therapist appropriately communicates and
encourages self-reÀection, understanding, acceptance and soothing. In their

process experiential approach to psychotherapy, Greenberg and colleagues (1993)
have emphasised therapeutic tasks that facilitate experiential rather than conceptual
processing of events. The routes to therapeutic change are via the empathic
exploration of the therapeutic narrative, the recognition of affect that is expressed
directly or indirectly in the narrative, and the therapist’s ability to reÀect on the
process of meaning-making and interpretation of affect that is contained in the
client’s report. Within this care-giving framework provided by the therapist, key
aspects of attachment security are characterised by empathy, forgiveness,
compassion and the capacity to make appearance reality distinctions. Therefore
there is an explicit attempt to help the person to develop an internal compassionate
and self-soothing stance towards their prior experiences and themselves. The
therapist works collaboratively with the client to develop and strengthen these
underdeveloped self-nurturing strategies. As part of this process, the development
of these skills in relating to the self and others is meshed with changes in the
clients’ beliefs about themselves and others. For example, where it becomes
apparent that a client tends to become very self-critical and derogating towards
her own behaviours and reactions when talking about particular experiences, it is
helpful to openly notice this within the session and to draw attention to these shifts
in emotions and self-appraisal. Characteristics of safe haven and secure base are
actively utilised to promote the development of therapeutic strategies. Cultivating
a secure base orientation involves the development of characteristics of courage,
openness, curiosity and exploration, whilst safe haven involves the development
of attunement, acceptance, caring, empathy, warmth, compassion, forgiveness.
The crucial therapeutic task is ¿nding a balance between these two domains that
optimises supporting the service user in responding to painful thoughts, feelings
and memories with these characteristics of secure attachment. This can unfold in
a variety of techniques focused on developing cognitive, emotional, attentional
and behavioural skills (Gumley et al. 2010; Gumley and Clark 2012).
Implications for mental health services

Attachment theory is invaluable in incorporating a formulation of insecure and
threat based recovery strategies within the context of therapist and client
relationships. However, working with people with a diagnosis of psychosis also
requires a co-ordinated multi-disciplinary response to clients’ needs. It seems
unreasonable to work with a client to encourage and develop their help-seeking
behaviours if the help that they receive is not the help that they were seeking in the
¿rst instance. Goodwin and colleagues (2003) proposed that a key function of
multi-disciplinary teams is to facilitate a ‘secure base’ through providing continuity
and consistency of care, providing sensitive and appropriate responses to affective
distress, and providing emotional containment during times of crisis. A crucial
challenge for services is developing capacity to provide a safe haven for service
users to seek help in the context of feelings of distress and threat. This involves
developing service capacities to tolerate listening to painful and distressing stories

whilst responding in an attuned and responsive way. In addition, services need to
balance safe haven with secure base by supporting service users in developing
autonomy, choice, curiosity and exploration. Achieving this balance within services
can present special challenges to the development of collaboration and the enabling
of service user choice and positive risk-taking. Attachment theory provides a
coherent framework within which to understand these recovery based challenges.
Conclusions
We have argued that attachment theory provides a key framework within which to
understand processes involved in recovery from psychosis. Although further
research is required to maximise the potential of attachment theory in this area, it
is encouraging that there is a growth in empirical studies demonstrating associations
between insecure attachment and symptoms of psychosis, as well as key factors
associated with blocked recovery such as the therapeutic relationship, a ‘sealing
over’ recovery style and poorer mentalisation skills. We have argued that the
therapeutic relationship is a key vehicle to facilitate recovery from psychosis. The
therapeutic relationship provides a context in which to establish security and trust
to enable the development of a coherent narrative and the reinforcement of
productive coping. The psychotherapeutic framework for this may involve both a
sensitisation and tolerance of affect that allows for increased mentalising capacity.
This process is not without its challenges. Constructing a safe haven/secure base
can, for some, create feelings of vulnerability and threat that produce apparently
contradictory or unexpected emotional or coping responses that in themselves can
elicit confused or unhelpful reactions from services. This can produce an
unintended con¿rmation of negative expectations of others. Therefore these
apparently contradictory responses need to be understood and explored in the
person’s life context. This is the work of applying attachment theory to recovery in
terms of overcoming the basic blocks and fears related to af¿liation. The
development of a secure base for recovery provides a bridge for help-seeking,
distress tolerance and distress reduction in the future. This has profound
implications not just for individual therapists but also for how services reÀect on
their own helpful (and unhelpful) responses to individuals and their families.
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Chapter 6
Understanding attachment,
trauma and dissociation in
complex developmental
trauma disorders
Kathy Steele and Onno van der Hart
Introduction
The heart of psychotherapy is in understanding and changing the ways in which
individuals experience, develop and maintain human relationships. Attachment
theory and the ¿eld of interpersonal neurobiology have gifted us with a nuanced
and powerful understanding of relationships, the mental representations of self
and other that shape relationships, and the regulatory and organising functions of
attachment. No one is more in need of help with attachment and regulation than
those who have been chronically abused and neglected in childhood. These
individuals generally suffer from a wide array of symptoms that can be understood
as complex developmental trauma disorders, including Complex Posttraumatic
Stress Disorder (C-PTSD), trauma-related Borderline Personality Disorder (BPD)
and the Dissociative Disorders. Our emphasis in this chapter will be on working
with attachment problems in patients who have a dissociative disorder.
Individuals who experienced chronic childhood interpersonal traumatisation have
had their development adversely impacted early in life across broad areas of
functioning. This leaves them with an unstable foundation for future healthy
development and adaptation, putting them at risk for ongoing psychological,
physiological and relational problems. These developmental issues distinguish them
from those who have classic PTSD related to a single traumatising incident that has
not altered the individual’s early developmental trajectory (Courtois and Ford 2009).
Although in recent years mental health professionals have developed a much
greater understanding of the relationship between childhood abuse and neglect and
attachment dif¿culties across the lifespan, many clinicians have yet to grasp the
central role of dissociation in generating and maintaining serious symptoms,
including many major attachment dif¿culties. In fact, dissociation is not only an
intrapsychic phenomenon but also an interpersonal one, being highly reactive to what
is happening in relationships in the present (Liotti 2009). Thus we will place a special
emphasis in this chapter on working with dissociation in the context of attachment.
The chapter begins with a description of how early secure attachment supports
regulation and integration of the child, and how abuse, neglect and severe
attachment disruptions adversely affect development. These overwhelming
Understanding attachment, trauma and dissociation 79
experiences create fertile ground for the child to dissociate, as she or he has the
impossible task of trying to live normal daily life while under chronic threat.
Dissociation in trauma is described, so that clinicians have a solid foundation and
rationale for integrative treatment interventions. Speci¿c trauma-related phobias
that maintain dissociation and their treatment are discussed.
Treatment of dissociation and related attachment problems will be delineated
within a phase-oriented treatment approach that is the current standard of care
(Boon, Steele and Van der Hart 2011; Chu 2011; Cloitre, Cohen and Koenen
2006; Courtois and Ford 2009; Davies and Frawley 1994; Howell 2011; ISSTD
2011; Van der Hart, Nijenhuis and Steele 2006). Phase-oriented treatment is based
on the premise that early trauma and attachment disruptions limit integrative
capacity and impede self and relational regulation skills. Therefore, treatment
begins with an initial phase of stabilisation, ego strengthening, and skills building.
The second phase focuses on treatment of traumatic memory and the ¿nal phase
on a more adaptive integration of the individual’s functioning across all domains.
Within each phase, treatment of trauma-related phobias that maintain dissociation
will be addressed. Due to space limitations, treating the phobia of attachment and
of attachment loss in the ¿rst phase of treatment will be emphasised in this chapter.
Attachment, trauma and dissociation

Children need safe, consistent and predictable relationships for healthy
development of self-regulation, maturation and integration (Porges 2011; Schore
2003). These types of relationships can only occur when we feel safe. It is dif¿cult
to maintain a sense of relationship when in danger, particularly when it involves
severe, or life, threat. Fortunately, evolution has endowed us with the capacity to
distinguish between safety and threat so that we can have secure relationships that
support our development and integration.
The integrative functions of safe attachment

When we feel safe, an inborn neural organisation or action system called the
social engagement system helps us to regulate ourselves and connect well with
others (Porges 2011). The social engagement system is the physiological
foundation for secure attachment. Via the vagal nerve branches, our physiology is
organised to support social behaviour such as movement, hearing and speaking
that facilitates bonding and attachment. Speci¿cally, the vagal nerve supplies the
muscles that control the social cues of eye gaze, facial expression, head movements
and prosody (the rhythm, stress and intonation of our voices). The vagal nerve
also helps control heart rate and thus our arousal level. The social engagement
system helps us maintain a calm state of being that promotes growth, integration
and restoration (Porges 2011).
Secure attachment supports the hard wiring of the child’s brain that will
determine to a large degree how well he or she is able to regulate and relate to
80 Kathy Steele and Onno van der Hart
others across the lifespan (Schore 2003). Consistent activation of the social
engagement system via secure attachments helps maintain a regulated
psychobiological foundation that supports ongoing integration of the child’s
personality, that is, the consistent and predictable ways of being that de¿ne the
child. The child learns not only to depend safely upon others to help soothe and
reassure but also to self-regulate and to integrate experience and a consistent sense
of self across time and situations.
Activation of action systems of daily life

Secure attachment and the social engagement system support activation of other
inborn action systems necessary for adaptive functioning in life (Van der Hart,
Nijenhuis and Steele 2006). These include exploration (so that we can be curious
and learn about our environment), play (supports learning and relating to others),
caregiving, socialness (so we can relate within groups), energy management
(healthy eating, sleeping and rest patterns) care-taking, and sexuality (so that we
can reproduce and maintain our species) (Lichtenberg and Kindler 1994; Panksepp
1998; Van der Hart et al. 2006).
Inhibition of defence
Secure attachment not only activates functions that support adaptive living, it also
inhibits unnecessary defence. For example, a child might be frightened by dogs,
but the parent reassures and supports the child in slowly approaching and petting
a friendly dog and gradually teaches the child to read the cues of whether it is safe
to approach a particular dog. Secure attachment has deactivated the defensive
reaction in the child and supports the child’s return to a regulated state where
ongoing integration can continue.
Defence against threat

Serious threat automatically activates defence and overrides the action systems of
daily life, including the social engagement system. A chronically fearful and
insecure person experiences persistent problems in many of the functions that are
organised by these action systems, which we can easily see in chronically
traumatised individuals. For example, in addition to relational problems, they
often have trouble being curious and trying new things (exploration), may have
anxiety in groups (socialness), have sleep and eating dif¿culties (energy
management), sexual problems (sexuality), tend to over or under care-take others
(caretaking), and are unable to enjoy themselves through play (Van der Hart et al.
2006).
From an evolutionary standpoint, secure attachment itself is an important ¿rst-
line defence against threat, as living within a protective group or being in the care
of a stronger, more able person is much safer than being out on one’s own (Porges
2011). For example, when a young child feels discomfort or distress, or is mildly
threatened, the ¿rst thing he or she will do is call out for a caregiver. This is a
natural defence called the attachment cry, and involves panic, frantic searching
and crying, and clinging behaviours (Ogden, Minton and Pain 2006; Steele, Van
der Hart and Nijenhuis 2001; Van der Hart et al.; Van der Kolk 1987). Its purpose
is to engage the caregiver for support, help and reassurance, so that the child can
return to a calm, comfortable state.
However, when threat becomes too great, the child no longer searches for an
attachment ¿gure but instead automatically reacts with evolutionary prepared
defences: freeze, Àight, or ¿ght, each mediated by the sympathetic nervous system,
resulting in extreme hyperarousal. When threat is severe enough to be perceived as
life threatening, the child may collapse in a kind of death feint, mediated by the
(dorsal vagal) parasympathetic system, resulting in extreme shut down and
hypoarousal (Porges 2011; Van der Hart et al. 2006). For infants and young
children, even non-violent severe attachment disruptions such as neglect or
abandonment can be physiologically interpreted as a life-threatening catastrophe,
evoking chronic defence (Bowlby 1969/82; Liotti 2009; Schore 2003). These
defence reactions are readily observed in chronically traumatised patients, and
recognising and treating them is an essential part of treatment.
Dissociation
When the child’s caregiver is seriously abusive or neglectful, the natural capacities
to distinguish between safety and threat, to become securely attached and engage
in all the functions of daily life, to defend oneself when in danger and to integrate
experience over time become greatly complicated and confused. The abused child
is dysregulated on a chronic basis without suf¿cient relational support to return to
a normal baseline that supports integration. Most importantly, the child is faced
with the impossible task of simultaneously approaching the caregiver out of need
and an inborn need to attach, and avoiding or defending against the same person.
Under these conditions of chronic threat, the child dissociates, unable to make
sense of and integrate the highly discrepant needs to attach and defend at the same
time. As Liotti (2009) noted, this approach and avoidance ‘exceeds the limited
capacity of the infant’s mind for organising coherent conscious experiences or
unitary memory structures’ (p. 55).
Dissociative attachment
The child develops a dissociative attachment style called disorganised/disoriented
or D-attachment (Liotti 1992, 2009; Main and Hesse 1990; McFadden 2011; Steele
et al. 2001; Van der Hart et al. 2006). D-attachment is strongly related to ongoing
and chronic dissociation (Barach 1991; Blisard 2003; Chu 2011; Howell 2011;
Liotti 1992, 2009; Lyons-Ruth et al. 2006; Ogawa et al.1997; Steele et al. 2001;
Van der Hart et al. 2006). D-attachment involves dissociation of the personality,
which is a shorthand term for our usual and enduring ways of being. Dissociation
occurs between ways of being that involve engagement in daily life and attachment
strategies and ways of being in which the individual is rigidly ¿xed in defences
(attachment cry, freeze, Àight, ¿ght, and collapse). In the face of perceived threat,
the individual may switch in an uncoordinated way between these very different
ways of being, resulting in what appear to be disorganised or contradictory actions.
In fact, these behaviours indicate an underlying dissociation of his or her personality.
A well-integrated person experiences all ways of being as belonging to him or
herself: ‘I am me, in the past and the present, and in all ways of my being.’ But a
dissociative person’s ways of being are not coordinated, they become activated at
the wrong time or in the wrong situations and are even actively in conÀict with
each other. For example, a person might have a terri¿ed, frozen child sense of self
in which he or she is mute and unable to move or think; an angry adolescent sense
of self in which he or she is perpetually enraged and avoidant of relationships, and
hates the child part; and an adult sense of self in which he or she is primarily
interested in work and avoidant of the child and adolescent parts (Van der Hart et
al. 2006).
Dissociative parts of the personality

These compartmentalised functions (sense of self and related feelings, thoughts,
perceptions, predictions, and behaviours) are referred to as dissociative parts of
the personality (Van der Hart et al. 2006). They are also called self-states, alters,
identities and other terms in the literature. By using the term ‘parts of the
personality’ we do not mean that a person has more than one personality, a
common misconception of dissociative disorders. Rather, the individual has more
than one sense of self within a single personality, each of which is related to
particular action systems and generally have rather limited ways of being. Each
part has its own unique ¿rst-person perspective (that is, a sense of ‘me, myself,
and I’) that is different from another part (Nijenhuis and Van der Hart 2011).
These parts are ¿xed in relatively rigid patterns of thinking, feeling, perceiving
and acting. They are not very open to change and learning.
Next, we discuss two basic organisations of dissociative parts, one type
organised by the action systems of daily life, including social engagement, and the
other organised by the various defences. These distinctions have important
treatment implications that will be discussed throughout the chapter.
Apparently Normal part of the Personality (ANP)

Dissociative parts mediated by action systems of daily life (attachment,
exploration, care taking, sexuality, etc.) have been called ‘apparently normal’
parts of the personality (ANP), based on the dissociative individual’s need to
function normally in daily life to the degree possible, in spite of signi¿cant
symptoms (Van der Hart et al. 2006). ANP involves the ways of being in which
the individual deals with daily life in the present as an adult. Typically the patient
as ANP is highly avoidant of any reminders of trauma. In many cases, a single
ANP is the major ‘shareholder’ of the personality and is the part of the patient that
acts in the world and presents to therapy. In more severe cases, there may be more
than one ANP, for example one that goes to work, one that takes care of the
children, one that socialises.
In terms of attachment, the patient in ANP mode may have a wide range of
capacities and functions. Often he or she is quite avoidant and depressed as ANP,
but more functional individuals may be able to engage in at least some relatively
healthy relationships. Treatment is geared toward improving function in daily life
and helping the patient as ANP accept and respond empathically to other
dissociative parts.
Emotional part of the Personality (EP)

Other dissociative parts are ¿xated in traumatic memories, in which the individual
is often relatively unaware of the present, or at least responds to the present as
though it were the past. We call this living in trauma-time (Van der Hart, Nijenhuis
and Solomon 2010). These parts are typically organised by defences (attachment
cry, Àight, ¿ght, freeze or collapse) and have been called ‘emotional’ parts of the
personality (EP) because of their chronic and intense hyper- or hypoarousal (Van
der Hart et al. 2006). Because EPs are ¿xed in defence, threat is perceived where
it does not exist, particularly in relationships. The attention of these parts is
narrowed to attend only to threat cues and so they often miss cues that might
indicate the present is safe. For example, the patient as EP can become afraid
when the therapist frowns in effortful listening, misperceiving the frown as an
indication of anger. In this part of the personality, the patient is unable to step back
and observe the situation as a whole, putting the frown into the proper context, or
at least checking out what it means with the therapist. He or she only reacts with
fear.
The therapist helps ANP and EP aspects of the patient become less avoidant and
more accepting of each other, eventually leading to more adaptive and integrative
functioning for the person as a whole. The individual must learn to accept each
part as an aspect of his or her self, though this can take time for those who are
extremely avoidant.
Trauma-related phobias: why dissociation

becomes chronic
Dissociation is maintained over time ¿rst and foremost because the individual
whose development has been disrupted may not have the integrative capacity to
fully accept and realise what is dissociated. This is why skills building is an
essential part of the ¿rst phase of treatment, so that the capacity to function and
integrate is strengthened as much as possible. Secondly, because integrative
capacity has been lacking for so long, the individual has developed major
avoidance strategies to prevent confrontation with what has been dissociated. This
leads to a series of inner-directed phobias.
Trauma-related phobias typically involve severe conÀicts and fear, shame, or
disgust of the dissociative individual’s experience and of various dissociative
parts. These phobias may be triggered strongly in relational contexts. They include:
• the phobia of mental actions, that is, of inner experience;

• the phobia of dissociative parts;
• the phobia of traumatic memory;
• the phobia of attachment and attachment loss;
• the phobia of healthy risk taking and change;
• and the phobia of intimacy.
Each dissociative part is typically isolated from other parts by these phobias that
involve painful conÀicts, defensive strategies and resistances to therapy. For
example, an angry part might feel disgusted by a needy part and punish the patient
when needs are expressed, while the needy part feels overwhelmed, criticised and
afraid of the angry part.
Overcoming inner-directed phobias is a central task in fostering integration of
the individual as a whole. Phobias are addressed in large part in sequence within
the three phases of treatment, beginning with the broad phobia of inner experience
(thoughts, emotions, sensations, wishes, perceptions, predictions, etc.) and the
patient’s experience with safety and threat in initial contacts with the therapist
(Steele et al. 2001, 2005; Van der Hart et al. 2006).
Phase-oriented treatment of complex developmental

trauma disorders
Phase-oriented treatment involves three overlapping phases of treatment. The
initial phase focuses on safety, skills building, stabilisation, symptom reduction
and building a co-operative therapeutic alliance in the face of multiple and
contradictory transferences. Once a modicum of safety has been established and
suf¿cient skills are in place, the second phase commences, in which traumatic
memories and enactments are addressed more thoroughly. In this phase important
work on insecure attachment to perpetrators is also accomplished. This phase is
followed by a third phase of grieving, solidifying and furthering integrative gains,
becoming more accepting of life as ever-changing, and promoting healthy risk-
taking to develop more intimate and meaningful relationships. A return to earlier
phases is often necessary over the course of treatment, according to the needs of
the patient. The foundation for therapy with severely traumatised individuals is a
secure therapeutic relationship that has strong boundaries.
Phase 1: establishing safety, stabilisation and

skills building
In this ¿rst phase of treatment, patients must ¿rst learn stabilisation skills,
including how to establish and maintain safety, arousal and impulse regulation,
the ability to reÀect on experience (Fonagy 1997), energy management, relational
skills, executive functioning, and skills to overcome chronic dissociation, as well
as other daily life skills (Boon et al. 2011; Chu 2011; Cloitre et al. 2006; Courtois
and Ford 2009; ISSTD 2011; Steele et al. 2005; Van der Hart et al. 2006). The
therapist should take an initial stance of interest and modulated empathy with the
patient as ANP, neither overly warm nor distant in feeling tone and not too probing
(Steele et al. 2001; Van der Hart et al. 2006).
Establishing safety
Much emphasis has been placed on the primacy of the therapeutic relationship.
However, what is often missed is the need for the patient to ¿rst experience a
physical sense of safety that allows for curiosity and co-operation, prior to
attachment with the therapist. Dissociative parts that are ¿xed in ¿ght, Àight,
freeze, or collapse defences (EPs) are focused on cues of threat, not relationship.
Early in therapy, therefore, relational interventions should generally be preceded
by those that address safety and collaborative co-operation, following the principle
that attachment cannot occur as long as serious threat is perceived. This involves
more than just cognitive awareness of safety, because patients often lament, ‘I
know I am safe, but I don’t feel safe!’ The therapist helps the patient identify the
physical sensations and postures that accompany being safe in order to have an
experiential ‘knowing’ or felt sense of safety (Ogden et al. 2006), sometimes
alternating awareness back and forth between a sensation associated with danger
and one associated with safety. It is only then that work can proceed on earning
secure attachment, with its felt sense of (relational) security.
Working in a window of tolerance

Treatment should be conducted in such a way that it remains within the patient’s
overall window of affective and integrative tolerance (Boon et al. 2011; Ogden et
al. 2006; Van der Hart et al. 2006). The best overall indication of whether therapy
is being well paced is how well the patient is functioning in daily life. In general,
if functioning over time is status quo or improving, therapy is likely going well.
Learning, co-operation and secure attachment cannot exist outside the range of
what the patient can tolerate.
All parts of the patient, beginning with the patient as ANP, need to learn to
recognise early signals of distress and practise distress tolerance and other
regulatory skills (Boon et al. 2011). The therapist should track small changes in
the patient from moment to moment so that dysregulation can be addressed
immediately it begins to occur (Ogden et al. 2006). For example, the therapist can
notice that the patient’s speech has become shaky, her mouth is dry, she is shifting
in her seat and looking around the room. Instead of continuing to talk, the therapist
can ask the patient to notice what she is experiencing and together they can work
toward regulation. The therapist is thus using his or her own capacities for
regulation and reÀection to help the patient learn self-regulatory skills. This is an
essential component of secure attachment that builds safety and co-operation and
lays the groundwork for integration.
Orienting parts to the present

Dissociative parts, in particular EPs, are often disoriented to time, place and even
person, living in trauma-time in which they perceive danger. This makes it
extremely dif¿cult for the individual to have safe relationships, including with the
therapist. To this end, ‘all parts’ are encouraged to focus on present experience in
the room with the therapist. Parts are ¿rst oriented to place, and then to person, as
efforts to develop attachment might be too activating at ¿rst. For example, ‘Let all
parts of you look around the room and see where you are. Can you notice
something that can be a reminder to your whole mind of the safe present?’ Parts
more oriented to the present are encouraged to inwardly remind other parts of the
present. Focusing on current reality for all parts of the patient is an important
integrative action that supports more accurate perceptions of the present and more
capacity to respond appropriately.
Overcoming the phobia of inner experience

The patient must become increasingly aware of, tolerate and understand inner
experiences that consist of mental actions. All interventions incorporate implicit
and explicit approaches that support overcoming this phobia. The patient, ¿rst as
ANP, must learn to accept feelings, thoughts, sensations, wishes, needs, fantasies
and perceptions without assigning value judgements to them. The patient is
routinely encouraged to be aware of and explore his or her present experience
(Ogden et al. 2006). The therapist should be consistently curious with the patient
about inner experience in the moment. For example, the therapist might ask, ‘As
we are talking about your job, what do you experience right now? Can you notice
if parts of you have some thoughts or feelings about it?’ In this way the therapist
constantly attends to process that accompanies content, and is able to slow down
and address the patient’s immediate experience.
Overcoming the phobia of attachment and attachment loss

The phobia of attachment in some parts of the personality is paradoxically
accompanied by an equally intense phobia of attachment loss (rejection,
abandonment, criticism) in other parts. The therapist should recognise that both
attachment and attachment loss are feared, and therefore must ¿nd a delicate
balance between enmeshment and distancing emotions and behaviours (counter
transferences), both of which may be extremely intense for the therapist (Dalenberg
2000; Steele et al. 2001).
Coping with counter transference

One of the most essential interventions in working with the attachment phobia is
for the therapist to understand and work with his or her countertransference
reactions, rather than act on them. The therapist is pulled toward extreme emotions
with these patients like no others. These may include rage, hatred, shame, guilt,
disgust, fear, despair, hopelessness, helplessness, intense love and loneliness
(Dalenberg 2000; Davies and Frawley 1994; Steele et al. 2001). The therapist can
also be seduced by feelings of omnipotence and overwhelming care-taking (‘I can
save this person’), engendered by the patient’s own wishes and the unresolved
past of the therapist. Supervision and consultation for these dif¿cult emotions are
strongly recommended, even for experienced therapists (Chu 2011; Courtois and
Ford 2009; Dalenberg 2000; Steele et al. 2001; Van der Hart et al. 2006).
Working with the conflict between attachment and

attachment loss
The patient’s combination of attachment minimising and maximising strategies
should be recognised by the therapist (Steele et al. 2001; Van der Hart et al.
2006). The more need is evoked for the patient in the relationship with the
therapist, the more defensive parts (EPs) become fearful and enraged, fearing the
therapist’s withdrawal or rejection. They are ashamed of dependency and greatly
fear vulnerability. They turn shame and anger inward toward needy parts, resulting
in dysregulation and often in self-destructive behaviours (drinking, self-harm,
etc.). These situations, in turn, create more crises, perpetuating a maladaptive
need–shame–rage cycle (Boon et al. 2011). The most important interventions are
for the therapist (1) to consistently encourage adult aspects of the patient (ANPs)
to acknowledge dependency needs and accept responsibility for child parts in
collaboration with the therapist; and (2) to help the patient resolve the conÀict
between these young needy parts and defensive parts that avoid attachment.
The phobia of attachment loss is often mediated by the attachment cry, the early
defence of calling out for a caregiver. Many young child-like EPs are ¿xed in this
defence. Behavioural manifestations typically include dif¿culty ending and
leaving sessions, crisis calls in between sessions, panic when the therapist goes
away, and frantic expression of need and other attempts at frequent contact with
the therapist outside of sessions. These behaviours are unfortunately often labelled
as ‘manipulative’, but actually represent efforts to attain safety via care-taking and
attachment, since these parts are dissociated from adult inner resources that could
be soothing and helpful.
Treatment does not call for the therapist to meet every need and demand and be
constantly available, but rather to be consistent and predictable (Steele et al.
2001). In fact, the therapist needs to set appropriate boundaries and limits on
contact outside of session. This helps prevent too many dependency behaviours
that can upset the equilibrium of the patient, and allows him or her to bring
dependency needs into the therapy room where they can be talked about. The
following case example illustrates some ways of working with this conÀict.
Marge is a 48-year-old woman with a dissociative disorder who was extremely

phobic of a child part that cried all the time, calling out for help, and also of an
inner critical part that was always telling the child part to ‘shut up’ internally.
This inner conflict was so intense that the patient began calling the therapist
frequently between sessions to get help with her anxiety. The therapist first
helped the patient verbalise more about her conflict about dependency on the
therapist and addressed her concerns. Then she asked for permission to
address the critical part and determined that the function of this part was to
maintain safety by keeping the ‘crybaby’ quiet so that the child part would not
‘cry too much and get in trouble’. This critical part was living in trauma-time,
unaware of the present, and was well-defended by rage against dependency
needs. The therapist helped orient the critical part to the present and agreed
that she also did not want the child part (or any part of Marge) to be in such a
painful state. The therapist then encouraged Marge to understand the function
of the critical part, as well as the dependency yearnings of the child part. She
gradually became less phobic and more compassionate of these parts of herself
and could accept their functions. The therapist supported an alliance between
the critical part and the adult self of the patient, which in turn were able to
support the child part in being acknowledged and helped in appropriate ways.
This significantly calmed the inner conflict.
Overcoming the phobia of dissociative parts

By de¿nition, at least some dissociative parts are avoided because the patient
experiences them as feared, shameful or disgusting. As noted above, dissociative
individuals tend to wish either that the therapist would ‘get rid of’ parts, or work
with them without the involvement of the patient as ANP. Beginning early in
therapy, the therapist should encourage active inner communication and co-
operation between the patient as ANP and other parts in a paced manner that
fosters integration over the long term. The therapist might say something like, ‘I
can empathise with your wish for those needy and angry parts of you to disappear.
Yet, in all these years, you have not been able to make that happen. That is
because these aspects of you are a normal part of being human. I am con¿dent
that together, you and I can begin to make sense out of all these ways of being,
and help you deal with them so that you feel more safe and comfortable with
every part of yourself’.
Treatment is directed ¿rst towards helping the patient as ANP understand and
become more empathic and engaged with all parts of him or herself, orienting
parts to the present, establishing safety and inviting all parts to become involved
in a co-operative therapeutic alliance. The therapist may often say something like,
‘It is important that you and I invite all parts of you [or every part of your mind,
or you in all your ways of being] to listen and give feedback about what we are
discussing now’. When the therapist works with parts living in trauma-time (EPs)
in the ¿rst phase of treatment, it should be to establish safety, orient to the present
and develop co-operation in therapy and in daily life with other parts, rather than
exploring traumatic material.
Once the patient is stable, functioning in daily life to the degree possible, can
engage in regulation, and has some inner awareness and co-operation, the
treatment of traumatic memories can take a more prominent place in therapy.
Phase 2: integrating traumatic memories

The major phobia addressed in Phase 2 is that of traumatic memories, many of
which involve severe attachment disruptions or trauma. In addition, disorganised
attachment to abusive and neglectful family members must also be addressed. In
this chapter, we focus on the attachment aspects of Phase 2. Further reading on the
treatment of traumatic memories can be found in Chu 2011; Kluft 1996; Van der
Hart et al. 2006; and Van der Hart, Steele, Boon and Brown 1993.
Treatment of insecure attachment to the perpetrator

The inner conÀict between attachment to and defence against caregivers who are
perpetrators becomes heightened when traumatic memories are reactivated. Some
patients may be enmeshed with their families in the present, unable to set healthy
boundaries and limits. Simultaneously, certain dissociative parts of the individual
may hold strong feelings of hatred, anger, shame, neediness, or terror toward
family perpetrators and others (Steele et al. 2001).
The therapist must empathically explore all the patient’s conÀicted feelings and
beliefs related to perpetrators and not blame them, remembering that one part of
the patient can have an un-ambivalently positive view of the perpetrator, while
another holds a completely negative view. For example, the therapist can say, ‘I
can empathise that parts of you hate your mother – she hurt you so very much. On
the other hand, I can also empathise with feelings of love and yearning that some
parts of you experience – she was sometimes kind. I wonder if perhaps all parts of
you might join in understanding and accepting how these very different feelings
can co-exist. Let’s explore how you manage this painful conÀict’.
Working with perpetrator-imitating parts

One particular type of part that bears mentioning is those that imitate the
perpetrator. They have so strongly identi¿ed with the perpetrator that they literally
experience themselves as being that person as he or she was in the past.
Interventions with these parts should begin early in therapy and are intensi¿ed in
the second phase of treatment (Blisard 2003; Boon et al. 2011; Chu 2011; Howell
2011; Steele et al. 2001; Van der Hart et al. 2006). Treatment is directed toward
time orientation to the present, challenging the ¿xed belief that the part is the
original perpetrator and providing psychoeducation about the original survival
value of these parts so that empathy can be developed. The therapist should ¿rst
focus on safety and co-operation rather than attachment with these parts.
Overcoming phobia of traumatic memory

This is one of the most dif¿cult phobias to overcome, requiring high and sustained
integrative capacity. The intensity and duration of exposure, or guided synthesis,
must be matched to the patient’s overall capacity to integrate these painful
experiences (Van der Hart et al. 2006). As memories of attachment trauma surface,
traumatic transference will heighten. The therapist should be acutely aware of
multiple and contradictory transference and countertransference enactments.
It is essential that the therapist help the patient remember rather than relive
traumatic experiences. This is accomplished by careful pacing that ensures the
patient is grounded in the present, within his or her window of tolerance, and in
contact with the therapist during these sessions (Van der Hart et al. 2006).
Phase 3: Personality integration and rehabilitation

Phase 3 involves higher levels of integration, such that dissociative parts are
accepted and integrated as aspects of a single self and personality. It is also a time
for the patient to focus increased energy on creating a more ful¿lling and adaptive
life. During this period of therapy, the phobia of attachment and attachment loss
returns in the form of developing new and healthy relationships and risking
intimacy.
Though begun early in Phase 1, ongoing resolution of the phobia of healthy risk
taking and change becomes a more targeted focus of Phase 3. As the patient makes
efforts to be more involved in present life over the course of this phase, he or she
increasingly experiences the conÀict between the desire to change and intense
fears of doing so. In fact, adaptive change in this phase of treatment requires some
of the most dif¿cult integrative work of painful grieving and risk taking.
The patient should be assisted in approaching the phobia of intimacy in a
graduated manner; overcoming fear of emotional intimacy prior to physical and
sexual intimacy (as opposed to just having sex), as the last two require the ¿rst to
be in place. Usually there is extreme resistance to the experience of loss, an
inevitable risk associated with intimacy. Many individuals say, ‘I would rather not
have any relationship than run the risk of getting hurt so badly again.’ The patient
must slowly learn to tolerate the very ordinary conÀicts and dif¿culties that arise
within normal intimate relationships. This requires adequate conÀict resolution
skills, empathy, regulation and reÀective functioning skills, and the ability to
distinguish between minor and major relationship problems (Boon et al. 2011;
Courtois and Ford 2009; Steele et al. 2001; Van der Hart et al. 2006). A case
example follows.
Greg met a nice woman in an evening class he was taking. He had immediate
fears that she would not like him, which his therapist challenged and helped
him overcome. Then a part of him began having fantasies of getting married to
her, without even going on a date. Greg’s therapist slowed him down and
helped him realise he was retreating into a fantasy to avoid the hard work and
risk of building a relationship. The therapist helped him take one small step at
a time: making small talk, showing interest in what the woman was talking
about, learning about the timing of sharing more vulnerable things. Greg asked
the woman to go out for coffee but she was not able to go during the time he
asked. He was devastated, and a part of him got angry in defence and wanted
nothing to do with her. But gradually he was able to accept the possibility that
it was not a rejection. The therapist continued to help Greg work with his fear
of getting close and his fear of loss. After a few weeks, he asked again, and the
woman accepted his offer.
Finally, it is common for additional traumatic memories and dissociative parts to

emerge in Phase 3 in response to a growing capacity to integrate. During such
times, Phase 1 and Phase 2 issues need to be revisited. Patients who cannot
successfully complete Phase 3 and reach the point where they no longer have
dissociation of the personality often continue to have dif¿culty with normal life,
despite signi¿cant relief from traumatic intrusions (Kluft 1993).
Integration
All interventions across the course of therapy should promote a higher capacity
for integration in the patient. The more the therapist is even-handedly inclusive of
all parts in therapy, accepts them as inter-related aspects of one individual rather
than separate ‘personalities’ and encourages the patient as a whole to accept these
parts of him or herself, the more consistently integration is likely to occur.
Additional techniques to promote integration among dissociative parts are beyond
the scope of this chapter, and may be found in Boon et al. 2011; Chu 2011; Van
der Hart et al. 2006; and Kluft 1993, 2006.
Conclusion
Attachment disruptions and attachment trauma are inherent in chronic childhood
traumatisation and affect not only the relationships of adult survivors in daily life
but also the therapeutic relationship. Early attachment trauma may manifest in
therapy in the patient’s phobias of attachment and of attachment loss vis-à-vis the
therapist, often simultaneously present among different dissociative parts of the
personality and known as D-attachment. Phase-oriented treatment, as the standard
of care, pertains to all dimensions of therapy, but also, and especially, to helping
patients to overcome their attachment-related phobias.
The focus on overcoming attachment-related phobias evolves over the course
of these phases, with initial establishment of a felt sense of safety prior to
attachment. In Phase 1 work with attachment phobias of ANPs are emphasised,
while in Phase 2 conÀicts among parts (EPs and ANPs) regarding attachment to
the perpetrator is addressed. In Phase 3, the patient as a whole person strives
toward greater intimacy (and adaptive risk taking) in relationships.
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Chapter 7

personality disorders
Kenneth N. Levy, Kevin B. Meehan and
Christina M. Temes
Introduction
Bowlby (1977) contended that internal working models of attachment help explain
‘the many forms of emotional distress and personality disturbances, including
anxiety, anger, depression, and emotional detachment, to which unwilling
separations and loss give rise’ (p. 201). Bowlby postulated that insecure attachment
lies at the centre of disordered personality traits, and he tied the overt expression
of felt insecurity to speci¿c characterological disorders. Given that personality
disorders are highly prevalent, chronic and debilitating to those who suffer from
them, it is imperative to identify etiological factors contributing to the development
and maintenance of these disorders. As will be discussed, attachment theory and
research provide a comprehensive framework within which personality pathology
can be understood. In this chapter we will review the empirical literature on
attachment theory, with a focus on assessment and intervention for personality
disorders (PDs). Further, we will demonstrate the clinical utility of attachment
theory and research for conceptualising personality pathology.
Theory and assessment of attachment

Bowlby (1977) held that childhood attachment underlies the ‘later capacity to make
affectional bonds as well as a whole range of adult dysfunctions’ including ‘marital
problems and trouble with children, as well as . . . neurotic symptoms and personality
disorders’ (p. 206). Thus Bowlby (1973, 1982) postulated that early attachment
experiences have long-lasting effects that persist across the lifespan, are among the
major determinants of personality organisation, and have speci¿c clinical relevance.
Longitudinal studies have con¿rmed the predictability of later functioning and
adaptation from infant attachment styles, with considerable, although variable,
stability of attachment classi¿cation from infancy to adulthood (Hamilton 2000;
Waters et al. 2000; Wein¿eld, Sroufe, and Egeland 2000), which is dependent on
intervening experiences in relationships (Fraley 2002; Grossmann, Grossmann and
Waters 2005; Lewis, Feiring and Rosenthal 2000; Waters et al. 2000).
From the seminal work of Bowlby, attachment theory and research have
evolved into two traditions (interview and self-report), each with its own
methodology for assessing attachment patterns.
96 Kenneth N. Levy, Kevin B. Meehan and Christina M. Temes
Interview
Main and her colleagues developed the Adult Attachment Interview (AAI:
George, Kaplan and Main 1985), which evaluates the interviewee’s conception of
how early attachment relationships have inÀuenced adult personality by probing
for speci¿c memories that both corroborate and contradict how the attachment
history has been conceptualised. Secure attachment on the AAI is characterised by
a well-organised, undefended discourse style in which emotions are freely
expressed, and by a high degree of coherence exhibited in the discussion of
attachment relationships, regardless of how positively or negatively these
experiences are portrayed. These individuals maintain a balanced and realistic-
seeming view of early relationships, value attachment relationships, and view
attachment-related experiences as inÀuential to their development.
In contrast, dismissive attachment is characterised by a devaluation of the
importance of attachment relationships on the AAI, or relationships are portrayed
in an idealised fashion with few corroborating examples. These individuals are
judged to have low ‘coherence of mind’ because of the vagueness and sparseness
of their descriptions, as well as the inconsistency between the vaguely positive
generalisations and ‘leaked’ evidence to the contrary. Preoccupied attachment is
characterised by parental relationships on the AAI described with pervasive anger,
passivity and attempts to please parents, even when the relationship is described
as positive. These individuals have a tendency towards incoherence in their
descriptions, with excessively long, grammatically entangled sentences, reversion
to childlike speech, and confusion regarding past and present relationships.
The Unresolved/disorganised classi¿cation is assigned when an individual
displays lapses in the monitoring of reasoning or discourse when discussing
experiences of loss and abuse. These lapses include highly implausible statements
regarding the causes and consequences of traumatic attachment-related events,
loss of memory for attachment-related traumas, and confusion and silence around
discussion of trauma or loss. Cannot Classify is assigned when an individual
displays a combination of contradictory or incompatible attachment patterns, or
when no single state of mind with respect to attachment is predominant. This
occurs when the individual shifts attachment patterns in mid-interview, when the
individual demonstrates different attachment patterns with different attachment
¿gures, or when the individual shows a mixture of different attachment patterns
within the same transcript or passage.
Self-report
In contrast to Main’s focus on relationships with parents, Hazan and Shaver
(1987) and colleagues (Shaver, Hazan and Bradshaw 1988), using a social
psychological perspective, evaluate romantic love as an attachment process. They
translated Ainsworth’s descriptions of the three infant attachment types (Ainsworth
et al. 1978) into a single-item, vignette-based measure in which individuals
Attachment theory and personality disorders 97
characterised themselves as secure, avoidant, or anxious-ambivalent in romantic

relationships. In subsequent research, Bartholomew (1990, 1994) and Bartholomew
and Horowitz (1991) developed a four-category classi¿cation of adult attachment
that corresponds to a two-dimensional model of anxiety and avoidance: secure
(low anxiety/low avoidance); preoccupied (high anxiety/low avoidance);
dismissing-avoidant (low anxiety/high avoidance); and fearful-avoidant (high
anxiety/high avoidance). Although categorical comparisons between the AAI and
self-report measures have typically failed to correspond with each other
(Bartholomew and Shaver 1998; Crowell, Fraley and Shaver 1999), studies that
have related the dimensional coding scales from the AAI to the self-report
measures have found that they are signi¿cantly related, even if the two categorical
typologies were not signi¿cantly related (Shaver, Belsky and Brennan 2000).
Formulations of personality disorders from an

attachment perspective
Bowlby (1973) believed that attachment dif¿culties increase vulnerability to
personality pathology and can help identify the speci¿c types of dif¿culties that
arise. For instance, Bowlby connected anxious ambivalent attachment to ‘a
tendency to make excessive demands on others and to be anxious and clingy when
they are not met’, and linked this presentation to that seen with dependent and
hysterical personalities. Bowlby also described how avoidant attachment in
childhood – postulated to be a product of caretakers’ rebuf¿ng a child’s bids for
comfort or protection – may be related to later diagnoses of narcissistic personality
or ‘affectionless and psychopathic personalities’ (1973: 14). Thus Bowlby
postulated that early attachment experiences have long-lasting effects across the
lifespan, and these experiences are among the major determinates of personality
organisation and pathology.
Further, virtually all PDs are characterised by persistent dif¿culties in
interpersonal relations (Levy 2005). For example, impoverished relationships are
a cardinal feature of both schizoid and avoidant PDs. Those with schizoid pathology
appear defensively devoid of any interest in human interaction, whereas the
avoidant pathology is typically characterised by a simultaneous desire for, and fear
of, close relationships (Sheldon and West 1990). Those with borderline personality
disorder (BPD) and dependent PD struggle to be alone and are preoccupied by
fears of abandonment and the dissolution of close relationships (Gunderson and
Lyons-Ruth 2008). Further, intense and stormy relationships are one of the central
features of BPD (Clarkin et al. 1983; McGlashan 1986; Modestin 1987). Those
with dependent pathology appear incapable of functioning without the aid of
others (Bornstein and O’Neill 1992; Livesley, Schroeder and Jackson 1990).
Integrating Blatt’s (1995) cognitive-developmental psychoanalytic theory with
attachment theory, Levy and Blatt proposed that within each attachment pattern,
there may exist more and less adaptive forms of dismissing and preoccupied
attachment (Blatt and Levy 2003; Levy and Blatt 1999). These developmental
levels are based on the degree of differentiation and integration of representational

or working models that underlie attachment patterns.
In terms of PDs, Levy and Blatt (1999) noted that several PDs (i.e. histrionic,
dependent, BPD) appear to be focused in different ways, and possibly at different
developmental levels, on issues of interpersonal relatedness. They proposed that
preoccupied attachment would run along a relatedness continuum from non-
personality disordered individuals to those with BPD. Those without PDs would
generally value attachment, intimacy and closeness. Those at the next level would be
more gregarious and exaggerate their emphasis on relatedness. At another level
below are those with a hysterical style, who not only exaggerate closeness and overly
value others but may defend against ideas inconsistent with their desires, and more
histrionic individuals who are overly dependent and easily show anger in attachment
relationships. Finally, at the lowest level of functioning are those with BPD for
whom strong desires for closeness and intimacy coupled with strong interpersonal
sensitivity lead to the most chaotic and disrupted patterns of relating to others.
In contrast, another set of PDs (i.e. avoidant, obsessive-compulsive, narcissistic,
antisocial) appear to express a preoccupation with establishing, preserving and
maintaining a sense of self, possibly in different ways and at different developmental
levels. Levy and Blatt (1999) proposed that avoidant attachment would run along
a self-de¿nitional continuum from non-personality disordered individuals who are
striving for personal development, to those who are more obsessive, to those with
avoidant PD, to those with narcissistic PD, and ¿nally – at the lowest developmental
levels – to those with BPD and antisocial PD. Levy and Blatt (1999) proposed that
BPD would be related to both preoccupied and avoidant attachment, which is now
backed up by a host of studies (see Levy 2005 for a review).
Association between attachment and

Research has largely supported theoretical assertions of an overlap between PDs
and insecure attachment. Much attention in the literature has been given to
insecure attachment and BPD (see the Liotti chapter in this volume) and to a lesser
extent antisocial personality. There is much less data on attachment variables and
other PDs, and what is available tends to compare dimensions of self-reported
adult romantic attachment to self-reported PD symptoms (see Rosenstein et al.
1996). Within that literature, while there has been consistency in ¿nding a negative
relationship overall between attachment security and personality pathology
(Meyer et al. 2001; Meyer and Pilkonis 2005), the relationships between speci¿c
PDs and insecure attachment types are less consistent.
Meyer and Pilkonis (2005) evaluated the relationship between adult romantic
attachment (using the Experiences in Close Relationships scale) and PD symptoms
(using the SCID-II questionnaire) in a sample of 176 college students. Their
results indicated that attachment security was associated with an absence of PD
features, while a dismissive style was strongly associated with schizoid PD
features. A preoccupied style was associated with histrionic, BPD and dependent
PD features; and a fearful style was associated with avoidant PD features. Those
with paranoid, obsessive-compulsive, narcissistic and schizotypal features fell
between the preoccupied and fearful styles.
Meyer and Pilkonis (2005) report similar data in a clinical sample of 152
inpatients and outpatients diagnosed with DSM-III consensus ratings (Meyer et
al. 2001). In line with the non-clinical study, dismissive style was associated with
schizoid PD diagnosis, a fearful style was associated with avoidant PD diagnosis,
and a preoccupied style was strongly associated with histrionic, borderline and
dependent PD features. However, those with paranoid, obsessive-compulsive,
narcissistic and schizotypal features fell more between the dismissive and fearful
styles in the clinical sample.
Levy (1993) examined the relationship between attachment patterns and PDs in
a sample of 217 college students using Hazan and Shaver’s Adult Attachment
Questionnaire (AAQ), Bartholomew’s Relationship Questionnaire (RQ) and the
Millon Multiaxial Clinical Inventory (MCMI). Attachment security was negatively
related to the schizoid, avoidant, schizotypal, passive-aggressive and borderline
scales. Dismissive attachment was positively associated with paranoid, antisocial
and narcissistic personality scales; fearful avoidance was associated with schizoid,
avoidant, and schizotypal scales; and preoccupied attachment was associated with
schizotypal, avoidant, dependent and BPD scales.
Alexander (1993) examined the relationship between trauma, attachment and
PDs in a sample of 112 adult female incest survivors. She assessed attachment
using the RQ and assessed PDs using the MCMI-II (Millon 1992). Only 14 per
cent of the sample rated themselves as secure, 13 per cent rated themselves as
preoccupied, 16 per cent as dismissing and 58 per cent as fearfully avoidant.
Preoccupied attachment was associated with dependent, avoidant, self-defeating
and borderline PDs. Fearful avoidance was correlated with avoidant, self-defeating
and borderline PDs and high scores on the SCL-90-R. Dismissing individuals
reported the least distress, most likely due to their proclivity to suppress negative
affect (Kobak and Sceery 1988).
Brennan and Shaver (1998) examined the connections between adult romantic
attachment patterns (using the RQ) and PDs (using the Personality Diagnostic
Questionnaire) in a non-clinical sample of 1,407 adolescents and young adults.
Their results indicated that those rated secure with respect to attachment were half
as likely to self-rate having a PD, whereas those rated as fearful were four times
more likely, those rated as preoccupied were three times more likely, and those
rated as dismissive were 1.3 times more likely to self-rate the presence of a PD.
Discriminant function analysis was used to predict attachment dimensions based
on PD symptoms. Three functions emerged, which differentially predicted
attachment ratings on the basis of PD features. The ¿rst function, from secure to
fearful, was characterised by paranoid, schizotypal, avoidant, self-defeating,
BPD, narcissistic, and obsessive-compulsive PDs on the fearful side of the
dimension. The second function, from dismissive to preoccupied, was characterised
by dependent and histrionic PDs on the preoccupied side of the dimension and
schizoid PD on the dismissive side of the dimension. Finally, the third function,
characterised by passive-aggressive, sadistic and antisocial PDs, did not
correspond to attachment dimensions.
Using the AAI, Rosenstein and Horowitz (1996) found in an adolescent
inpatient sample that preoccupied attachment was uniquely associated with
avoidant PD, whereas dismissing attachment was uniquely associated with
narcissistic, antisocial and paranoid PDs. Similarly, van IJzendoorn and colleagues
(1997), in a criminal offender group, found that preoccupied attachment tended to
be associated with anxiety related personality disorders (cluster C) and that
dismissing attachment was associated with antisocial PD. These ¿ndings were
con¿rmed in a meta-analysis examining AAI distributions in clinical samples
(Bakermans-Kranenburg and van IJzendoorn 2009).
Despite some differences across studies, for the most part, across both interview
and self-report measures and various age groups and samples, the ¿ndings
converge. Both preoccupied and dismissing attachment are associated with BPD.
Generally preoccupied attachment is uniquely associated with the anxiety based
PDs such as dependent and histrionic PD, whereas dismissing attachment is
associated with antisocial, narcissistic and some of the cluster A PDs, in particular
schizoid and paranoid PDs. Fearful avoidance has sometimes been associated
with cluster A PDs and sometimes with cluster C PDs.
Clinical features of attachment types in

Based on the delineation of Levy and Blatt (1999), and re¿ned by the
aforementioned research, the clinical characteristics of several PDs will be
discussed in terms of their predominant attachment styles. While some disorders
have most often been found to correspond to a preoccupied style (i.e. dependent
and histrionic PD), a dismissive style (i.e. schizoid and antisocial PD) and a fearful
style (i.e. avoidant PD), others have a less distinctive attachment style (i.e.
narcissistic and paranoid PD) but are nonetheless notable for characteristic
attachment-related features.
Personality pathology with preoccupied styles

Levy and Blatt (1999) note that PDs characterised by the preoccupied style (i.e.
histrionic, dependent, BPD) tend to focus in different ways on issues of interpersonal
relatedness. Because such individuals often have a negative model of themselves
but a positive model of others (Bartholomew 1990), they are likely to look to the
therapist to meet needs that they feel unable to address within themselves. Thus
preoccupied individuals are often likely to seek treatment (Levy et al. 2012). Such
individuals are likely to disclose a great deal of information to the therapist, with
evocative descriptions of themselves and others that engage the therapist’s
attention. However, their discourse often lacks the narrative coherence that would
aid in working through the experience or would allow for others to fully join with
their experience.
Further, preoccupied individuals with personality pathology are likely to
assume that the therapist has more knowledge about them than can be realistically
expected, and as a result not explain and contextualise their thinking for the
therapist. At best, the therapist may often feel that she is working hard to make
links within her own mind between disparate pieces of information, since the
patient has not provided such narrative bridges. At worst, the therapist may feel
lost in a chaotic, entangled narrative that leads to confusion and frustration. Thus
even though the preoccupied patient may eagerly attend and appear to be working
very hard in treatment, such work may not translate into a productive dialogue that
allows for shifts in the patient’s representations of self and others.
Ms. D, diagnosed with histrionic PD, often began her sessions breathlessly
reporting an entangled series of events during the week, with little sequence or
structure. Narratives were often pressured and organised around her
subjective affective experience, with only cursory anchors in objective events,
which prohibited the therapist from following the progression that led to a
particular feeling. ‘What happened on Monday? I was freaking out, that’s what
happened on Monday. Why? Because it felt like my guts were being torn out,
that’s why.’ Like the therapist, Ms. D would become lost in her own narratives
in ways that she too found destabilising, as she would begin to feel herself
drowning in the affect with no structure to grasp on to. Further, efforts on the
therapist’s part to slow her down and fill in some of the gaps in her narrative
would be met with frustration. Given that Ms. D’s preoccupation was embedded
in pervasive anger at the inconsistent care of attachment figures, this style of
expression was also understood to reflect a desire for the therapist to be a
completely reliable and omniscient attachment figure who could finally fill her
deep well of unmet need states. As a result, the therapist would remark, ‘You
want me to be completely in sync with you, to know what you are thinking
without having to say it. This is why it must be so frustrating for you to be
seeing what you are in my face – that I am quite lost in this story and too
confused to respond in the way you wish I would’. Over time Ms. D became
increasingly aware of the relational impact of her preoccupying anger, as well
as the function it served in relation to underlying longings for connection.
The work of Dozier and colleagues (2001) suggests a seemingly contradictory

stance on the part of the therapist: to remain securely present with the patient
while simultaneously maintaining suf¿cient distance from becoming entangled in
the patient’s production. This secure detachment allows the therapist suf¿cient
distance to clarify and confront breaks and omissions in the patient’s discourse
(Clarkin, Yeomans and Kernberg 2006). Slade suggests that progress is slow-
moving with preoccupied patients, and that it is gained through the therapist’s
‘emotional availability and tolerance for fragmentation and chaos’ as they aid the
patient in forming less distorted and/or chaotic representations of self and others
(Slade 1999: 588).
Personality pathology with dismissive styles

Many with dismissive attachment appear valuing of attachment in their idealisation
of caregivers, and yet they are often unable to remember speci¿c events that
would corroborate their general event representations. Others can recall negative
events with caregivers, but by restricting affect may remain disconnected to the
feelings such experiences normally evoke. Finally, many with dismissive
attachment are openly derogating of others and the need for relationships that
have any dependency attached to them.
Levy and Blatt (1999) note that PDs organised around avoidance (i.e. avoidant,
obsessive-compulsive, narcissistic and antisocial PDs) are characterised by a
preoccupation with establishing, preserving and maintaining a sense of self.
Because individuals with dismissive avoidance often have a positive model of
themselves and a negative model of others (Bartholomew 1990), they are unlikely
to expect that help from and dependency on others will lead to change. Therefore
dismissive patients are less likely to seek treatment of their own accord (Levy et
al. 2012). When these individuals enter therapy it is often at the behest of another:
a signi¿cant other who makes it a condition of staying together; an ultimatum
from a boss in order to keep a job; a mandate from a court in order to stay out of
jail; or a recommendation from a lawyer in order to provide the appearance of
remorse. Early in treatment, such individuals often maintain a distance from the
therapist, disclose little and express scepticism about the treatment. Though they
may appear compliant in relaying personal information, their discourse will often
lack the details needed to create vivid, complex and multifaceted images of self
and others in the mind of the therapist. At best, the therapist may often feel that
she is ‘going through the motions’ of a treatment with a distant and super¿cially
compliant patient. At worst the therapist may repeatedly feel she has to answer to
the criticisms of an individual who continually has ‘one foot out the door’.
Therefore the early phases of treatment with dismissive patients often focus on
the high threat of drop-out. As with preoccupied patients, this challenges the
therapist to balance two seemingly contradictory demands. On one hand,
dismissive patients often become more distressed and confused when confronted
with dif¿cult issues in treatment (Dozier et al. 2001). At the same time, not
directly confronting threats to treatment creates an increased risk of drop-out
(Clarkin, Yeomans and Kernberg 2006). The capacity of the therapist to
emotionally engage herself in a narrative that may not be engaging to begin with,
and to bring direct emotional expression to a narrative that often omits complex
affects, may provide an optimal space for intervening with such patients. Despite
these challenges in engaging and retaining dismissive patients in treatment, when
they follow through with treatment they do seem to fare better in terms of outcome
(Fonagy et al. 1996).
Dismissive attachment tends to be at its most extreme in individuals with
malignant narcissism, antisocial PD, and/or sociopathy/psychopathy (Blatt and
Levy 2003; Levy and Blatt 1999 ). These individuals are competitive, aggressive,
preoccupied with power and exploitation, and tend to aggress against others or use
them for instrumental means. Similarly, Karen Horney (1945, 1950) described a
pattern that she characterised as ‘moving against people’. The following clinical
example illustrates such dynamics.
As is common with those with antisocial PD, Mr. M was court-mandated to

treatment. During a public argument he was having with his girlfriend he had
pummelled an innocent bystander who he believed was about to intervene. He
went into what he described as a blind rage and threw punches at the police
officers that were responding to the call for help. Initially he failed to share that
he was court-mandated to attend sessions; this information came to light after
the therapist questioned his motivation for treatment and suggested that they
end their work together. Mr. M’s attitude in treatment was generally cavalier,
and it was difficult to get him to be serious about his situation or his internal
experience. He vacillated between treating therapy as a game and as an
imposition forced upon him. He oscillated between seeing the therapist as a
naïve fool who was dumb to the ways of the world and seeing the therapist as
corrupt and going through the motions of therapy with little interest in his
improvement. When he viewed the therapist as naïve, he held him in disdain as
weak and unable to help. He berated the therapist as someone who ‘just
doesn’t know’, who would be eaten alive in the ‘real world’, and who probably
cried at weddings, funerals and even sad movies. When he saw the therapist as
corrupt there was a subtle identification with being both powerful and
protected against others’ manipulations, but in those moments the therapist
was also disinterested, uncaring and dishonest. In these moments, he saw the
therapist as ‘crying fake tears for the dumb saps who believe that he really
cares’. As therapy progressed, the vacillation between these two positions
gradually entered the patient’s awareness; the motivations for and consequences
of each position became more salient and resonate. Although such awareness
often angered the patient, it also allowed him to see that his views of the
therapist were mental representations and not the actual reality of the therapist
or others in the world.
Personality pathology on the fearful to dismissive continuum

As previously discussed, Levy and Blatt (1999) note that those with PDs
characterised by avoidance are concerned with creating and maintaining a sense
of self, which manifests in a number of ways. Because individuals with a fearfully
avoidant style have both a negative model of themselves and a negative model of
others (Bartholomew 1990), they are unlikely to expect that they can depend on
either themselves or anyone else to improve their circumstances. For example,
those with avoidant personality pathology tend to desire intimate relationships but
fear that their own inadequacies will become a source of humiliation at the hands
of critical others. In contrast, patients with narcissistic and paranoid personality
pathology tend to lead with a dismissive view of others, but this stance may be
taken to belie some level of attachment anxiety and feelings of vulnerability.
Ms. N, who was diagnosed with narcissistic PD, began her treatment by
referring to the therapist’s office as ‘the nicest broom closet I have ever seen’,
which was quickly followed by reprimands for a series of perceived failures: he
had no water cooler in his office, the office was too far from where she had to
park, the weather did not suit her. She was hostile, but it seemed that part of
her wanted the therapist to care for her – she wanted him to provide
nourishment, intimacy and atmospheric comfort. And even before he said
anything more than ‘Come in’, she was angry for wanting these things from
him. If in fact she did want these things from him and was sad that he could not
provide them, she was also angry that he had evoked such desire in her. It also
seemed that she took great pleasure in knowing that the therapist was incapable
of making a water cooler appear or moving the parking garage. And, even if he
could get her some water and find her a closer parking spot, he could not
change the weather. Thus it was the therapist who was incapable, not her.
Fearfully dismissive patients are likely to alternate between aggression and

neediness in the early stages of treatment. Such patients may also vacillate quickly
between idealisations and devaluations, leaving the therapist feeling confused and
deskilled. Therapists have to be on guard not to over-interpret these behaviours,
nor to respond defensively or aggressively, or collude with the pathology through
passivity. Avoiding these problematic reactions can be facilitated by the therapist’s
maintaining his or her own reÀective and non-defensive stance, as well as through
involvement in some form of supervision or consultation.
Attachment and interventions for personality disorders

From its inception, Bowlby believed that attachment theory had particular
relevance for psychotherapy. There are a number of ways in which attachment and
psychotherapy may intersect, and many of these connections have been examined
empirically (see Borelli and David 2003; Daniel 2006; Levy et al. 2011; Obegi and
Berant 2009; Steele and Steele 2008 for reviews). Findings from this body of
research indicate the clinical importance of accounting for patients’ attachment
styles and the potential fruitfulness of addressing issues around attachment within
treatment. In particular, this work suggests that patient attachment status may be
extremely relevant to the course and outcome of psychotherapy for PDs.
Attachment-based interventions
Most existing psychotherapies implicitly employ techniques and principles that
are congruous with attachment theory, particularly those concerning the
importance of a healthy therapeutic relationship as well as the exploration and
updating of mental representations of signi¿cant relationships and the self. Until
recently, few psychotherapies were directly based on the principles of attachment
theory; however, in recent years, attachment-based interventions have been
developed for a number of problems (e.g. Johnson 1996) and recently for
personality disordered patients. For example, mentalisation-based therapy (MBT:
Bateman and Fonagy 1999, 2001, 2008) was designed as a long-term,
psychoanalytically-oriented, partial hospitalisation treatment for BPD. This
treatment model is based on the idea that patients were not able to develop the
capacity of mentalisation (i.e. the social-cognitive and affective process through
which one makes sense of intentional behaviour in the self and others by reÀecting
on mental states) within the context of an early attachment relationship, and that
fostering the development of this capacity in turn leads to more stability in terms
of the self and relationships with others. This goal of MBT rests on developing a
safe attachment relationship between client and therapist to provide a context in
which these mental states can be explored. MBT has been demonstrated to be
effective over long-term follow-up with regard to reduction of depressive
symptoms, suicidality, parasuicidality and length of inpatient stays, as well as
improvement in social functioning (Bateman and Fonagy 2009).
Attachment moderating psychotherapy process and outcome

A number of studies have examined how client attachment relates to the process
and outcome of psychotherapies for PDs and other conditions. Generally, secure
attachment has been associated with better treatment outcomes across
psychotherapies for patients with PDs (Meyer and Pilkonis 2005; Strauss et al.
2006). Conversely, these studies suggest that clients who are more anxious with
respect to attachment may demonstrate different trajectories of treatment
engagement and outcome than do more avoidant clients. Given that variation in
these attachment styles differentially characterises patients with PDs (Levy and
Blatt 1999), these characteristics are useful to consider when making predictions
regarding the course of treatment in these individuals.
As noted earlier, clients with PDs who are more anxious with respect to
attachment (particularly preoccupied individuals) may initially present as very
engaged and interested in pursuing treatment. Empirical studies in this area have
indicated that individuals with high levels of attachment anxiety are more likely
to perceive distress and seek help for emotional dif¿culties (Vogel and Wei 2005).
Additionally, preoccupied individuals in particular tend to be more frequent users
of medical services in general; for example, preoccupied individuals with cluster
B PDs report longer medical hospitalisations than do matched individuals of other
attachment classi¿cations (Hoermann et al. 2004). Although they may appear
more disclosing and dependent on providers, preoccupied clients are not more
compliant to treatment recommendations (Dozier 1990; Riggs and Jacobvitz
2002). Additionally, there is evidence that higher attachment anxiety may be
especially predictive of poorer treatment outcomes among both preoccupied and
fearful-avoidant clients with PDs (Fonagy et al. 1996; Strauss et al. 2006).
By contrast, more avoidant individuals tend to report less distress and help-
seeking behaviours (Vogel and Wei 2005), and they tend to be less compliant to
treatment recommendations (although in a more subtle manner than preoccupied
patients) and exhibit generally weaker therapeutic alliances than other attachment
groups (Eames and Roth 2000; Mallinckrodt, Porter and Kivlighan 2005;
Satter¿eld and Lyddon 1998). However, there is some evidence from a mixed
sample that included PDs that they may perform better than their anxious
counterparts with respect to outcome. For instance, Fonagy et al. (1996) found
that dismissive patients were most likely to show improvement during treatment,
as compared to patients exhibiting other attachment styles including preoccupied.
These ¿ndings suggest that while avoidant (particularly dismissing) clients may
seem detached, they may be able to effectively utilise treatment; conversely, while
preoccupied individuals may seem particularly engaged, they may not be able to
use interventions in a helpful way. Of course, these ¿ndings may not hold up in
PD samples and should be con¿rmed.
Change in attachment in personality disorders

Some researchers have examined changes in attachment status as a result of
treatment for individuals with PDs. Generally, the ¿ndings of these studies have
suggested that treatment may lead to changes in attachment status for these
patients, although this impact may differ depending on the characteristics of
treatment (e.g. treatment length). Levy and colleagues (Diamond et al. 2003;
Levy et al. 2006, 2007) have examined changes in attachment status as assessed
by the AAI in patients diagnosed with BPD. In a pilot study (Levy et al. 2007) of
10 patients in a year-long course of Transference Focused Psychotherapy (TFP) it
was found that a third of the patients were classi¿ed as secure with respect to
attachment post-treatment, and 60 per cent of those previously classi¿ed as
unresolved with respect to trauma and/or loss were no longer so by the end of
treatment. In a randomised controlled trial (Levy et al. 2006), the researchers
examined changes in attachment in 90 patients with BPD who were randomised

to receive one of three treatments: TFP, dialectical behaviour therapy (DBT), or a
modi¿ed psychodynamic supportive psychotherapy (PST). After a year of
treatment, within the TFP group 7 of 22 patients (31.8 per cent) changed from an
insecure to secure attachment classi¿cation; this change was not observed within
the other two treatment groups. This ¿nding with regard to change in attachment
in TFP was recently replicated in an RCT in Munich and Vienna (Buchheim et al.
2012). In a chapter publication, Fonagy and colleagues (1995) reported ¿ndings
from a subset of 35 of the 85 inpatients from the Cassel Hospital inpatient study
(described in Fonagy et al. 1996). This subset of patients was comprised of
individuals from a mixed diagnosis sample, who were mostly characterised as
severely disturbed, treatment resistant and personality disordered. All 35 inpatients
were classi¿ed as insecure during their initial interview; however, 14 (40 per cent)
of the 35 inpatients were assigned a secure classi¿cation upon discharge,
representing a statistically signi¿cant increase in the proportion of secure
classi¿cation. These ¿ndings are important because they show that attachment
patterns can change as a function of treatment, but neither the speci¿c
psychopathology nor the treatment were well speci¿ed. Additionally, to date a
more detailed description of the changes in AAI status observed in this study has
not been published, making reports of these ¿ndings dif¿cult to interpret.
Another recent study examined change in attachment following short-term
inpatient treatment in a sample of 40 women diagnosed with BPD, avoidant PD,
or both disorders. Although patients symptomatically improved over time, there
was little evidence of a shift in the proportion of securely attached individuals
within this sample. The authors did note that overall ratings for attachment
avoidance were higher after treatment, and that a shift from ambivalent to avoidant
attachment was associated with better treatment outcomes for patients with BPD.
The authors argued that this change was reÀective of a de-activation of the
attachment system, or a shift away from the enmeshment characteristic of more
preoccupied styles. This study suggests that the shifts in attachment that may
occur as a result of short-term therapy may be more subtle and that shifts from
insecurity to security are less likely in short-term treatment, particularly when
compared to the long-term treatments.
Attachment as a process variable in psychotherapy with

Some preliminary work has indicated that attachment-related constructs may also
be used as a lens through which to examine psychotherapy process. Samstag and
colleagues (2008) used the narrative coherence coding system from the AAI to
examine psychotherapy process as a predictor of treatment outcome within 48
client–therapist dyads. This sample included clients with primarily cluster C PDs
(with comorbid depression and/or anxiety) who were divided into three groups
based on outcome: (1) drop-out (termination within ¿rst third of treatment);
(2) good outcome (high reliable change); and (3) poor outcome (low reliable
change). Coherence was rated for a portion of sessions that were randomly
selected from the ¿rst third of treatment. Coherence ratings were signi¿cantly
higher for the good outcome group, as compared with the drop-out and poor
outcome groups. These ¿ndings suggest that more highly coherent narratives
occurring within the context of psychotherapy may be an indication of a
particularly fruitful collaboration within the client–therapist dyad. Furthermore, it
is possible that patient-level factors, including attachment, may inÀuence the level
of narrative coherency, which may in turn inÀuence the course of psychotherapy.
Conclusion
As has been discussed, attachment theory and research provide a robust framework
for conceptualising personality disorders. In terms of assessment, evaluating
personality disorders in terms of thematic concerns of interpersonal relatedness
and self-de¿nition, valence of models of self and others, as well as level of
attachment anxiety and avoidance, may inform case conceptualisation and
treatment planning. Attachment theory and research also have broad implications
for therapeutic interventions with personality-disordered patients. This includes
attachment-based treatments for personality disorders such as MBT (Bateman and
Fonagy 1999), which speci¿cally target de¿cits in mentalisation that occur in the
context of heightened activation of the attachment system. Change in attachment
patterns has also been observed in TFP, a treatment for personality disorders that
speci¿cally targets models of self and others. Lastly, attachment research has
identi¿ed prognostic indicators in psychotherapy as a function of attachment
style. Taken together, the clinical utility of attachment theory and research for
conceptualising personality pathology is too powerful for clinicians to ignore.
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Chapter 8
Disorganised attachment in
the pathogenesis and the
psychotherapy of borderline
personality disorder
Giovanni Liotti
Controlled studies suggest that attachment insecurity is a risk factor for Borderline
Personality Disorder (BPD), as it is for other mental disorders (for reviews,
see Agrawal et al. 2004; and Dozier, Stovall-McClough and Albus 2008).
Disorganisation of early attachment and associated adult states of mind have been
studied in relation to the pathogenesis of and psychotherapy for BPD more than
other dimensions and types of attachment insecurity. Quite a number of clinical
and empirical research studies suggest that, although it is not a speci¿c risk factor
for BPD, attachment disorganisation plays an important role in borderline
psychopathology (e.g. Bateman and Fonagy 2004; Buchheim and George 2011;
Dozier, Stovall-McClough and Albus 2008; Holmes 2004; Howell 2008; Levy,
Beeney and Temes 2011; Liotti 2007, 2011a, 2011b; Lyons-Ruth et al. 2007;
Morse et al. 2009; Steele and Siever 2010). These studies support the idea that the
fundamental features of BPD can be explained by a developmental model based
on attachment disorganisation. Although we lack conclusive research evidence
for the hypothesis that the developmental pathways leading to the disorder begin
with early attachment disorganisation in the majority of BPD cases (Levy 2005),
two controlled studies suggest that this may indeed be the case (Carlson, Egeland
and Sroufe 2009; Lyons-Ruth et al. 2007).
Disorganisation of infant attachment and its

developmental sequels
About 80 per cent of infants’ attachments to the caregivers in low-risk samples can
be reliably classi¿ed, in the Strange Situation procedure (Ainsworth et al. 1978),
into three main organised patterns (secure, insecure-avoidant, insecure-resistant).
Most of the remaining attachments are characterised by a lack of behavioural and
attentional organisation: they are called disorganised attachments. In samples of
families at high risk for psychopathology, the percentage of disorganised
attachments may be as high as 80 per cent (Lyons-Ruth and Jacobvitz 2008).
Infants with disorganised attachment manifest bizarre and/or contradictory
behaviour when reuniting with their caregiver after a brief separation: bizarre
behaviour such as freezing, hiding or head-banging, and contradictory behaviour
114 Giovanni Liotti
such as trying to approach the attachment ¿gure with head averted or interrupting
abruptly a beginning approach to the caregiver by changing direction or collapsing to
the ground (Main and Solomon 1990). Unresolved experiences of losses and traumas
in the caregiver’s Adult Attachment Interview (AAI: Hesse 2008) are a frequent
precursor of disorganised attachment in the infants, and are signi¿cantly less frequent
in the caregivers of infants with organised attachment patterns (for a meta-analysis of
research on this topic, see Van IJzendoorn, Schuengel and Bakermans-Kranenburg
1999). An important mediating factor between the caregiver’s unresolved state of
mind and the infant’s attachment disorganisation is that the infant’s fear is increased
or at least not soothed in the attachment–caregiving interactions. Parental behaviour
that is either frightened and indirectly frightening, or aggressive and straightforwardly
frightening to the infant has been described in studies of infant attachment
disorganisation (Main and Hesse 1990; Schuengel, Bakermans-Kranenburg and Van
IJzendoorn 1999). Other adverse inÀuences in caregivers’ past attachment experiences
have also been evidenced as antecedents of infant attachment disorganisation. These
antecedents of early attachment disorganisation are expressed through hostile and
helpless states of mind concerning the attachment–caregiving interaction (Lyons-
Ruth et al. 2003), and through ‘abdication’ – assessed with the Caregiving Interview
(Solomon and George 2011) – of the responsibility of caregiving in the face of the
infant’s expression of attachment needs.
Although the type of interaction between the infant and the caregiver plays a
key role in infant attachment disorganisation, genetic inÀuences exert a moderating
inÀuence (Bakermans-Kranenburg and Van IJzendoorn 2007; Gervai 2009).
Attachment may inÀuence the expression of genes related to dysregulation of
emotions and impulses (attachment security inhibits the expression of these
genes), and conversely these genes increase the risk of developing attachment
disorganisation in the presence of fearful and severely misattuned caregiver–child
interactions. Given the existing evidence that genetic and temperamental factors
play a role, together with attachment experiences, in impulse regulation
(Zimmerman, Mohr and Spangler 2009) and in the psychopathology of BPD, the
gene-environment interaction in infant attachment disorganisation may contribute
to reconciling genetic and attachment-based theories of BPD.
Clinical observations and data from controlled research studies converge in
supporting the hypothesis that infant attachment disorganisation is a risk factor for
setting into motion dissociative mental processes able to inÀuence cognitive and
emotional development (Dutra et al. 2009; Hesse et al. 2003; Liotti 1992, 2004,
2011a; Lyons-Ruth 2003; Main and Morgan 1996; Ogawa et al. 1997). Two
longitudinal controlled studies (Dutra et al. 2008; Ogawa et al. 1997) provide
robust evidence that children and adolescents who had disorganised attachment in
infancy are more prone to dissociative mental processes than their peers who have
histories of organised early attachments. Thus it can be argued that dissociated
(i.e. multiple, dramatic and non-integrated) representations of self-with-other
characterise the Internal Working Model (IWM: Bowlby 1969) of disorganised
attachment. The rationale for this hypothesis may be summarised as follows.
Disorganised attachment in the pathogenesis of BPD 115
An attachment ¿gure who is neglecting, helpless, frightened, or hostile and

straightforwardly frightening to the infant, creates a situation in which the source
of potential comfort is also, at the same time, the source of fear, even when this
caregiver’s behaviour is not obvious maltreatment. This situation has been called
‘fright without solution’ (Main and Hesse 1990), because infants cannot ¿nd relief
from fear either in Àying from the caregiver or in approaching her or him. The
experience of fright without solution in infant attachment interactions can be
regarded as an early relational trauma (Schore 2009) that causes dissociation
among the ¿rst representations of self-with-other. The construction of the multiple,
dramatic, and non-integrated representations of self and a single attachment ¿gure
that characterise the disorganised IWM can be explained as a consequence of
these early dissociative processes (Liotti 1992, 2004, 2006, 2009).
In a longitudinal study, the multiple and non-integrated representations of self-
with-others that stem from these attachment–caregiving experiences have been
shown to mediate between early disorganised attachment and adult BPD symptoms
(Carlson, Egeland and Sroufe 2009). This is in keeping with the ¿ndings of a
study suggesting that ‘painful incoherence’ (rather than other features such as
mood instability) is at the core of BPD symptomatology (Meares et al. 2011). The
clinical relevance of understanding the developmental trajectory leading from
disorganised attachment to ‘painful incoherence’ and to BPD justi¿es theoretically
informed speculations on the features of the contradictory and non-integrated
representations stemming from the disorganised IWM. Liotti (1999, 2004)
suggested that they are akin to the three basic roles of the ‘drama triangle’
(Karpman 1968): the powerful rescuer, the equally powerful but malevolent
persecutor, and the powerless victim. Being at least potentially available and
willing to help and comfort the infant, parents and other caregivers are perceived
by children as rescuers. At the same time, when they are neglecting, subtly hostile,
or prone to episodes of aggression, they are perceived as persecutors.
Simultaneously, because they express their helplessness, fear and suffering
(caused by their own unresolved traumatic memories) while taking care of their
infants, the parents of disorganised children are perceived as victims. These
reciprocally incompatible representational prototypes are the base for construing
the behaviour of self and others during later attachment interactions. Being
constructed during the ¿rst two years of life, these representations pertain to the
non-verbal domain of inner representations – that is, they are ‘sub-symbolic’
(Bucci 1997) and operate at the implicit level of self-knowledge (Amini et al.
1996). In other words, they are aspects of the ongoing implicit relational knowing
that characterises the early phases of personality development and persists
throughout the lifespan (Lyons-Ruth 1998, 1999). Therefore, throughout the
developmental years the multiple and non-integrated representations of the self
and of the single caregiver manifest themselves in communication as intersubjective
enactments rather than as explicit verbalised structures of memory (Ginot 2007,
2009). No synthesis of them in semantic memory and in fully conscious narratives
is therefore possible, at least during childhood. The different, incompatible,
116 Giovanni Liotti
simultaneous representations of self-with-other of the disorganised IWM tend to

remain compartmentalised throughout the early phases of personality development.
Compartmentalisation, it should be remembered, is one of the two basic aspects of
dissociation (Holmes et al. 2005), the other being detachment (expressed mainly
in the symptoms of depersonalisation).
The compartmentalised representations of disorganised attachment, together
with the dramatic re-experiencing of fear without solution during later attachment
interaction, tend to hamper the higher (conscious and regulatory) mental functions
during personality development, so that mentalisation de¿cits, emotional
dysregulation and impulsivity may also follow infant attachment disorganisation
(Bateman and Fonagy 2004). It should be emphasised that both dissociation
among representations of self-with-other and mentalisation de¿cits tend to occur
during the experience of attachment needs and wishes rather than in moments
where interpersonal behaviour is motivated by systems different from attachment
(e.g. the competitive, the sexual, the caregiving or the cooperative systems: Liotti,
Cortina and Farina 2008; Liotti and Gilbert 2011).
Remarkably, disorganised attachment in infancy develops into rigid, controlling
behaviour in middle childhood (Lyons-Ruth and Jacobvitz 2008; Solomon,
George and De Jong 1995; Van IJzendoorn, Schuengel and Bakermans-
Kranenburg 1999). These controlling strategies seem to compensate for
disorganisation in the child–parent interactions: they allow for organised
interpersonal exchanges with the caregivers, thus reducing the likelihood of
dissociative processes during these exchanges (Liotti 2011a, 2011b).
There is evidence that infants disorganised in their attachments can either
become bossy children who strive to obtain dominance by exerting aggressive
competitiveness toward the caregiver (controlling-punitive strategy), or become
children who invert the attachment relationship and display precocious caregiving
toward their parents (controlling-caregiving strategy). A major cause of the
controlling-caregiving strategy is the relationship with a vulnerable, helpless
parent who encourages the child to invert the normal direction of the attachment–
caregiving strategy. A parent who perceives the child as powerful and evil may
be one particularly malignant condition for the development of a controlling-
punitive strategy (for examples, see Hesse et al. 2003). The controlling strategies
collapse in the face of events (e.g. traumas, pain, threats of separation) that
stimulate intensely and durably the child’s attachment system (Hesse et al. 2003).
During the phases of collapse of the controlling strategies, the child’s thought
and behaviour suggest that dissociative processes are at work, presumably
because of the reactivation of the disorganised IWM (Hesse et al. 2003; Liotti
2004, 2011a, 2011b, 2012). It is noteworthy that children with a controlling-
punitive strategy are more prone than other children to develop externalising
disorders characterised by impulse dyscontrol, while children with a controlling-
caregiving strategy tend to develop internalising disorders, characterised by
anxiety and depression (Moss et al. 2006). It can be hypothesised that a
controlling-punitive strategy mediates between infant attachment disorganisation
and adult cluster B (‘dramatic’) personality disorders including BPD, while a

controlling-caregiving strategy may be a risk factor for other personality
disorders, anxiety disorders and mood disorders.
Research studies conducted with the AAI or with self-report measures of
attachment patterns in adults suggest that adult states of mind linked to infant
attachment disorganisation are signi¿cantly related to a variety of adult mental
disorders (Bakerman-Kranenburg and Van IJzendoorn 2009; Dozier, Stovall-
McClough and Albus 2008; Levy 2005; Lyons-Ruth and Jacobvitz 2008). It is
important to remark that the adult states of mind linked to attachment
disorganisation have been called different names according to the different
methods for coding the interviews used in the assessment, or according to
different self-report measures of adult attachment. The domain of attachment
disorganisation comprises AAI adult states of mind classi¿ed either ‘unresolved
as to attachment traumas and losses’ (U: Hesse 2008) or ‘hostile and helpless’
(HH: Lyons-Ruth et al. 2003). Moreover, two other AAI states of mind, called
‘preoccupied with traumatic events’ (E3: Hesse 2008) and ‘cannot classify’ (CC:
Hesse 2008), arguably are, respectively, the lower and the higher extremes in the
dimension of caregiving behaviour related to infant attachment disorganisation.
The features of the CC state of mind, in particular, closely parallel those typical
of BPD (multiple, contradictory, incompatible and unintegrated working models,
often leading to chaotic and mood-dependent interpersonal behaviour). Thus,
three AAI codes (E3, CC and HH) should be considered together with the code
U when reading reviews of AAI studies on the relation between BPD and infant
attachment disorganisation. It is also noteworthy that some of the older AAI
studies of borderline patients (e.g. many of those reviewed in Agrawal et al.
2004) did not code the AAI transcripts for the possible E3, U, CC or HH
classi¿cations, because these codes were introduced and came to be more widely
used only relatively late in AAI research. Finally, it should be noted that other
states of mind related to attachment, assessed with self-report measures, may
also be related to the domain of disorganisation. For instance, the ‘fearful’
attachment style, assessed in adults through self-report questionnaires, that is
statistically linked to borderline features (Choi-Kain et al. 2009; Scott, Levy and
Pincus 2009), may be one expression in adults of the experience of fright without
solution that characterises infant attachment disorganisation.
In summary, it is reasonable to conclude that infant disorganised attachment
may lead to adaptational vulnerabilities (e.g. a controlling-punitive strategy
developed in middle childhood) which, especially as a consequence of further
traumatic experiences, can cause BPD. However, disorganised attachment can
also be an antecedent of other disorders (Dozier, Stovall-McClough and Albus
2008; Levy 2005). Different mechanisms must be involved in the developmental
pathways leading from infant disorganised attachment to other types of
adaptational vulnerabilities which in turn are linked to adult disorders different
from BPD.
118 Giovanni Liotti
Psychopathology of BPD: a model based on attachment

disorganisation
The presence of a disorganised IWM may help to explain the genesis of the
fundamental aspects of BPD:
• Poorly integrated (split or dissociated) ego states and the lack of a stable
sense of self, involving dissociative processes, is conceptualised as a frequent
developmental sequel of the disorganised IWM, especially when later
interactions between the child and the family members have been traumatic,
as reported by a majority of BPD patients (Carlson, Egeland and Sroufe 2009;
Levy, Beeney and Temes 2011).
• Feelings of emptiness, or dissociative blank spells (a subtype of
depersonalisation), and a fortiori clear-cut dissociative symptoms can also be
explained as a consequence of this dissociative tendency.
• Self-injurious behaviour may be one way of trying to cope with the experience
of emptiness and depersonalisation through self-inÀicted bodily pain, as
Linehan (1993) has convincingly argued.
• Unstable and intense interpersonal relationships, affective lability, impulsivity
and the typical bursts of rage can be understood as a consequence of the
de¿cits in mentalising capacities and in emotional regulation – de¿cits that
seem to be characteristic developmental sequels of infant attachment
disorganisation (Levy et al. 2005).
• Chronic fears of abandonment, intolerance of aloneness, and abnormal
sensitivity to feeling intruded upon by well-meaning others, accompanied by
mentalisation de¿cits, may stem from the underlying disorganised IWM
(Bateman and Fonagy 2004).
Consideration of the dynamics of the controlling strategies that typically follow

infant attachment disorganisation offers potential insights into the immediate
interpersonal antecedents of the most disturbing symptoms of BPD patients, and
into the threats to the therapeutic alliance that typically plague their
psychotherapeutic relationships. The controlling strategies keep a brake on the
activation of the attachment system through the activation of interpersonal
motivational systems different from the attachment system (notably the ranking
system and the caregiving system: Liotti 2011a, 2011b).1 Thus the interpersonal
behaviour and the inner experience of self and others can achieve a suf¿cient
degree of coherence and organisation, even if the cost is a tendency to ranking
competitiveness (similar to that observed in narcissistic or antisocial personality)
or to compulsive nurturance (similar to that observed in dependent personality).
However, events that strongly stimulate the attachment system – such as traumas,
separation from the attachment ¿gures and the formation of new affectional bonds
– cause the collapse of the controlling strategies and the surfacing of the
dissociative processes inherent to the disorganised IWM (Liotti 2011a, 2011b).
On the basis of this hypothesis on the developmental psychopathology of BPD,

the most disturbing symptoms (emptiness, dissociative experiences, self-injurious
behaviour, fear of abandonment, outbursts of rage) and the typical interpersonal
problems linked to split representations of self and signi¿cant others will appear
or become particularly intense during experiences that involve the activation of
the attachment system: the formation of new affectional bonds (including the
bond to the psychotherapist), traumas or events reminiscent of past traumas,
losses, or impending separations from attachment ¿gures. The dynamics that
underpin the typical interpersonal dif¿culties of borderline patients are linkable
both to the activation of the disorganised attachment system (with the multiple
and dissociated representations of self and other as rescuer, persecutor and victim),
and to the effort of regaining a measure of organisation through the use of a
controlling-punitive strategy. The knowledge of these dynamics may be useful to
the psychotherapist facing an outburst of unjusti¿ed dominant anger in the
therapeutic relationship with a borderline patient after a series of sessions where
the patient was apparently feeling comfortable in the therapeutic dialogue or even
idealising the therapist (for clinical vignettes, see Liotti 2011a, 2012). The
clinician may hypothesise that feelings of emotional closeness to the therapist
primed the patient’s wishes to be helped and soothed, and that these attachment
feelings in turn activated a disorganised IWM, with the concomitant experiences
of fear without solution and dissociation between dramatic compartmentalised
representations of self-with-other (i.e. the role-relationships between rescuer,
persecutor and victim of the drama triangle begun to surface in the patient’s
consciousness as ways of construing the therapeutic relationship). The patient
may then have tried to regain control over the relationship and over his or her own
inner experiences by resorting to the controlling-punitive strategies he or she
developed since childhood to keep a brake on attachment motivations.
This aspect of the psychopathological consequences of early attachment
disorganisation and later attachment traumas is usefully captured by the hypothesis
that borderline patients, and more generally patients with disorders related to
developmental complex trauma (Classen et al. 2006; Courtois and Ford 2009),
develop opposite and simultaneous phobias of inner feelings related to attachment
motives, such as feelings of emotional closeness and feelings of impending losses
in the relationship with signi¿cant others (Van der Hart, Nijenhuis and Steele
2006). These otherwise normal (and, as far as emotional closeness is concerned,
much desired) feelings become, for the borderline patient, forerunners of utter
disorganisation of inner experience, of dissociative mental processes and of the
surfacing consciousness of fragmented, irrational and dramatic representations of
self and others as frightening persecutors and helpless victims. These patients
become therefore phobic of such inner forerunners. Psychophysiology (Rockliff
et al. 2008) and neuroimaging (Longe et al. 2009) studies have evidenced the
body and brain correlates of the somehow paradoxical fear of much desired
emotional closeness and compassionate feelings. Recently developed self-report
measures of fear of compassionate feelings provide evidence of the beliefs and
attitudes related to the phobia of attachment closeness (Gilbert et al. 2011).
120 Giovanni Liotti
Contributions of the attachment-based model to the

psychotherapy of BPD
First and foremost, the model of BPD based on the knowledge of attachment
disorganisation and its developmental sequels suggests that the clinician should
carefully monitor the activation of the attachment system in the patient during
psychotherapy. Such activation, if not dealt with properly and promptly, predicts
dif¿culties and dilemmas in the therapeutic relationship that may threaten the
alliance and even cause premature interruption of the treatment (Holmes 2004;
Liotti 2007, 2011a; Liotti, Cortina and Farina 2008). Especially at the beginning of
the treatment, strong and long-lasting activation of the patient’s still disorganised
attachment system within the clinical exchange may foster unbearable phobias of
attachment feelings and dissociative processes. It can also hinder the use of
mentalising or metacognitive abilities (Liotti and Gilbert 2011; Prunetti et al. 2008).
Different approaches to the problem of dealing with the dilemmas created by
the activation of a disorganised IWM of attachment within the therapeutic
relationship can be devised by exploiting strategies and techniques of different
models of BPD psychotherapy, even if these models do not always consider, at
least explicitly, attachment dynamics. For instance, it can be argued that Dialectic
Behaviour Therapy (DBT: Linehan 1993) may be instrumental in dealing with the
activation of the disorganised IWM in the therapeutic relationship, thanks to
the careful attention paid both to the patient’s behaviour indicative of feeling the
unbearable emotional closeness to the therapist (phobia of attachment closeness),
and to the opposite behaviours suggesting fear of the therapist’s emotional
distance or fear of separation from the therapist (phobia of attachment loss). The
DBT therapist is trained to respond to each of these opposite attitudes by
dialectically shifting from taking prudent emotional distance from patients, and
offering them empathic closeness through validating their emotions or contrasting
their tendency to withdraw from the treatment (for a treatise of the compatibility
of Linehan’s dialectic model with an attachment-based approach to BPD, see
Liotti 2007).
Some approaches to dealing with the troublesome consequences of the
activation of a disorganised IWM in the therapeutic relationship straightforwardly
strive to change it. In compassionate mind training (Gilbert 2009) patients are
trained in the ability to imagine idealised soothing others to cope with inner
sufferings through compassionate feelings, rather than with phobic avoidance or
with punitive aggressiveness directed at others or at the self. In therapies inspired
by the theory of structural dissociation of the personality, the same goal of
relinquishing both phobic avoidance of soothing and punitive aggressiveness in
response to inner suffering is pursued by addressing the opposite simultaneous
phobias of attachment closeness and attachment loss through a sort of cognitive-
behavioural desensitisation approach (Van der Hart, Nijenhuis and Steele 2006).
In schema focused therapy (SFP: Giesen-Bloo et al. 2006; Young, Klosko, and
Weishaar 2003) the correction of the patients’ IWM of attachment is achieved
through ‘reparenting’ by providing corrective relational experiences. Other

approaches to the therapeutic revision of patients’ disorganised IWMs rely on
enhancing patients’ capacity to reÀect on inner experiences (mentalisation based
treatment, MBT: Bateman and Fonagy 2004) and on working with the transference
(Yeomans, Clarkin and Kernberg 2002). Indeed, there is emerging evidence that
transference focused psychotherapy (TFP) of BPD can change the patient’s state
of mind concerning attachment in the direction of more organised and more secure
patterns (Levy et al. 2006).
We can assume that attachment theory informs explicitly or implicitly most
current models of BPD psychotherapy, and that there are many different ways of
addressing the problems created by a disorganised IWM, in the psychotherapy
relationship and any other signi¿cant relationships in which borderline patients
are engaged. An attachment-based model of BPD, moreover, provides a
particularly interesting background for understanding a shared feature of the two
diverse types of BPD psychotherapy: DBT (Linehan 1993) and MBT (Bateman
and Fonagy 2004). This shared feature is the exploiting of interventions provided
by at least two different therapists in at least two separate, albeit integrated,
settings. The complex interpersonal dynamics created by parallel integrated
interventions may be crucial in explaining why two otherwise so different types of
intervention are so remarkably similar in their capacity of reducing the risk of
premature interruption of the treatment – a well-known major hindrance in any
treatment of BPD.
The bene¿ts of having two therapists (e.g. an individual therapist and a group
therapist) working in two parallel and integrated settings may be explained,
according to the model of the disorder based on attachment disorganisation. When
the patient is guided by an IWM of disorganised attachment in construing the
therapist’s behaviour, the therapeutic relationship may become so unbearably
dramatic, changeable and complex for both partners that serious ruptures of the
therapeutic alliance cannot be avoided, or repaired before the patient drops out of
the treatment. However, the interaction with two therapists in two separate but
integrated settings – ‘integrated’ means here that the three partners, patient, ¿rst
therapist and second therapist know, and as far as the two therapists are concerned
understand in a similar way, what happens in each setting – prevents overly
intense or protracted activation of the attachment system in the patient (Liotti
2004, 2007; Liotti, Cortina and Farina 2008). The contention of attachment theory
that explains why having two therapists (working as ‘one team’: Bateman and
Fonagy 2004) may prevent the activation of a disorganised IWM in the therapeutic
relationship, or at least allow for a repair of the ruptures in the therapeutic alliance
contingent upon it, was originally called ‘monotropy’ (Bowlby 1958; see also
Ainsworth 1982). Monotropy refers to the observation that although from
childhood any person can become attached to more than one person, and although
the hierarchy of preference for the various attachment ¿gures can change, he or
she is biased to be attached especially to one ¿gure at any given moment, so that
the other persons in the hierarchy become subsidiary or secondary attachment
122 Giovanni Liotti
¿gures (Bowlby 1969/1982). The implication of monotropy for understanding

how a patient becomes attached to two therapists in a parallel integrated treatment
is that the patient’s attachment system is likely to be active more often and more
intensely during the clinical exchanges with one therapist (let us call her or him X)
than with those with the other (Y). The untoward consequences of the activation
of the disorganised IWM during the clinical dialogue with X (collapses in the
metacognitive abilities, surfacing of poorly explicable fear in an until then positive
interaction, blank spells and other dissociative symptoms, attempts at re-
establishing control over the interaction through punitive strategies) may then be
better explored and coped with during the clinical exchanges with Y. Just because
the patient’s emotional-motivational state is less inÀuenced by the attached system
during the dialogue with him or her, Y is in a much better and safer position than
X to address the patient’s capacity for self-reÀection (less undermined by the
surfacing of the disorganised IWM than it is during the exchanges with X), and
therefore to explore therapeutically fears of attachment and of attachment loss, or
the meaning of aggressive and punitive attitudes.
The arguments supporting the idea that de¿cits in mentalisation ability and in
emotion regulation in borderline patients are less trait-like than state-dependent,
and that they depend on the activation of attachment (care-seeking) motives, have
been summarised by Liotti and Gilbert (2011). A detailed account of other reasons
besides monotropy that may explain, in terms of attachment theory, the usefulness
of parallel integrated settings in the treatment of BPD may be found in Liotti,
Cortina and Farina 2008. Here, space allows only for some summarising and
concluding remarks regarding any approach to the psychotherapy of BPD
informed by attachment theory and research.
First, such approaches justify on theoretical grounds the importance of paying
continuing and close attention from the beginning of the clinical exchange, and
even more than in the psychotherapy of any other disorder, to the dynamics of the
therapeutic alliance, that is a primary requisite for any successful treatment of
BPD (as it is for all the complex trauma-related disorders: see e.g. Courtois, Ford
and Cloitre 2009; Van der Hart, Nijenhuis and Steele 2006). The theoretical
justi¿cation provided by an attachment informed approach is particularly clear:
BPD is mainly a disorder grounded in attachment trauma, and the activation of the
attachment system in the therapeutic relationship predicts the re-enactment of
attachment-related traumatic memories. The more ef¿cient way of limiting the
consequences of such activation is to interact with the patient in line with the co-
operative motivational system, by building up a therapeutic alliance from the very
beginning of treatment (e.g. through careful contracting, as in DBT: Linehan
1993).
Second, any therapeutic manoeuvre aimed at correcting the disorganised IWM,
such as working on traumatic attachment memories and phobias of attachment
feelings, and providing transference interpretations, should follow the
establishment, stabilisation and consolidation of the alliance, and never put it at
risk of ruptures. Even the therapist’s empathic comments, and those aimed at
fostering the patient’s mentalising abilities, should be carefully titrated and

worded so as to avoid as far as possible the activation of the patient’s attachment
system, especially in the ¿rst phase of the treatment (Prunetti et al. 2008).
Third, while aiming at increasing the patient’s mentalising abilities and her or
his competencies in emotional self-regulation, the therapist should acknowledge,
tolerate and respect the possibility that borderline patients have learned to exercise
these abilities and competencies through controlling strategies involving either
punitive aggressiveness or compulsive care-giving. Any comment of the therapist,
in the ¿rst phase of the treatment, on the inappropriateness of these attitudes in the
present context may create a situation that, from the patient’s perspective, is
intrinsically contradictory: to be invited to give up their only possibility of
tolerating emotional closeness and impending attachment feelings without losing
the ability of mentalising or of regulating attachment emotions, and at the same
time be invited to mentalise and regulate their affects.
Fourth, as a consequence of all the above considerations, the therapist should be
aware that only the prolonged experience of an alternative, secure and rewarding
way of relating, based on the cooperative exchanges typical of the therapeutic
alliance, can allow borderline patients to reÀect on the interpersonal dynamics
based on the attachment system and thus begin to explore new and more secure
ways of expressing attachment needs and feelings, and of responding to those
expressed by signi¿cant others.
If readers ¿nd that features of the attachment-based approach to treatment are
compatible with the main strategies and prescriptions of other models – DBT,
MBT, TFP, SFP – then the main aim of this chapter will have been achieved.
Note
1 An outlook on how the different motivational systems selected by evolutionary processes
(caregiving, social ranking, sexual bonding and egalitarian cooperation), that alternate
normally with attachment (care-seeking) in regulating human interpersonal interactions,
may show up in verbal communication during clinical exchanges is provided by Fassone
et al. (2012). Among these systems, the care-giving and the ranking systems play a key
role in the controlling strategies, while the cooperative system is crucial in intersubjective
egalitarian exchanges (Cortina and Liotti 2010; Liotti and Gilbert 2011) and in the
therapeutic alliance.
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128 Giovanni Liotti
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Chapter 9
Starving for affection

Attachment narrative therapy with
eating disorders
Rudi Dallos
Introduction
The eating disorders, especially anorexia and bulimia, are among the most
dangerous and most dif¿cult to treat of the various mental health problems
(Bruch 1973; Ward et al. 2001). In this chapter a multi-level perspective will
be presented, exploring the experiences of young adults and including a focus
on attachment patterns, family relationships and the cultural contexts underlying
eating disorders. Though the emphasis will be on anorexia, the model offered
is also seen as applicable to bulimia. The discussion will not rely excessively
on diagnostic categories and it is suggested that there is often an overlap
between restricting and purging forms of eating disorders. These symptoms
may also be coupled with depression, anxiety, obsessive compulsive behaviours
and even deliberate self-harm (Fairbairn and Brownell 2002). In including a
family perspective, it is emphasised that the formulation is not intended to be
‘parent blaming’.
The family context

The primary task for the child is how to secure her own attachment needs and this
concerns how she learns to turn to others for emotional support and attempts to
manage her own feelings. Attachment theory has emphasised that children develop
their attachment strategies based on how their parents have responded to their
attachment needs (Ainsworth et al. 1978; Bowlby 1988; Crittenden 2006). Where
parents are able to respond consistently to provide care and comfort to a child
when he or she is distressed, then a secure pattern is seen to develop. In cases
where the child develops an avoidant pattern, parents are seen to respond
consistently but with little care and affection and with a message that encourages
the child to become overly self-reliant. In anxious-ambivalent patterns the parents
have been found to respond inconsistently, at times not being available and at
other times excessively anxious themselves or intruding into the child’s activities.
Finally, some children develop ‘disorganised’ or extreme strategies, typically in
contexts where the parents have responded in frightening or abusive ways. In
130 Rudi Dallos
these situations the child experiences a severe dilemma in that the person who is
meant to provide attachment security may at the same time be a source of threat
or distress (Crittenden 2006; Dallos 2006).
A child may develop similar or contrasting patterns to that of their parents. For
example, where both parents show anxious-ambivalent strategies, a child may
develop an avoidant, emotionally distancing strategy in order to gain some
emotional distance from their parents’ volatile emotional dynamics. Alternatively,
where both parents show insecure avoidant relational patterns, a child may
develop exaggerated displays of emotion to mobilise emotional responses in their
otherwise unresponsive parents. Where both parents have different types of
insecure patterns, the task is more dif¿cult in that the child needs to negotiate a
complex task of developing either a pattern of suppressing feelings or exaggerated
displays of emotion, or some mixture of the two.
The triadic perspective

The development of affect regulation in attachment theory has predominantly
been viewed as a dyadic process, mainly between the child and her mother
(Ainsworth et al. 1978; Crittenden 2006; Mikulincer, Shaver and Pereg 2003).
However, even at a dyadic level, how the mother responds to the infant is
inÀuenced by her relationship with the child’s father. It is also important to
consider that some parents are inÀuenced by the continuing relationship with their
own parents, and the grandparents in turn have a relationship with the grandchildren.
Some parents are closely tied to, and continually supported by, their own parents.
In other families, members may be distant or may even have made a deliberate
attempt to avoid, or be completely cut off from, their parents.
The parents’ emotional, romantic relationship is evolving alongside the
child’s development and constitutes a central attachment relationship and
emotional context for the child (Hall et al. 2003; Hazan and Shaver 1987). If
the couple are experiencing conÀict, distress or anxiety, for example about
possible separation, then the mother is likely to be emotionally distracted and
either less available to the child or possibly turning to the child for comfort.
The partners need to develop some shared understandings and expectations
about how they will meet each other’s needs and those of the child (Dallos and
Denford 2005; Hall et al. 2003). Where each partner brings a history of secure
attachment to the relationship, they are able to discuss their positive and
negative feelings for each other. They can also develop shared beliefs and
avenues of communication about how they will be able to manage anxieties
about the relationship and the child’s emotions. Where both partners bring a
dismissive pattern, this may lead to a shared belief system that they should not
burden others with emotional demands and should instead attempt to suppress
anxieties, display false positive affect and function at an emotional distance.
For partners bringing joint preoccupied patterns, there may be an expectation
that they have a right to demand emotional immediacy, to express strong
Starving for affection 131
feelings, and to make strong demands and criticisms of others. Where couples
hold similar individual attachment patterns, agreements and shared frameworks
can develop, albeit with escalating emotional distancing or entanglement. The
situation becomes more complex when they bring different strategies in which
such agreements are harder to develop and eventually may present a more
confusing context for their children. For example, one parent may offer comfort
and the other may be critical that the child is being ‘spoilt’ and needs more
discipline and clear boundaries.
A child needs its parents to help manage her own anxieties, but also responds
and potentially helps the parents to manage theirs (Dallos 2006). Most parents do
not deliberately draw a child into meeting their needs. Instead, a child may evolve
a function of regulating the attachment needs of her parents. Byng-Hall (1995)
coined the term ‘distance regulator’ for how a child plays such a stabilising role
for a couple. The patterns emerging here are shaped by the interplay of the
individual attachment patterns of the parents; where both parents demonstrate
preoccupied patterns the child may function to keep the parents apart and to
attempt to de-escalate their anxious/angry patterns. Where both have avoidant
styles the child may play an important role in enabling some emotional connection
between them. In both these patterns, children can establish reasonably consistent
roles that can help to regulate their parents’ relationship. However, the most
dif¿cult may be where the parents have differing attachment strategies. Here the
child may need to switch patterns to connect with each parent and to mitigate each
parent’s strategy, for example calming the mother down or getting the father to
say what he feels rather than just to withdraw. This is an incredibly demanding
task, especially for a young child. It is possible that, though the onset of eating
disorders may be in adolescence, the child has struggled to manage these demands
for years. This task may become increasingly unacceptable at adolescence when
the young person is also faced with the need to develop their own early romantic
relationships.
A triadic perspective offers an important extension to attachment theory, but it
also offers a connection to a substantial body of literature in systemic family
therapy that points towards a signi¿cant role of triadic processes in the development
and maintenance of eating disorders (Palazzoli 1974). It has also been observed
that families with a young person suffering from an eating disorder frequently
demonstrated a pattern of conÀict avoidance and enmeshment, and that the parents
experienced dif¿culties in working collaboratively with each other in managing
the eating disorder (Minuchin, Rosman and Baker 1978; Ringer and Crittenden
2006). Palazzoli (1974) further suggested that these families were characterised
by covert conÀicts in which the child with an eating disorder had been triangulated,
notably in being conscripted to take sides between the parents. Moreover, she
argued that the more this process was secret and disguised the more potentially
confusing and problematic it could be for the child.
132 Rudi Dallos
Corrective and replicative scripts

The concept of attachment scripts (Byng-Hall 1995) introduces the notion of
autonomy and choice into attachment theory; corrective scripts involve an
attempt to do things differently, better than our parents, for example to be more
emotionally available for our children or to have a more affectionate relationship
with our partner. Replicative scripts constitute attempts to repeat what we saw
as good, desirable features of our childhood experiences with our parents.
Family members vary in the extent to which they consciously hold these scripts,
but are usually able to articulate them quickly when prompted (Byng-Hall 1995;
Dallos 2006).
Corrective and replicative scripts can in some cases have a pendulum quality
when there is an extreme swing from one generation to the next. Where this
occurs, the intent to do things differently appears to be fuelled by powerful
emotions such as anger or disappointment regarding the parents. The concept of a
script includes the idea that it contains Àexibility and potential ability to adapt
itself according to the speci¿c circumstances and changes in the environment
(Byng-Hall 1995). In families where there are problematic processes, this
Àexibility appears to become impeded. Intense experiences or danger and distress
experiences in the parents’ childhoods may be connected to strong intentions to
avoid such experiences in their own families. For example, some parents have a
strong desire to be closer to their children, have healthier food and more enjoyable
mealtimes. However, without direct experience to draw on from their own
childhoods, this corrective script can be an abstract and idealised aspiration which
is hard to achieve in reality.
The ability to adapt our scripts to our children also connects with the concept
of reÀective functioning or mentalisation (Fonagy et al. 1991). It is suggested
that parents need to accurately reÀect back to the infant, the infant’s internal
emotional states such as distress, anger, sadness, and to communicate
simultaneously that these states are manageable and will not overwhelm them.
Where parents themselves have not experienced such accurate reÀection and
containment, they may ¿nd it all the harder to adjust and adapt their efforts at
corrective scripts for the child. This may add up to a ‘double’ dif¿culty in that
they perceive themselves as trying to do things better but in fact they are
potentially more, not less, confusing for their child than their own experience had
been. The child’s experience may be that their parent wants to be closer and more
sensitive to them, but they are doing it in a way which does not feel consistent
with their parents’ perceptions. The culmination of this process appears to be a
highly frustrating experience for both parents and the child. For the parents: ‘I
am trying to do it better than my parents, why doesn’t she understand?’ For the
child: ‘They tell me they are doing things better and I should be grateful but it
does not feel empathetic or sensitive’ (Dallos 2006).
A systemic, attachment formulation of eating disorders

The above dynamics are common to a whole range of problems. What may also
predispose a family towards a member developing an eating disorder is that there
has been a negative or contradictory tradition in the family in relation to food as
an attachment experience. Food is one of the earliest and most fundamental forms
of pleasure and distress experienced by the infant (Bowlby 1969; Friedman 1996).
As adults we can only imagine what it must feel like for an infant to feel the
craving for food and drink without conscious awareness that this desperate need
will be relieved. At the same time, it can constitute an extremely sensitive and
sensual experience of contact with the mother’s body and the comforting taste and
smell of milk. Bowlby (1969) suggested that the child internalises the mother in
terms of whether her breasts provide a consistent and speedy release for the baby
from the distress of hunger. In contrast, feeding could also be an unpredictable,
frustrating experience that maintains an unpleasant state of distress and anxiety
for the baby. In these early interactions mothers vary in how much they are able
to manage the intimacy and sensuality of feelings relating to feeding. Some
mothers appear to become very anxious and concerned to offer physical contact
and others ¿nd contact uncomfortable.
Bowlby (1969) argued that food and the resolution of the anxiety generated by
hunger provide an important early arena in which these attachment patterns and
affect regulation develop. In effect, eating and attachment can become intertwined
such that in the avoidant attachment patterns, for example, the experience of
hunger appears not to be associated with an anticipation of comfort and pleasure
but with attempts to self-regulate and avoid comfort seeking. Avoidant dispositional
representations may constitute a move towards a self-reliance regarding food,
perhaps as in solitary eating, which does not require dependence on another to
provide the release of discomfort from hunger. In more extreme forms, it may be
that the avoidance generalises to the extent that comfort itself is avoided. Accounts
from people with anorexic symptoms suggest that they do not transcend hunger,
but come to tolerate the suffering of intense discomfort (Orbach 2008).
If food is not construed as a positive and pleasurable experience then its
cessation may not initially be experienced as a loss of receiving comfort. However,
eventually the symptoms resulting from eating problems may elicit concern and
attachment responses from the parents (Humphrey 1989). It appears to constitute
an ‘attachment ambivalence’ of being simultaneously both a dismissing and
preoccupying process: on the one hand it appears to constitute a dismissive
attempt at rejection of comfort through food, but on the other hand, as the illness
progresses, it may also elicit and serve to maintain an anxious response from the
parents. Hence it can ¿t with an anxious-ambivalent attachment with the mother
or father, or a mixed avoidant-anxious ambivalent pattern between the parents.
Hence an important feature of anorexia is that the individual simultaneously
(avoidantly) rejects the comfort of food but also elicits anxiety and provision of
care (O’Kearney 1996).
134 Rudi Dallos
The development of a triangulated dynamic in the family in which the young

person with the eating disorder has become entangled is not exclusive to eating
disorders. It appears that in many families with an eating disorder, there has been
both a lack of provision of emotional comfort at times of distress and in turn a lack
of a connection between food and comfort. Attachment seeking and response to
separation and lack of availability of comfort elicit reactions of both anxiety and
protest, but since protest may be discouraged in families with an eating disorder,
it becomes expressed through refusal to take in food (Dallos and Denford 2005;
Minuchin, Rosman and Baker 1978; O’Kearney 1996). Such protest can represent
for the parents a painful sense of failure in their attempts to make a better emotional
environment for their children than had been their experience. This may in turn
lead to less con¿dence in responding to the child’s distress and their indirect plea
for comfort. In turn, anxiety about the child’s ‘illness’ may make it all the more
dif¿cult for the parents to work together and to resolve their own attachment
needs as a couple.
A focus on attachment and comfort permits some freedom to move away from
what can become a relentless and often unhelpful focus on the eating problems. In
our experience, the young people presenting with the eating disorder often wish to
move away from an exclusive focus on food, whereas the parents are anxious that
the problems with eating are not sidelined in the sessions. Our research and
clinical experience suggests that insecure attachment patterns operate across the
generations. The parents frequently experience dissatisfactions in their attachment
relationship with each other as a couple and appear to turn to a child to help meet
their own emotional needs. However, this is not simply some sel¿sh sacri¿cing of
their child; it is also driven by a corrective script – an intention to have a closer,
more intimate, loving relationship with them than they experienced with their own
parents. In some cases this corrective script appears to be fuelled by powerful
unresolved traumatic experiences.
Child’s distress
Parents: Sense of failure…
Parent: Want to be
more emotionally available but
not sure how to do this
Child: Lack of comfort, refusal to eat
Ambivalent response,
especially to protest
Figure 9.1 Corrective scripts and patterns of escalating distress

Attachment narrative therapy

A broad framework for utilising systemic attachment and narrative ideas –
Attachment Narrative Therapy (Dallos 2006) is illustrated below. This employs
four key stages in the intervention process:
Creating a secure base

In this stage it is recognised that coming for therapy can be an extremely anxiety-
provoking experience for many families. It appears to be especially the case for
families where anorexia is the presenting problem. Hence the ¿rst session emphasises
safety, validation and invites families to comment on the pacing of the work and
how comfortable they feel. It indirectly invites attention to their feelings and how
these are communicated, and conveys a message that negative or distressing feelings
in the session can be commented on and they will be responded to.
Exploration
In this stage the materials for subsequent changes are gathered through a variety
of forms of exploration, such as genograms, sculpts with objects, tracking
circularities, identifying attachment dilemmas, their explanations of the problems
and trans-generational patterns of attachment and comforting. It recognises that
such exploration can also provoke anxieties and the emphasis on pacing and
commenting on their experience of reÀecting and the work is maintained.
Considering alternatives
This stage utilises the material from the exploration and extends these to consider
exceptions and unique outcomes, and focuses on the parents’ corrective and
replicative scripts. Particularly important here is a consideration of what they have
attempted to change and whether this has worked. Frequently, families here mention
that they have wanted to be more emotionally available than their own parents had
been but have experienced a sense of failure in not being able to achieve this.
Maintaining the therapeutic base

In this stage it is recognised that for many families developing a sense of trust with
the therapist has been a new and powerful experience. Discussions take place
about how the relationship can continue in terms of what ideas and feelings family
members will take away and what we will remember about our work with them.
This also recognises the need to consider future problems that may arise and to
maintain a sense of continuing support by offering a further session if required. In
our experience, for many families the potential of future support is suf¿cient and
they do not in fact need to take up further sessions.
136 Rudi Dallos
Using attachment narrative therapy
Case study 1: The Morrison family

Mary Morrison, aged 19, was attending treatment for anorexia at an eating
disorder unit as a day patient following a three-month period as an inpatient.
She was living at home with her father (Bill) and older brother Peter. Mrs.
Morrison was living with her mother and father nearby, having ‘moved out’
approximately six months before the start of Mary’s anorexia. Mary had gone
to university some distance away from the family home about four months
after her mother had moved out. She quickly lost weight and had to return
home after six weeks and was admitted to a local eating disorder unit. The
parents were living separately, with Mrs Morrison visiting the home every day
to do the domestic chores. Mary indicated that she felt confused about her
parents’ relationship and confided that she was very angry with her mother,
partly because she thought that her mother had spread a rumour that she and
her father might have had an incestuous relationship.
In the initial sessions Mary cried repeatedly and though aware of her distress,
neither parent made overt attempts to comfort her. When asked what her
sadness was about she repeated that ‘People are lying to me, I don’t know what
is going on’. There appeared to be a shared family belief that ‘It’s best to avoid
difficult feelings’ and that ‘It’s dangerous to express our needs and vulnerabilities’.
Creating a secure base

It was made clear that the purpose of the sessions was not to look for blame
and that we might never fully discover the causes. However, we would try to
find ways of resisting the problem. The family were also asked how they felt
about an approach where we did not spend all of the time in the sessions
looking at the anorexia but also spent time on other matters.
Exploring attachment narratives

Mary appeared to be very distressed in the early sessions and repeatedly
mentioned feelings that things were ‘unreal’ and that people were ‘lying to her’.
Part of this exploration attempted to discuss Mary’s difficulties as not just
related to the anorexia but as part of ‘normal’ development; for example, that
becoming a young adult, moving away from home and becoming more
independent involves difficulties for all families. This led into a discussion, with
the aid of a genogram, of how each parent left home, and more broadly into
the nature of their relationships with their parents. During this discussion, Mrs
Morrison described that she had moved out to start work and that her family
had been close and warm. Mr Morrison’s story was a stark contrast:
THERAPIST: So can you tell me, Bill, how was it for you, becoming adult, leaving
home…?
MR MORRISON: Well I didn’t really have a home. I was brought up in various
children’s homes, it was O.K. I suppose.
THERAPIST: Could you tell me a little bit more about that, where were your
parents…?
MR MORRISON: My mother was very ill and in hospital, she died in hospital
when I was ﬁve. My father drank a lot and carried on with various women.
His answer to every problem was to have a drink. I thought it was terrible
my mum lying in hospital while he was doing that, but what can you do?
THERAPIST: So what happened when your mother died?
MR MORRISON: His girlfriend moved in with us and she couldn’t stand me so I
was put in a children’s home…
THERAPIST: That must have been pretty tough for you?
MR MORRISON: No, not really, I don’t think about it, it doesn’t really matter to
me. You just have to get on with life … no point crying about it.
THERAPIST: Have you ever talked to anybody before about these experiences?
MRS MORRISON: He has told me, but I’m glad he is doing it now … he keeps it
all bottled up I think …
Mrs Morrison explained that her husband’s tendency to deny feelings of

vulnerability had driven her away. He eventually admitted that he had been
hurt by his wife’s departure and we hypothesised that possibly Mary had
stepped into the role of surrogate wife to meet her father’s emotional needs.
Mr Morrison denied that he needed emotional support from his daughter but
at the same time described a daily ritual of massaging her feet to ‘help her to
relax’. We were concerned at the potential sexual implications of this ritual
and there appeared to be a confusing dynamic for Mary, who may have been
aware of her father’s need for physical and emotional contact but in providing
this was incurring the concern of her mother about possible incest. Mary also
appeared to try to deny her own feelings of loss at her mother moving out by
taking a critical stance towards her.
138 Rudi Dallos
Considering alternatives
A number of the following sessions were focused on exploring the possible
impact of Mr Morrison’s experiences and on the parents’ relationship. It was
suggested that they might attend as a couple to discuss their own issues, which
they agreed to. Mr Morrison was described by his wife as ‘working all the time’
and was sacrificing himself to look after everybody practically but was not able
to do so emotionally. Mrs Morrison indicated that she did want to be back with
her husband but that this was hard because he was so emotionally shut off.
Eventually, in an individual session and later in a session with the couple, Bill
admitted that he still cared for his wife and wanted her back. It seemed that his
reluctance to admit this was because he did not want to betray his special
relationship with Mary. An attempt was made to monitor the changes in Mary’s
attachments to her parents carefully and not to go too fast. Gradually Mary was
spending more time with her friends, had started to work again and though still
struggling with the anorexia she was managing to avoid a readmission to the unit.
Maintaining the therapeutic base

Some significant changes appeared to have occurred in the family, most notably
that Mary seemed to be less emotionally triangulated between her parents and
was becoming emotionally more independent and more connected to her
mother. However, there was a danger that her father was cutting off emotionally
too quickly and this was upsetting for her. His history in childhood had been that
his needs would not be met and there was a danger that he was feeling this again.
Sessions at intervals of six weeks were offered but they agreed that they did not
need further sessions since the problems had significantly improved. Considering
future issues, the pace of Mary’s independence was discussed and the family
members agreed that they would monitor this and Mary confirmed that she did
not feel emotionally ‘pushed out’ when her parents spent time together.
Case study 2: Kathy

This case permits more detailed analysis because, as well as therapy, the family
took part in our research study. This involved individual semi-structured
interviews, Adult Attachment Interviews (AAI) and a family interview.
Kathy, aged 17, had been suffering with an anorexic form of eating disorder for
over 18 months. Kathy was the youngest of four children; her three brothers
were all over nine years older than her. Her brother Pete had returned to live
at home for a while and had been close to Kathy when she was younger. Kathy
had suffered with anorexia for over three years and had attended an outpatient
unit. Her parents (Dawn and Albert) were living together and had been married
for over 30 years.
Dad’s weekend partner

when Dawn was a child
Albert 58 Dawn 56
Kathy 17 Pete 32 Darren 26 Mark 34
Figure 9.2 Kathy and her family – genogram
Trans-generational patterns
Dawn and Albert confided that their relationship was in difficulty and that
Dawn had wanted to leave the relationship, having ‘found passion’ elsewhere.
She described how her mother had ‘suffered in silence’ while her father had a
long-term relationship with another woman and her mother had become
depressed and suicidal. The AAIs for Dawn and Albert indicated they had
probably each brought insecure attachment patterns to their current
relationship: Albert displayed a dismissive pattern in that he avoided talking
about his feelings of vulnerability, had forgotten difficult emotional experiences
from his childhood, and engaged in largely analytic, intellectualising ways
140 Rudi Dallos
of discussing relationships. He discussed having had a mother who was

preoccupied with her own health and not emotionally available and a father
with a quick temper. Dawn in contrast displayed considerable emotionality in
her interview, became aroused and appeared preoccupied and overwrought by
painful memories from her childhood. It was as if she quickly started to relive
the experiences, not having found ways to resolve and come to terms with
them. These patterns were also revealed in the family sessions where Albert
engaged in attempts to rationalise family issues and Kathy’s difficulties, whereas
Kathy repeatedly became tearful and upset.
Both parents had negative memories of mealtimes, a broad sense of a lack of
comfort in their childhoods and little experience of food being used in their
past or the current families as a source of comfort, warmth or pleasure.
However, it was clear in Kathy’s family, as with others, that not all of the
children found it difficult to eat. Given Kathy’s central role as a connection
between her parents, it is likely that she had become finely tuned to the
emotional distress between her parents.
They used to hate each other so much I always used to be so scared that
one of them would do something stupid and I would come home and I
used to hate coming home just in case something happened. And they’ve
both got the worst tempers, even dad … dad’s is rarely seen but it is
really bad …
It appeared that Kathy had internalised the conflict between her parents such
that it was a continual preoccupation. Consequently family mealtimes at home
may have started to generalise into being progressively more aversive.
Corrective scripts and unresolved traumas

Dawn said she had resolved not to have the kind of unsatisfactory marital
relationship that she had seen her own mother ‘put up with’. She also wanted
a closer relationship with Kathy than had been possible with her own mother.
Likewise, Albert said his own father had been an angry and frightening man at
times due to his ‘illness’ and a demanding physical job. Consequently he had
wanted to be a less severe and intimidating father than his own. However,
neither Albert nor Dawn appeared to have been able to reflect upon and
integrate their early emotional experiences; instead, these appeared to intrude
into their relationship with Kathy. At times Albert appeared to repeat some of
the angry, dismissing reactions of his father. Similarly, Dawn would at times act
in a sullen, childlike, dependent way with Kathy in a reversal of roles, where

Kathy was expected to care for and contain her mother’s feelings. This
appeared to be combined with open expression of sadness and regret about
her relationship with Albert and mirroring her own mother’s sense of futility
and depression.
As Dawn attempted to ‘do things differently’, for example, be closer to
Kathy, it seemed that she could rapidly catastrophise when starting to feel it
was not working, and believe that Kathy did not appreciate her. This appeared
to lead her to make more emotional demands on Kathy, to become angry with
her or to blame Kathy for preferring her father. It was also possible that two
opposing corrective scripts were in play for her: wanting to be close to Kathy
but also wishing to be an independent woman and not run the risk of being
lonely and dependent on her husband as she felt her mother had been. In one
family session, Kathy described how nice it was when she was little and her
mother was off work for a few days and they had a nice meal together. We
noticed a rather dazed reaction from Dawn, as if this voiced her worst fear,
namely that the eating disorder was caused by her unavailability as a mother
and provider of food.
Triadic relationships and triangulation

It appeared that from birth, Kathy played an essential role for her parents: she
represented an opportunity for Dawn to relive and correct her relationship
with her own mother and to provide an ‘emotional glue’. Albert described
Dawn as so happy to have the daughter she had so long wished for that it made
their relationship more emotionally and physically intimate. It appeared that
Kathy came to recognise that she was significantly important to both her
parents and their relationship. However, as the conflicts between her parents
resurfaced, Kathy found herself drawn into taking sides. She described her
sense of being caught between her parents in the role of emotional regulator
for their relationship, and how she needed to keep her symptoms of anorexia
in order to promote some stability and calm in the family:
The only thing I ever hear them talking about is me and if I didn’t have this
[anorexia] it’s kind of like, would everything fall apart, at least it’s keeping
them talking. And they won’t argue while I’ve got this because it might
make me worse. So um … that’s kind of bought, sort of like, I’m not in
control as such but I’ve got more control over the situation that way …
142 Rudi Dallos
Kathy demonstrated a pattern of attempting to withdraw emotionally, for

example as she described above regarding her father. At the same time, she
was often drawn into escalating, tearful patterns of mutual emotional demands
and accusations with her mother. These demands to take sides appeared to
make it difficult for her to consistently use an avoidant/dismissing style of
relating in emotionally tense and difficult moments. Furthermore, the continual
sense of imminent threat and catastrophe regarding her parents’ relationship
also appeared to have contributed to anxious intrusions of feelings and images
that disrupted her attempts to self-regulate and calm herself.
Therapeutic interventions
We were able to make connections between comfort, their own histories and
the role of food. As part of these discussions, we were able to comment on
and share aspects of the parents’ childhood experiences in order to help make
connections with the family and help reduce a sense of blame or inadequacy.
Key family relationships across the generations were discussed and connections
made with the current family patterns of relating. For example, how they were
attempting to do things differently and the positive intentions they had for their
relationship with Kathy. In these discussions Kathy was at points able to
validate how her mother had tried to make things better, because at times
Dawn was reluctant to consider that she had been able to do anything better
and had ‘got it all wrong’. The focus of these conversations stayed on their
positive intentions rather than digressing into what was not working currently.
Gradually both Dawn and Albert were able to identify some aspects of how
their intentions had been positive and could be developed further. Kathy’s
weight increased to normal levels and her emotional state also improved. The
positive changes were maintained at 18 months and at an eight year follow-up.
Following a number of sessions allowing Dawn and Albert to discuss their
marital relationship they decided to maintain their marriage, and their
relationship had significantly improved.
Discussion
For both these families, the Morrisons and Kathy’s, triangulation was a central
issue. Minuchin (1974) has indicated that all family members contribute to
maintaining the process; for example, when Kathy went away to university she
returned frequently, perhaps in part to monitor the well-being of her parents as
well as for her own needs. The child’s symptoms, their concern about their parents,
and the special role they have gained can also make it dif¿cult for a couple to
resolve their own issues. Though in both the cases described the couple’s
relationship was an important focus, and improved considerably, we are not
suggesting that anorexia is invariably causally linked to dif¿culties in the parents’
relationship. Typically, in the families we have worked with, there is a counter
explanation that the anorexia had caused the problems in the parents’ relationship.
As with Minuchin’s clari¿cation above, a systemic perspective suggests that the
causal processes are not simply linear. However, what does seem to be common
is that the parents of young people with anorexia (and even of older people with
the condition) typically appear to have had dif¿cult and emotionally barren
childhood attachment experiences, and alongside this, negative experiences of
food and family mealtimes. This appears to leave them at dif¿culty in dealing with
their children’s attachments needs and being able to relate attachment needs to
eating problems. The central proposition of this chapter is that food is inextricably
tied in with comfort and attachment. Though popular magazines and the media
talk repeatedly of ‘comfort eating’ in relation to other eating problems such as
obesity, this linking between food and comfort is relatively, and perhaps
surprisingly, under-researched (O’Shaughnessy and Dallos 2009). Part of the
reason may be that such research can be seen as parent blaming. However, as
suggested in this chapter, parents are typically attempting corrective scripts – to
do things better than was their experience. It is important to be able to recognise
what makes this so hard for the parents to achieve. Recognition of their own
dif¿cult attachment experiences offers a compassionate, not a blaming, stance that
arguably helps to recognise the frustrations they experience when their efforts to
‘do it better’ appear to be ineffective or even damaging.
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Chapter 10
An attachment perspective on
understanding and managing
medically unexplained symptoms
Robert G. Maunder and Jonathan J. Hunter
Simon is a 37-year-old teacher. He has been referred for psychiatric assessment

by his family doctor after three referrals to specialists (gastroenterologist,
cardiologist and neurologist) have produced no explanation for a cluster of
symptoms, including chest and epigastric pain, intermittent ‘pins and needles’ in
both hands, and diarrhoea. The symptoms have persisted for six months and
have been severe enough that he has recently taken a leave of absence from
work. He is embarrassed and a little angry that his doctor suggested seeing a
psychiatrist, as it is clear that the symptoms ‘are real, not just in my head’. His
doctor suggested that the symptoms might be due to stress, but Simon notes
that he has had a career that is stressful but satisfying for many years without
it causing a problem like this. There do not appear to be any obvious changes
in his life preceding the onset of pain and the subsequent emergence of
diarrhoea and peripheral parasthesia.
Gathering the history of these symptoms is time consuming and somewhat
confusing because Simon has trouble organising and completing his thoughts. ‘I
first had this pain, in the stomach’ (he points), ‘although I wouldn’t call it a pain
as much as a twisting feeling at first, and nausea, and … sharp pain, but I don’t
eat fibre anymore, just little snacks, and they want me to go back to school, but
really, could you work with this sort of pain? I mean I double over, and think of
the kids… and the nausea, which, I mean, I don’t throw up but I could and I
know it isn’t a heart attack but you would think that too, at first. And she says
“Just relax” like that is something you can just do when you’ve got a feeling that
literally takes your breath away … I have a cousin with Crohn’s disease who
had investigations for two years before they figured out what was going on so
I know things get missed …’
Simon’s situation is all too common. Physical symptoms that are never adequately
explained by organic disease are one of the most common and challenging
phenomena in medicine, accounting for about one in three symptoms reported to
146 Robert G. Maunder and Jonathan J. Hunter
primary care physicians (Escobar et al. 1998; Kroenke 2003) and for most health
care visits (Katon, Sullivan and Walker 2001).
The phenomena referred to collectively as medically unexplained symptoms
(MUS) are diverse, ranging from a single symptom such as lower back pain to
complex functional and psychiatric syndromes. Management of MUS is
complicated by lack of certainty about the cause of symptoms, and often by
disagreement between patient and clinician as to the role of psychological factors.
The likelihood of co-morbid psychiatric diagnosis and of dissatisfaction in
patient–provider interaction increases as the number of reported symptoms
increase (Simon and Von Korff 1991).
Observational reports of healthy people in the community show that experiencing
an unexplained symptom is common, with most people having symptoms every
few days, for which they do not seek medical help (Demers et al. 1980; White,
Williams and Greenberg 1961). MUS may be accompanied by psychological
variables (especially a history of childhood adversity and symptoms of depression
and anxiety) more often in tertiary care settings than in the community (Smith et
al. 1990; Talley, Howell and Poulton 2001; Whitehead et al. 1988) although the
evidence is inconsistent (Locke et al. 2004). Problematic MUS are not identi¿ed
by the nature of the physical symptoms but by multiplicity of symptoms, dif¿cult
patient–provider interactions, co-morbid psychiatric syndromes and high
utilisation of medical resources (Katon, Sullivan and Walker 2001). Thus, while
psychological contributions to MUS are not universal, it remains controversial
whether psychological variables are associated with the occurrence of physical
symptoms or with medical help-seeking. This chapter focuses on the phenomena
that are most challenging to manage, problematic MUS, rather than on the
occurrence of symptoms in themselves.
Current approaches to management of MUS

The treatment of MUS is less than optimal. While randomised controlled trials
support the value of cognitive-behavioural therapy (CBT) and antidepressants
(Kroenke 2007; Sumathipala 2007), the clinical application of these interventions
remains problematic. With respect to CBT, evidence supports the value of CBT
provided by specialists, but interventions by primary care physicians have had
disappointing results (Kroenke 2007). Since the greatest burden of MUS occurs in
primary care, this is a major limitation. With respect to antidepressants, trials
which demonstrate statistically signi¿cant bene¿ts often fail to report the
prevalence of side effects, which are a common limiting factor that may account
for the high rates of treatment withdrawal in these studies (Sumathipala 2007).
The choice of outcome variables in treatment trials has been inconsistent, but
reduced psychological distress and reduced medical costs have been more readily
achieved than resolution of physical symptoms (Kroenke 2007).
Evidence also supports simpler interventions. Psychiatric consultation followed
by a letter to the primary care physician outlining principles of management
An attachment perspective on unexplained symptoms 147
reduces medical utilisation and improves functional status (Smith, Monson and
Ray 1986; Smith, Rost and Kashner 1995). The letter evaluated in these
interventions provided a diagnosis (somatisation disorder) and described its
chronic relapsing and remitting course and its low morbidity and mortality. It
recommended brief regular appointments every four to six weeks and avoiding ‘as
needed’ appointments. Also that every appointment should include a brief physical
exam focused on the body system in which symptoms occur and that hospitalisation,
diagnostic procedures, surgery and laboratory tests should be avoided unless
clearly indicated. Finally, the referring physician was encouraged to avoid telling
the patient that symptoms were ‘in their head’ and instead to assume that the
development of symptoms was outside of their conscious control and awareness.
Applying this sound advice is challenging. Problematic MUS raise doubts for
most clinicians and introduce conÀicts between healthcare providers and patients
that interfere with good care. Clinicians are often concerned about missing an
occult organic diagnosis; the lack of a medical explanation for symptoms does not
mean the impossibility of one. Clinicians may worry about being criticised, or
offending a patient with the implication that physical symptoms are not being
taken seriously. The limited effectiveness of evidence-based interventions
contributes more frustration. Very often, management of MUS requires a capacity
to work respectfully and with con¿dence in spite of diagnostic uncertainty and a
patient who actively doubts the value of the interaction.
For all of these reasons, we have found it helpful to formulate the interaction
between a healthcare provider and a patient with problematic MUS as a dif¿cult
interpersonal interaction, and therefore to use an understanding of interpersonal
psychology, speci¿cally attachment theory, as a basis for managing care.
Attachment theory
Attachment theory was described by John Bowlby as a theory of the development
of close protective relationships between infants and parents (Bowlby 1969).
Attachment theory can be framed in a manner that translates readily into a
formulation of problematic MUS, as follows. A primary purpose of attachment
relationships is to provide a mechanism for a vulnerable individual to receive
protection and solace from a care-providing individual (known as an attachment
¿gure) at times of danger. This goal is achieved through a series of interpersonal
signals (attachment behaviours) that are triggered by the perception of danger.
These include crying, moving towards the parent and clinging – any of which may
elicit an effective response from a care-provider. If the danger is the presence of a
predator, the care-providing response might include protective proximity, which
provides shelter from the predator and soothing contact. Signals of potential
danger can come from within as well as from the external environment; pain and
other symptoms of injury and illness are also effective triggers of attachment
behaviours.
The pool of attachment behaviours a child is born with is shaped by the

ampli¿cation of behaviours that are more successful in achieving attachment
goals and the relative extinction of behaviours that are less successful. Through
this process one internalises a self-image as an individual who is an effective self-
regulator of danger and distress, or not. There are marked individual differences
between infants in the ease with which expressions of distress are elicited, patterns
of approach and withdrawal with respect to the parent, and the effectiveness of
contact in reducing distress and providing solace (Ainsworth et al. 1978).
Interactions between infants and their primary care-providers typically result in
stable patterns of attachment behaviours.
Individual patterns of attachment remain identi¿able throughout the lifespan,
with several important modi¿cations later in life (Mikulincer and Shaver 2007).
For adults, the attachment ¿gure is typically a committed romantic partner, or in
some cases another close con¿dante. Adult attachment ¿gures can be identi¿ed by
three roles that they perform: being the person to whom one most wants to be
close, the person one turns to at times of great adversity (a safe haven), and the
person from whom one ¿nds the security to go out and explore independently (a
secure base) (Hazan and Shaver 1994). The roles are usually transferred from
parents to peers and partners in late adolescence or early adulthood (Fraley and
Davis 1997).
Individual differences in adult attachment have been classi¿ed in several ways,
based on theoretical and measurement considerations. In this chapter we describe
prototypes that capture the core elements of these patterns, using the system
introduced by Bartholomew and Horowitz (1991), who described four categories
of attachment: secure, preoccupied, dismissing and fearful. We modify their
descriptions to include aspects of insecure attachment drawn from research on
attachment ‘states of mind’ (George and West 2001; Hesse 2008) – speci¿cally,
impaired narrative coherence and mentalising. These prototypes and the evidence
upon which they are derived are described in more detail elsewhere (Maunder and
Hunter 2009, 2012).
Secure
The secure pattern is not commonly associated with problematic MUS
(Ciechanowski et al. 2002a) and is described to provide contrast with the insecure
patterns. Secure attachment is characterised by a positive self-image as resilient,
resourceful and capable of eliciting help when warranted. Expectations of others
tend to be realistic and, within those limits, positive. Expressions of distress and
other behaviours that elicit care from others tend to be proportionate to need and
communicated clearly enough to promote a constructive response. While a person
with secure attachment may experience intense distress, others are usually able to
appreciate and understand both the distress and its relationship to circumstances
in a manner that facilitates a constructive response.
Preoccupied
The preoccupied pattern is characterised by a negative self-image as fragile or
unworthy of love and caring. This negative self-view is accompanied by intense
attachment anxiety, which refers to an exaggerated, fearful expectation of rejection
by, or loss of, the attachment ¿gure. Attachment behaviour includes vigilance for
the presence and responsiveness of others, frequent expressions of distress, and
preoccupation with interpersonal proximity. Although proximity and support are
actively sought, they are often insuf¿cient to reduce distress and are perceived to
be unsatisfactory. Communication of distress may lack coherence because of
intense affect, vague descriptors, a lack of clarity about timelines and individuals
in the narrative, and mixed, multiple, fragmentary narrative threads.
Dismissing
The dismissing pattern is characterised by a negative image of others as
untrustworthy or disappointing. This is accompanied by attachment avoidance,
which refers to a pattern of avoiding intimacy and dependency through interpersonal
distance, self-reliance and the devaluation of the importance of intimate or
supportive relationships. Expressions of distress are suppressed. The communication
of perceived distress is truncated by the omission of detail and the use of
conventional or clichéd phrases, and general conclusions about oneself provided in
the absence of supportive and contextualising evidence. Attachment avoidance can
be understood as a defensive strategy, protecting the dismissing individual from the
disappointment and pain that is expected to result from the ineffective responses of
others to expressions of need (Shaver and Mikulincer 2002).
Fearful
The fearful pattern is especially relevant to problematic MUS. It is characterised
by negative expectations of both self and other and by the combination of
prominent attachment anxiety and attachment avoidance. Whereas dismissing
attachment appears as a pattern of self-reliance and comfort with interpersonal
distance, fearful attachment is characterised by a strategy of maintaining
interpersonal distance that does not appear to provide comfort. Distress is
communicated in a manner that does not elicit a caring response from the other, or
that even actively discourages such a response. If attachment avoidance is
understood as a defensive strategy, fearful attachment represents a situation in
which avoidant defences are used but fail to protect the individual against negative
affect (Shaver and Mikulincer 2002). Fearful attachment represents the pattern of
insecure attachment in which insecurity is most severe. Clinically, the opposing
pulls of attachment anxiety and attachment avoidance can manifest as inconsistent
help-seeking/help-rejecting behaviour, a common feature of dif¿cult patient–
provider interactions (Groves 1978).
Simon has a fearful attachment style. His primary method of coping with the
recent health challenge has been to try to tough it out on his own. His distress is
intense when he discusses his symptoms (a characteristic of attachment anxiety)
but he does not welcome gestures of support or sympathy in response. He is
mistrustful that he will be accurately understood and expects others to be
unhelpful (a characteristic of attachment avoidance). During the psychiatric
consultation, his ambivalence about expressing distress and seeking help manifests
indirectly as a combination of: (1) overt messages that he does not wish to be
there and has very little expectation of practical help; and (2) an implied contrary
message that he is reluctant to give up the contact. The latter is demonstrated
when his many questions, concerns and objections to the psychiatrist’s statement
of her understanding of the situation and recommendations lead to an
appointment extended much longer than a typical consultation.
An attachment formulation of MUS

The attachment formulation of MUS views the perception of a physical symptom
as an internal signal of potential danger; the expression of distress and seeking of
medical attention for the symptom as care-seeking attachment behaviours; and the
relationship in which care is sought as an attachment relationship in which the
healthcare provider is assigned the role of attachment ¿gure (Ciechanowski et al.
2002b; Hunter and Maunder 2001; Maunder and Hunter 2004). The attachment
patterns that would be predicted to be most strongly associated with problematic
MUS are the patterns that feature high attachment anxiety, i.e. preoccupied and
fearful. Indeed, the preoccupied and fearful patterns of attachment are associated
with the highest prevalence of unexplained symptoms, signi¿cantly higher than
occurs in secure or dismissing patterns (Ciechanowski et al. 2002a; Ciechanowski
et al. 2002b).
Through established patterns of attachment behaviour, adult responses to
physical symptoms are directly linked to general patterns of response to perceived
dangers that have occurred throughout life. For example, a person with a new
symptom has to choose to do something about it or to ignore it. A symptom must,
therefore, meet some personal threshold of concern to result in a medical
interaction. A person with a secure attachment might seek medical attention
because a symptom is severe or disabling, because it does not ¿t with previous
experiences of benign symptoms, because it is similar to a previous problem that
required medical treatment, because it doesn’t go away when expected, or because
it is combined with other symptoms in a worrisome pattern. In the absence of such
signs of special concern, a secure person may choose to tolerate a new symptom
and wait for its spontaneous resolution, or may assess and deal with its likely
cause (e.g. reducing evening coffee consumption to reduce recent insomnia).
On the other hand, a person with prominent attachment anxiety has had
developmental experiences that reinforce the expectation that the likely response
to danger (whether from within or from others) will be ineffective, and has not had
the opportunity to develop a capacity for affect regulation that would facilitate
tolerating uncertainty while waiting to see how seriously to interpret a new danger
signal. He or she is thus unlikely to interpret a new symptom as benign and has
trouble tolerating distress while waiting for the symptom to subside. Vigilance for
signs of danger may result in ampli¿cation of mild or nonspeci¿c physical
sensations. Anxiety caused by the initial experience of a worrisome symptom
focuses attention on the symptom and ampli¿es it, while further complicating the
picture by causing a wide range of physical consequences of anxiety, heightening
concern even more. These secondary effects of anxiety include tachycardia, rapid
breathing, muscle tension and effects of hyperventilation such as lightheadedness
and symmetrical distal paraesthesias.
The primary coping strategies associated with attachment anxiety are to
express distress and seek proximity to an attachment ¿gure. In a medical setting,
distress may be expressed directly as negative affect, but is often indirectly
expressed by reporting symptoms and requesting tests. In the context of this
anxiety, reassurance of a benign etiology and other forms of medical support are
not effective (because they miss the point that the patient’s primary dif¿culty is
feeling insecure), often leading doctors to respond to the persistent distress with
extra investigations and consultations with specialists. A doctor who is responsive
to physical symptoms and inattentive to psychological distress reinforces a
patient’s selective focus on MUS.
The anomalies of communication that are associated with insecure attachment
add to the dif¿culty of assessing physical symptoms. People with preoccupied
attachment tend to express their concern in a manner that conveys emotional
distress much more effectively than it provides medical information. Timelines
are often confusing. Relevant characters in the illness narrative may be mentioned
without providing explanatory context. Narrative threads are often truncated and
interrupted before they reach a logical conclusion, as anxiety drives the narrator to
a new thought or topic. Reassurance and understanding is actively and often
prematurely sought from the medical practitioner (Maunder et al. 2006b).
A clinician’s dif¿culty providing effective reassurance may trigger other
unhelpful responses within the clinician, such as anger. Since a person with high
attachment anxiety expects rejection, a self-ful¿lling interpersonal vicious circle
may ensue. The clinician perceives a patient to be excessively anxious and clingy
and responds with efforts to truncate the expressions of distress and create greater
interpersonal distance. In a medical setting, distancing behaviour by the attachment
¿gure (clinician) may take the form of writing a prescription too quickly in order
to terminate the contact, providing a referral to another resource, or offering an
appointment far in the future. Such distancing behaviour reinforces a patient’s
expectation of rejection and their self-image of unworthiness and increases the
pressure to maintain contact. Ending the appointment may provoke a crisis, often
resulting in unusually long and yet unproductive medical appointments.
Patient–provider interactions are further complicated when a patient with MUS
has a fearful pattern of attachment because of the added contribution of attachment
avoidance. In the fearful pattern, opposing forces of proximity-seeking and
attachment avoidance lead to conÀictual help-seeking/help-rejecting behaviour.
Communication is impaired by combinations of the excessive detail and vague
usages of language that are characteristic of attachment anxiety and the premature
truncation of enquiry and interpersonal distancing that are characteristic of
attachment avoidance. These complex dynamics likely explain why emergency
department physicians, who rarely perceive secure patients to be dif¿cult to deal
with, more commonly experience interactions with preoccupied and dismissing
patients to be dif¿cult (17–19 per cent of interactions), and very commonly
experience interactions with patients with fearful attachment to be dif¿cult (39 per
cent of interactions) (Maunder et al. 2006a).
Problematic MUS are associated with multiplicity of symptoms, dif¿cult patient–
provider interactions, co-morbid psychiatric syndromes, high utilisation of medical
resources (Katon, Sullivan and Walker 2001) and childhood adversity (McCauley
et al. 1997). Insecure attachment is also often associated with a history of adverse
developmental experience, co-morbid anxiety and depression, multiple somatic
complaints and patient–provider dif¿culty. Since insecure attachment is more
common and severe among those who have experienced major childhood adversity
(Alexander et al. 1998; Lyons-Ruth and Block 1996), an attachment formulation of
MUS may help to explain why a history of childhood adversity is so common
among patients with problematic MUS. As well, insecure attachment is consistently
found to be a risk factor in itself for anxiety and depressive disorders (Bifulco et al.
2002a; Bifulco et al. 2002b). Thus there is a close homology between expected
patterns of symptom presentation in insecure attachment and the characteristics of
problematic MUS. Adopting a developmental formulation of MUS, based on
attachment theory, may help clinicians to maintain an empathic and compassionate
response to patients whose behaviour can otherwise elicit unhelpful frustration.
An attachment-informed approach to the

management of MUS
The attachment formulation views an interaction between a clinician and a patient
with MUS as a dynamic interpersonal system in which the goal is to restore a
patient’s feeling of security. This perspective can help to reframe an interaction in
which exclusive attention to the goals of investigation, diagnosis and treatment of
a physical symptom frequently leads to unsatisfactory outcomes. The ways in
which the clinician and patient can restore a patient’s sense of security are: (1) for
the clinician to provide external regulation of a patient’s distressing affect; (2) for
a patient to enhance his or her capacity for self-regulation of distressing affect; and
(3) to enhance access to other sources of support and improve their effectiveness.
Providing external regulation

Two of the primary functions of someone serving (even temporarily) as an
attachment ¿gure are to provide a safe haven that shelters an individual from
perceived threats and a secure base from which to reassess resources and
challenges. Needless to say, in order for a clinician to provide a calming base for
an anxious patient, the clinician must ¿rst be feeling reasonably calm him or
herself. Problematic MUS may provide a challenge to the clinician’s sense of
security because of concerns about missing an occult organic diagnosis or about
conÀict with a patient. Having a familiar formulation of the problem may in itself
serve to mitigate unnecessary anxiety on the clinician’s part.
Several evidence-based strategies for managing problematic MUS can be
understood as serving a helpful attachment function. Validating a patient’s
symptoms and providing an explanatory model1 reassures a patient that their
suffering is being taken seriously and that they are being kept ‘in mind’. Providing
such an understanding is an example of the attachment ¿gure’s capacity to
mentalise (i.e. the ability to reÀect upon the mental life of others and of oneself),
which is a powerful contributor to security. (Although a discussion of mentalising
is beyond the scope of this chapter, see Allen 2003 and Fonagy and colleagues
1991 for a description of the development of mentalising and its relationship to
attachment security, and Bateman and Fonagy 2009 for evidence of its role in
psychotherapy). A clinician’s diagnostic and therapeutic conservatism not only
reduces the risk of iatrogenic harm and excessive costs but also conveys a sense
of calm and rational evaluation of the magnitude of the risks signalled by the
MUS. Reliability and responsiveness are characteristics of an attachment ¿gure
that promote security (Belsky 2008). A clinician can provide a reliable, predictable
and responsive interaction by scheduling frequent (even if brief) appointments
during which full attention is paid to the MUS as well as their context.
Beyond predictability and responsiveness, regularly scheduled appointments
(rather than ad hoc crisis appointments) serve an additional, important role in
problematic MUS by disrupting the contingency between reporting symptoms
and receiving support. A vicious circle can occur in which distress (expressed as
symptoms) promotes attentive contact, reinforcing the value of the medicalisation
of distress as an attachment behaviour, which leads to more symptom reporting,
increasingly frustrating medical interactions, more intense insecurity and so on.
Regularly scheduled appointments make attentive care predictable and reduce the
value of additional symptom reporting as an attachment behaviour.
Enhancing self-regulation
Improving a patient’s ability to feel more secure by self-regulating distress is even
more important than efforts to provide external support. This begins during the
initial history taking, which should include an enquiry into previous health
problems and major stressors and how a patient responded to these. Very often
this enquiry into preferred modes of coping will reveal personal strengths and
experience with effective affect management that can be highlighted and

reinforced. Even while ¿rst hearing their story, a clinician can remind a patient
with MUS about personal strengths that are forgotten or under-emphasised.
Additionally, preferred modes of coping that are ultimately counter-productive
(such as substance use) can be identi¿ed as targets for change.
Education in skills that enhance self-regulation of distressing affect, such as
various relaxation techniques, is often valuable both because it gives a person
with MUS tools to reduce distress and because it bolsters their sense of self-
control and mastery, which are important contributors to feeling secure.
Optimising other sources of support

Preoccupied and fearful patterns of attachment are consistently associated with
ineffective social support (Mikulincer and Shaver 2007), which may perpetuate
problematic MUS. The fearful expectation of invalidating and rejecting responses
from others often leads to a self-ful¿lling prophecy. A communication style that
emphasises distress but interferes with a coherent understanding of the person’s
situation compromises the ability of others to understand, sympathise and remain
available. Clinging and otherwise excessively dependent requests for support may
make others feel overwhelmed and prone to withdrawal. Insisting on attention to
physical symptoms (which others may be unable to reduce), rather than dif¿culties
that con¿dantes may be able to address more effectively, further impairs the value
of interacting with others.
Much of modern medical care takes place within the context of a multi-
disciplinary team. This can be an ideal model for a patient with MUS, as it
distributes the inevitable frustration across several individuals, thus preventing
any single practitioner from burning out. However, it requires excellent intra-team
communication, and a commitment to ‘staying on message’. Otherwise a patient
with MUS may come to focus idealistically on one member, while devaluing the
input of others. This may eventually result in the team structure and communication
becoming as chaotic as the patient’s internal world. A team that is cohesive and
communicates well, on the other hand, provides affect-regulating structure that a
patient can internalise to create greater order. Thus regular, consistent meetings in
which a clear care plan is developed and reviewed, and in which team members
are encouraged to articulate their experiences – asking for team resolution of new
requests, for instance – will allow the clinic to maintain its ‘secure base’ function
for the patient.
The same risk of miscommunication and unintended conÀict occurs in the broader
health network. Many patients with MUS have involved a wide array of professionals
and non-professionals in their care, ranging from medical specialists and generalists
to providers of alternative care and spiritual support, friends and family. Given the
nature of the presentation of problematic MUS and the dif¿culties with effective
treatment, much advice will be received that is ineffective and in conÀict with
guidance from other sources. The drive for obtaining comfort through proximity to
others means that contact with ineffective sources of care is likely to be perpetuated
because the individual will be reluctant to give up any contact, even while new
‘experts’ are sought. Few of these contacts will be well-informed as to what is
happening in the other interactions. As with the systemic chaos that can occur in a
clinic team, this pattern of ‘fragmentation of the agents of care’ (as originally
described by Donald Winnicott (1989)) is even more dif¿cult in the broader
community. Thus one of the important tasks of a healthcare provider assuming
primary care of a person with MUS is to try to bring order and clear communication
to a fragmented network of care providers. Emphasising the importance of
communication between these individuals and seeking a patient’s permission for
open communication is an important ¿rst step. Over time, encouraging a patient to
retain sources of care who are making a unique and valuable contribution and
to limit contact with those whose care is being perpetuated ‘just in case’ will help to
bolster the quality of support received within the healthcare system.
Similarly, one also seeks to facilitate the interactions of a patient and their
closest family members and con¿dantes. The goal here is to improve their
perception of the quality of support they receive in all regards, not only with their
MUS. Thoughtful, non-blaming couple- or family-based sessions can clarify a
plan for dealing with the patient’s distress when it is expressed within the family,
with a goal of containing anxiety. Explication of the interpersonal circumstances
that exacerbate feelings of insecurity – and thus amplify MUS – may lead to a
different familial interaction that provides support and structured reassurance.
The psychiatrist explains to Simon that unexplained symptoms such as his are
a common problem and that very often an underlying disease is not identified.
She suggests that while she does not know what is causing Simon’s symptoms,
it is obvious that the pain is real and it would be helpful to discuss how to limit
its impact on his life. Taking the extra time required to work through Simon’s
objections and concerns, the psychiatrist offers him a plan that focuses on
three goals: (1) preventing unintentional complications by avoiding unnecessary
tests and excessive consultations with specialists; (2) maintaining regular,
scheduled contact with a consistent, trusted healthcare provider every 4–6
weeks to monitor his symptoms and discuss practical steps to limit their
impact; and (3) learning techniques that aid in reducing the distress that the
symptoms are causing and sometimes help to reduce pain. They discuss
resources available to learn relaxation techniques and mindfulness meditation.
Although Simon is not interested in pursuing cognitive-behavioural therapy, the
psychiatrist describes its potential value and offers to pass on information
about its availability to the family doctor in her consultation letter, for Simon’s
future reference. Simon is disappointed that the plan is not designed to
eliminate his symptoms, but feels that his concerns have been heard and have
not been minimised. He leaves the office feeling cautiously optimistic.
Summary
Medically unexplained symptoms are a common yet vexing problem that often
leads to intense resource utilisation. The most investigated therapeutic
interventions, such as CBT, are often ineffective in creating change. An attachment
formulation is a parsimonious means of understanding problematic MUS as a
social communication of need and insecurity, within the context of a preoccupied
or fearful insecure attachment pattern. The goal of the MUS is understood as
communicating an ongoing need for proximity to those who can provide solace
– in this case a healthcare worker.
Typical medical interventions designed to reduce symptoms, and thus make
ongoing contact unnecessary, are unconsciously resisted by patients who are both
highly invested in the need for personal validation and support and disadvantaged
by the withdrawal of medical support that would accompany a ‘cure’. The
resulting conÀict in which medical intervention can appear to be both sought and
rejected contributes to frustration and hopelessness in clinicians. Pre-emptively
addressing the attachment needs of a patient, with consistency across time and
between clinic personnel, may provide additional bene¿ts in the effort to reduce
the distress and frequent presentations associated with MUS, increase recognition
of the role of emotion and relationship issues in the quality of life of patients with
MUS, and reduce the costs of healthcare.
Note
1 The most appropriate explanatory model varies depending on circumstances and on
¿nding a model that both clinician and patient can agree is valuable. Typically, the most
useful ‘model’ is not complex and is suf¿ciently Àexible to simply provide an acceptable
vocabulary for enquiry – it may involve the physiological effects of stress or of anxiety,
anger or depression, or simply be a mutual agreement on relevant issues that are
secondary to having MUS, such as conÀict with doctors, unhelpful patterns of help-
seeking, or ineffective social support.
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Section 3
Specific populations
Chapter 11
Bringing a gendered
perspective to attachment
theory in therapy
Susie Orbach
This chapter argues that understanding the gendered aspects of attachment is of

value. Many current mental health issues, from violence against self, aggression
towards others, body dysmorphias, eating problems and sexuality concerns to
insecurity in relationships and in parenting, arise out of the gendered prescriptions
that mark our child rearing and psycho-social relationships. An awareness of the
inÀections of gender on the clinician and on the patient is important in providing
understanding at a suf¿ciently complex level.
Attachment theory offers itself as gender neutral. Not exactly gender blind, for
there is much in the work that relates to the attachment style of the mother.1 But like
a good deal of psychological and psychoanalytic theory, the meaning of the mother’s
gender, how it will inform her psyche, her social practice, the woman’s own
understanding of the signi¿cance of her gender and that of the baby, the context into
which she parents and so on, is left absent. It is as though, because we are deemed
to share certain assumptions, these assumptions do not need to be questioned.
Bowlby’s work was one of questioning and deconstruction in the process of
theory making. He looked, he observed, he studied. He took apart things that
were taken for granted – sometimes the most obvious – and in recasting the basic
mechanisms of infant and child development as an attachment paradigm, he gave
us the means by which to see the signi¿cance of the early relational style between
mother and infant-toddler as indicative of the emotional security or insecurity of
the child and later the adult. Missing from Bowlby’s work (Bowlby 1969, 1973,
1980), but of interest to later generations who have found a resonance with the
attachment paradigm, has been attention to gender and the ways in which
conscious and unconscious apprehension of gender shape the mother’s self
experience and the ways in which she relates and attaches to children of different
genders.
Gender and infancy

Gender is not a given (Fine 2010; Hare-Mustin and Marecek 1990). It is a
psychological and social outcome of biological interpretation. A baby is anticipated
in gendered categories. There is no such thing as a non-gendered baby. There are
162 Susie Orbach
babies with male sexual characteristics, with female sexual characteristics and
with hermaphroditic sexual characteristics. The latter are commonly assigned the
more ‘appropriate’ gender at birth and historically ¿ngers were crossed that
secondary sexual characteristics of the opposite gender will not emerge at puberty
and that medical interventions to support the assigned gender will be relatively
trouble free.
It is well-nigh impossible to ask a new parent about the baby without reference
to gender. The conversation stops. Enquiries about the health and the weight of
the baby only take one so far. We need to know whether we are speaking of a baby
girl or a baby boy because sets of behaviours, attitudes, meanings, feelings and
expectations are unconsciously inÀuenced by gender. Without our recognising it,
the constructs of masculinity and femininity prompt us in both obvious and subtle
ways. These prompts always relate to the social, temporal, class and cultural
circumstances of what it means to be a girl or a boy. Just over a hundred years ago,
a boy would be dressed in pink and a girl in blue. Today we would ¿nd it hard to
dress the baby boy in pink (although it would be alright for the baby girl to wear
blue) and the reason is because, following the designation of gender, how we hold,
how we feed, how we potty train, the register of our voices, the fantasies we have
about how to treat the baby and relate to its well-being, depend on gender. Pink on
a baby boy transgresses the felt experience of gender. We are not used to it. It will
incline us to relate to that particular boy and his mother in a way that is out of
kilter to present cultural norms. It is not a neutral curiosity that he is dressed that
way. If or when we encounter this kind of ‘gendered’ discordance we come up
with explanations to explain it to ourselves.
Gender transmission is unconscious and conscious

On average, we breast feed boys for longer than girls (Belotti 1977). Each feed is
lengthier than for girls. Weaning is more gradual than it is for girls. Potty training
comes later than for girls. Holding is more frequent than it is for girls (Belotti
1977). These observable and the not so observable behaviours are part of the
attachment environment. They are not separate from it but are woven into the
very texture of relating. They shape the mother’s experience of her mothering in
explicit and subtle ways, inÀecting both her sense of herself and her sense of the
new baby to whom she is relating. Her conscious and unconscious feelings and
knowledge about gender are central to the mother–baby couple. Consider for a
moment, then, the emotional implications of the use of the word greedy in
relation to a hungry girl infant versus the use of the word eager in relation to a
hungry boy. These adverbs describe the infant’s appetites in ways that range
from a (mild-ish) criticism of the infant’s appetite to an embrace and enjoyment
of it. The word is not value free. Maybe the mother admires the girl baby’s
‘greed’. Maybe she fears for a daughter with a robust appetite. Most likely, she
will project on to her daughter feelings she has about her own appetite. These
will include her hopes and her fears which in themselves will encode the cultural
Bringing a gendered perspective 163
values seen to be intrinsic to femininity. Whatever the mother’s response, it is set

inside a matrix of familial and social beliefs that inevitably direct aspects of her
own femininity called forth by her conceptions of mothering. They form part of
the attachment nexus.
The transmission of attachment styles: from mother to

baby and from baby to mother
Feeding, holding and potty training are behaviours that are visible and easily
amenable to observation. If we reÀect on the often less visible gender-led
instructions that coalesce around issues of nurture, dependency, agency and
separation, we will see that these important aspects of development, so apparent
in childhood, adolescence and adulthood, have their roots in the very early relating
between mother and child. More on this presently.
The basis of secure attachment emerges out of the experience of having one’s
needs attended to in a relatively consistent manner. It involves being seen as an
individual – as both separate and connected to intimate others. The sense of being
an individual, that is to say, one’s own person, emerges from being recognised
and seen.
Recognition is the outcome of interpersonal relating. As one responds to and
initiates the various emotional and physical repertoires of infancy and early
toddlerhood, one inhabits a sense of being. Being seen and being responded to and
showing that one has been, make up the intersubjective ¿eld between the mothering
person and the baby. This interplay provides the basis of secure selfhood.
The nature of the relationship that is offered will come to constitute the
emotional bedrock of what organises the notion of ‘relationship’ in the baby’s
internal structure. The human infant is dependent on its caregiver and its own
idioms and desires will be honed in relation to those needs that the mother is able
to meet. Because the human infant is dependent outside of the womb for survival,
the baby is not able to turn away from the relationship with mother that to an
outsider looks negative and destructive. It cannot leave and ¿nd a more satisfactory
one. Even if it could, the journey from neonate to the kind of human being one is
going to be is formed through the relationship that is offered. If the baby
experiences a relationship which is negative and destructive, this will form part of
the baby’s developing sense of self. What the baby receives and what is received
back from the baby in the complex dialogue between mother and baby will be the
bedrock psychological foundation for the baby’s identity, its place in relation to
mother and it will form the template for future relationships.
Secure attachment
Attachment theory shows high correlation between a mother’s attachment pro¿le
and that of her offspring (Fonagy et al. 1995; Steele and Steele 2008). This makes
sense. The secure mother conveys con¿dence in her own being. She is thus able
164 Susie Orbach
to offer the baby a relationship of safety – one in which the baby will be accepted,
enjoyed and can thus thrive. The concerns of infancy – early feeding, sleeping,
walking and so on – are experienced as an aspect of mothering, not as a stimulus
to incapacity or extreme worry. The baby’s responsiveness to the mother reinforces
in the mother her sense of herself as an adequate mother. This is important. The
mother makes the baby and the baby makes the mother and they reciprocally
inÀuence one another’s emotional states.
Anxious attachment
The anxiously attached mother will ¿nd the needs of her infant more perplexing
and anxiety provoking. Out of her own history and the experience of being
attended to in an anxious manner, she will engage with her infant with a certain
hesitancy and nervousness and this in turn will be the emotional ambience that her
infant will absorb. The infant will then feed back this hesitancy and nervousness
to the mother, creating an emotional loop between them that is authenticated by
each of them through this felt sense of anxiety.
Avoidant dismissive attachment

The avoidant dismissive mother who is unused to close emotional contact in her
own emotional history may offer her infant a relationship that encodes this way of
being. She may treat the infant as though he or she were detached and should ‘get
on with it’, feeding, changing and putting the baby down in a mechanical manner.
Emotional dependency is refused and the mother–infant dyad is characterised by
missing and ambivalence.
Disorganised attachment
The disorganised mother, too, will convey in her actions and affect the jitteriness
which marks her relation to self and others. Her infant will know this as the
fundamental form of relating and it will imprint her own relation to self and be
part of what makes up the relationship between mother and herself.
All these different attachment styles2 show themselves in the therapy
relationship. They are an important dimension of the clinical situation and provide
useful information for the therapist and, in time, for the patient.
Culture and attachment styles

Woven into the attachment styles will be the beliefs and customs governing
gender (and other crucial social markings). Psychological femininity and
psychological masculinity become quasi material structures in the minds and
bodies of individuals.3 Just as babies are related to with reference to gender, so the
individual relates to her or himself with regard to the social practices of gender.
The question for psychoanalytic gender theorists is how the psychological forms
of being that signify gender are apprehended and played out.
We have seen that the very different treatment accorded to boy infants and girl
infants vis-à-vis feeding and potty training are an important aspect of gendering. I
have also suggested as an example that the language with which the child’s
appetite is described is gendered (there are many more I could use). How then do
the equally profound and deeply felt issues of dependency, autonomy, competition,
longing, envy, anger and sexuality, issues that are saturated by gender at many
levels (although perhaps not all), come to be enacted in the attachment relationship?
What is the primary parent or parental substitute doing in order to ensure that girls
become psychological girls and boys become psychological boys?
Girls have been historically raised to provide for the dependency needs of
others (Eichenbaum and Orbach 1982, 1983). This includes looking out for their
children and their intimate relationship as well as their parents. Boys have been
historically raised to provide for the economic shelter of others. In the old deal,
women looked after the men emotionally in return for the legitimacy of their
sexuality and for economic protection. While a woman’s activity was being a
midwife to the desires of others and she gained her sense of femininity in the
enactment of these behaviours, men were raised to be protective in a warrior-like
sense and to take on identities that encoded a narrative of the valiant, the
independent, the heroic.
While these stark realities have become muted, the vestiges of these gendered
imperatives continue, nowhere so manifest as in regard to issues of emotional
dependency. It is still the case that girls are directed to take care of the emotional
and dependency needs of others and to meet their own needs for nurture in the
service of caring for others (while appearing to be the dependent ones). Boys
meanwhile are still raised to expect that their dependency needs will be attended
to without them having to notice it, and that their sense of independence will rest
on the implicit knowledge that there is someone there for them (while appearing
to be need-free). While girls are schooled in the language of emotional initiative,
boys are schooled in the language of independence.
Girls and women bond together through identi¿cation and an af¿liative stance
that reaches for the common and familiar. Their sense of self is reinforced in
relationships of con¿rmation and empathy. Boys and men bond through
competition and challenge. They feel themselves to exist as boys and men as they
differentiate. While these descriptions may sound unre¿ned, they reÀect the felt
experience of femininity and masculinity today. This has signi¿cant implications
for heterosexuality, for girls’ and boys’ psychology, the psychological transactions
between women and men, for women and men’s sexuality, and of course for the
therapy relationship.
166 Susie Orbach
How can we make use of this in the therapy relationship?

The gender conscious therapist will observe that while women and men both
come to therapy in need, they show this differently. I am not making an argument
that disagrees with Bowlby, rather I am proposing that the forms of attachment
and the defence structures developed can additionally be seen through the gender
lens. For the therapist to ¿nd the words to enable the individual to understand the
ways in which their desires and motivations emerge is helpful. One does not say
to a patient: you are doing this because you are a woman and therefore you feel x.
Nor does one say, you feel this because you have a disorganised attachment.
Neither of these kind of statements would be therapy. However, it is helpful for
therapists to be able to understand gender phenomena that are woven into the
attachment paradigm. It is equally helpful for individuals to understand the
complexity of the ways in which their behaviours and desires are structured –
what they imagine they want, what gets in the way, the means by which they
inadvertently trip themselves up and so on.
In regards to women, there are a cluster of issues that come up frequently
whatever the speci¿cs of the attachment structure. These include: a fear of
dependency; a tendency to give to the other in ways that might be quite driven; a
dif¿culty with receiving and digesting the care and attention that comes towards
one; a hyper-criticality towards their own physical sense of self that negatively
affects sexuality and body acceptance.
These themes emerge in the therapy and they are often enacted within the
therapy relationship within the transference–countertransference dynamic. If one
is a woman working with a woman, one’s own identi¿cation with these struggles
needs to be addressed in supervisory and seminar settings so that there is not an
unconscious collusion with the dif¿culties that are being presented (Eichenbaum
and Orbach 1982). When we started The Women’s Therapy Centre three and a
half decades ago, it was noticeable how, after about six sessions, women would
say that they felt so much better and that they were ready to stop therapy. This
sentiment was accurate on many levels but the persistence with which it emerged
encouraged us to reÀect. In our study groups, we came to understand that this was
almost like a built-in protection – a defence – against a woman’s longing for
attachment and dependency. The dilemma was that having felt listened to – which
went against her experience – she felt compelled to put a lid on her desire for
contact. The wish to stop came from fears of being too vulnerable, too much in
need, too attached. Engaging with this issue and being aware of the tendency
towards collusion with the woman’s disdain and reluctance around her dependency
and attachment needs, as well as her longing for that attachment and the dif¿culties
with acceptance, was and is crucial. It opens the way to productive therapies
(Orbach 1990; Orbach and Eichenbaum 1986).
If one is a man working with women, a different but equally collusive aspect
may be evoked in relation to the woman’s hesitancy about dependency. Men can
be as uneasy as women about women’s dependency needs. They may concur with
the patient’s criticism of her own longings as being ‘too needy’ and read the
defence as the real issue instead of understanding it as the woman’s unconscious
fear of her own desires for deep attachment. Beyond this, the therapist may not
understand the dif¿culty with receiving that can be a challenge. In the absence of
being able to receive, women can become caught up in giving and in reassuring
the therapist how well he is doing. This points to another aspect that the male
therapist needs to be alerted to: the woman’s tendency to divert away from her
own conÀicts and desires. For a male therapist to notice and challenge his own
gendered prejudices is important.
If we turn now to the ways in which masculinity is woven into attachment,
then we can address the issues that need addressing in general in the therapy. The
gendered prejudices that are brought to masculinity are no less troublesome than
those brought to femininity and it is important for therapists to be aware of the
gendered expectations they carry and the ways in which these can ill service their
patients. A common issue for men in the initial stage of therapy is hesitancy with
showing their emotions, but when they are encouraged to do so, there is little
reluctance to staying in therapy. Their dif¿culty is with the premise of a process
that is not immediately solution based. It is not that men need to be coaxed into
being helped, but sometimes there is a need for a form of psycho-education in
which the links between feelings, behaviours and repressed conÀicts require
explication in order for the man to feel suf¿ciently comfortable to make use of
the therapy.
Men can also disdain attachment needs. They may do this through Àirting in the
session, by showing a strength that is supposed to nullify need and, commonly, by
making their own needs to be about the other’s neediness (often ascribing them to
their sexual partner). Teasing out and endeavouring to enable the individual to
recognise his own needs for attachment and dependency can be an important
aspect of the therapy. This may mean receiving them in the therapy relationship
and helping him to risk the recognition of his desire for attachment. This is a
tricky process. Part of socialisation, and woven into the attachment pattern towards
boys, is that a boy’s/man’s needs will be met (by a woman) without them being
exposed. The attention to men’s emotional states is something that can happen
surreptitiously – I do not mean this in an underhand sense but in the sense that
women feel it to be essential to their own identity to look after others, and attending
to men/boys is part of that. Thus, a man may not know about his attachment and
dependency needs unless they are not being met. If he has suffered the loss of a
partner or a relationship is in dif¿culty, the withdrawal of the other can highlight
the importance of an attachment/dependency need that boomerangs back on him.
When these needs land back they can be quite frightening, for the man may not be
accustomed to them. This is in distinction to the woman, who knows and is
frequently ashamed of these needs in herself.
Delicacy is required on the part of the therapist. Male therapists have to work
hard not to share the prejudices of the man who may scorn the needs that now
beset him. And women therapists have to work hard not simply to meet them but
168 Susie Orbach
to address with their patient how he can acknowledge this important aspect of who
he is. Meeting them in the therapy relationship without discussing what is
occurring reproduces the original disavowal and does not enable a man to feel a
con¿dence about his own acceptance of his needs.
Summary
In this chapter I am highlighting in general terms the differing ways attachment
needs can emerge, can be missed and can be addressed in therapy. Of course
there are many subtleties to the ways in which attachment and gender play out
and the manner in which the attachment and gender binaries occur within couples
(hetero- and homo-sexual couples) other than the therapeutic couple (Orbach
1993, 2007). My aim in this chapter has been to remind us of how profoundly
gender shapes our deepest sense(s) of self and our relation to others, and the
consequent shape of our defences against the most private longings and needs for
attachment that humans carry. In paying attention, rather than skirting over such
defences, we enable ourselves and our patients to enter into a deeper humanity in
which, instead of disavowal and shame, the recognition of attachment can be
known, held and acted on.
Notes
1 I use the term mother to describe the primary relationship between caregiver and child.
This person is most commonly female whether she is the mother, grandmother, nanny or
other substitute. Obviously there are extremely interesting consequences for the
emotional impact of gender when children are reared by two parents and the gender of
these parents will affect the attachment milieu in profound ways. This chapter restricts
itself to the impact of gender when the primary parent is a woman.
2 Of course for most people relational structures are not neatly packaged but contain
elements of perhaps two or more categories; nevertheless, they are a useful grid.
3 Obviously in some cases these are actually material but I use the term to describe the
obduracy of felt experience that structures the individual’s experience of being a girl or
a boy, a woman or a man.
References
Belotti, E.G. (1977). Little Girls. London: Writers and Readers.
——(1973). Attachment and Loss, Volume 2: Separation: anxiety and anger. New York:
Basic Books.
——(1980) Attachment and Loss, Volume 3: Loss: sadness and depression. New York:
Basic Books.
Eichenbaum, L. and Orbach, S. (1982). Understanding Women: a feminist psychoanalytic
approach. London: Penguin Books.
——(1983). What do Women Want? London: Michael Joseph.
Fine, C. (2010). Delusion of Gender. New York: Norton.
Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G. and Target, M.
(1995). The predictive validity of Mary Main’s adult attachment interview: a
psychoanalytical and developmental perspective on the transgenerational transmission
of attachment and borderline states. In S. Goldberg, R. Muir and J. Kerr (eds), Attachment
Theory: social, developmental and clinical perspectives, pp. 233–78. Hillsdale, NJ: The
Analytic Press.
Hare-Mustin, R.T. and Marecek, J. (1990). Making a Difference: psychology and the
construction of gender. New Haven: Yale University Press.
Orbach, S. (1990). Gender and dependency in psychotherapy. Journal of Social Work
Practice 4, 1–15.
——(1993). Women, men and intimacy. In C. Clulow (ed.), Rethinking Marriage: public
and private perspectives. London: Karnac.
——(2007). Separated attachments and sexual aliveness: how changing attachment
patterns can enhance intimacy, Attachment 1, 8–17. (Reprinted in C. Clulow [ed.], 2009:
Sex, Attachment and Couple Psychotherapy: psychoanalytic perspectives; London:
Karnac).
Orbach, S. and Eichenbaum, L. (1986). Separation and intimacy: crucial practice issues in
working with women in therapy. In S. Ernst and M. Maguire (eds), Living with the
Sphinx. London: The Women’s Press.
Steele, H. and Steele, M. (2008). Early attachment predicts emotion recognition at 6 and 11
years. Attachment and Human Development 10, 379–93.
Chapter 12
Attachment in African
Caribbean families
Lennox K. Thomas
Understanding attachment behaviour and its role in the life cycle is important
when working across cultures. This chapter focuses on therapeutic work with
people from Caribbean communities and what needs to be considered when
using attachment theory. Beginning with the history of attachment and loss, the
chapter moves on to consider mental health in Caribbean communities. A case
study of a Caribbean man is used to identify attachment based practice. Being
without ethnic frontier, attachment theory is useful if we can understand its
adapted styles in different communities. Studies conducted by Ainsworth (1967)
in different countries with a variety of parents and infants from different cultural
backgrounds focused on child-rearing styles and attachment. From studies in
Uganda and the USA, Ainsworth developed and categorised the Attachment
Styles – Secure, Avoidant and Resistant/Ambivalent – on the basis of how the
infant responds to a series of separations and reunions with their mother. Main
and Weston (1982) and Hesse and Main (2000) later described the category of
infants who displayed a Disorganised attachment style. Despite the establishment
of these ‘cross-cultural’ systems of classi¿cations of individual differences in
attachment, observations of caregivers and infants have demonstrated a range of
different attachment behaviours and caregiving practices across cultures,
including multiple caregiving and the suckling of other mother’s babies (Marvin
et al. 1977). In an interesting study based on attachment patterns in the USA and
Japan, Rothbaum and colleagues (2000) consider the cultural difference that
skews ¿ndings in attachment research. The authors found that descriptors such
as autonomy and independence are linked to Western individualism, which
would affect the lens through which attachment theorists see behaviour.
Attachment theory, they believe, is infused with Western assumptions. Whilst
attachment is a basic human behaviour, adaptation is dependent on cultural,
economic and social factors (Thomas 1996). In order to work effectively across
cultural and ethnic boundaries, a close view of the context is therefore always
important.
Attachment in African Caribbean families 171
A history of broken attachments

It would be dif¿cult to have a discussion about psychological treatment of
Caribbean people without talking about attachment separation and loss. The
region has a long history of separations and the breaking of family bonds. Without
the context of their enslavement and the patterns that developed during that time,
such as the separation of men and women and the anonymous fathering of children,
there will be little understanding of current family structure.
Basically, the system used separation of mothers from their babies, of loving
couples from each other, as a conscious and unconscious method of creating
anxiety, depression and hopelessness. Under this system the development of
togetherness in families was foreclosed.
(Fletchman-Smith 2011: 49)
People of the colonies had taken up arms to defend the empire during both world
wars. After the Second World War, West Indians were asked again to assist the
mother country in peacetime by the ministry of labour recruiting in the West Indies.
This led to large-scale postwar separations. The novelist Andrea Levy (2004) charts
the movement of a young Jamaican couple in her book Small Island. Like many
young people they saw their opportunities in the United Kingdom for work, a new
life and support for their families back home. Some parents did not expect to stay
away for long, having left spouses and children behind. Many children saw their
mothers leave to join dad and, in time, these children would leave grandparents to
join their parents in the United Kingdom (Arnold 1975, 1997; Feldman and Marriott
1969). These separations seem to have been accepted as a way of life and echoed
plantation separations. The children of Windrush parents who arrived between the
late ¿fties and the sixties were separated from all that was familiar to them and in
many cases faced dif¿culties. One might ask how this history relates to attachment
and the lives of people that are now seen by therapists and social workers.
Whilst the patient’s collective history of separation might be an unpleasant truth,
keeping it outside the scope and boundaries of therapy will not help their emotional
development. Tracking family patterns of broken attachments is important in order
to help them to understand what might have been set up for them long before they
were born, and which they are at risk of repeating. Separation is a big part of
Caribbean history and this became something to which the people of the region
were desensitised. The harshness of attitude to separation and loss came to be seen
as strength because to really experience such loss would destroy the soul. Being
able to support a family often meant leaving its youngest and eldest members
behind. Reunion of these families was generally smooth but some children had
dif¿culties settling down with their parents. Eve, a former patient, described
meeting with her mother at a UK airport after a separation of six years. Eve was
told that it was her mother, but she had been convinced that when the ship with her
mother on board had disappeared off the horizon in the Caribbean Sea, her four-
172 Lennox K. Thomas
year-old mind told her that the ship had sunk. This lady who was hugging her at the
airport in London must then have been a new mother whom she and her sister came
to refer to as ‘the lady’. It took some weeks for them to be convinced that it was the
same mother with whom they had had a loving relationship and whose leaving was
experienced as a death. This young girl settled well and was able to recognise in the
lady the loving aspects of the mother who was a distant memory to her.
Not all reunions went well and many children who joined parents at a later age
had greater dif¿culty making a loving connection. Some could not accept the
authority of people they hardly knew and demanded to be sent back home to their
grandparents. Many people had lived with parents in extended family groups, so
young parents who had left children behind hid their pain of separation by putting
a brave face on it, assured that their children were in the safe care of their
grandmothers. That they were missed and loved was not often shared with the
children who arrived from the Caribbean, because parents had often found it
dif¿cult to revisit their emotional partings from them. Feeling unwanted and not
thought about in their absence led in turn to these young people keeping their
feelings of hurt to themselves.
The mass evacuation of British city children during the Second World War and
the emotional dif¿culties experienced by both mothers and children seemed to
merit study. Prompted by the work of Bowlby, James and Joyce Robertson and
Claire Winnicott, a study was conducted by Elaine Arnold (Robertson) (1975)
with young Caribbean children who came to join their parents in the United
Kingdom. Dr Arnold followed up cohorts of these children as they moved into
adulthood, parenthood and now grandparenthood (Arnold 2012). When breakdown
in these relationships threatened the fabric of the family, many older children
were accommodated in children’s homes. With hindsight, social workers might
not have been so ready to take these children from their families without some
attempt at addressing the problems and trying to repair the fractured relationships.
There had been a variety of reasons for dif¿culties; in some cases there were new
young siblings born to parents in the UK. Some children were unable to engage
because of the loyal bonds they had developed with grandparents and were afraid
of risking this through closeness with parents in the UK. Others could not cope
with the change of circumstances and came to see their parents as preventing them
from returning to their beloved grandparents. Because time had lapsed, and in
some cases parents separated under the strain of being in the UK, children came
to a step-parent who they did not get on with.
Children’s institutions presented them with a culture shock and differed
considerably from the almost Victorian system of order and physical discipline
that many were accustomed to in the Caribbean. In many cases institutional care
further served to distance these young people from their family, because they
often absorbed the attitudes and customs of those around them. In some cases
incurring a third or fourth separation, some of these young people became closed
off emotionally or volatile and unhappy about the way they felt treated. This
degree of separation and loss is traumatic but was not always recognised and not
appropriately dealt with by the social care and probation services. Post Traumatic
Stress Disorder as a result of multiple separations, and its contribution to family
breakdown, was not entirely understood.
Mental health and Caribbean communities

There were many factors that contributed to mental ill-health in the new migrants
from the Caribbean. In addition to the many social problems, there were the
dif¿cult messages of racism and feeling unwanted in the cold mother country.
Children were equally exposed to these harsh experiences. On beginning school
many Caribbean children were assessed as educationally subnormal (Coard 1971).
At a later date in the United Kingdom black professionals questioned the degree
to which racism played a part in the diagnosis of subnormality in Caribbean
children. Bernard Coard began the debate in 1971 about the cultural biases in
psychological testing and how this played against black children. This is explored
in the publication How the West Indian Child is made Educationally Subnormal
by the British School System.
The issue of racist attitudes among white British professionals had not yet been
considered as a factor in the labelling of black children, which was coupled with
issues of the children’s identity and self esteem. In the United States, however,
African American psychologists were commissioned to study identity issues in
school children, and racial prejudice featured highly in this (Clarke and Clark 1947).
This study was later conducted in the United Kingdom by Davey and Norburn
(1980) in a similar enquiry about children in British schools. The ¿ndings of these
studies seemed to ask many questions about the prevalence of prejudiced attitudes
among school children, absorbed from the society around them. An important
outcome was the question of the degree to which black children had internalised
negative self identities and how false self issues had affected them. If developing
attachment relationships is a lifelong activity and children move into trusting
relationships outside the home, how does racism affect this? In a society that can be
openly discriminatory, how does this locate black children in relationships outside
the home, in the nursery or school? Some black children employed a ‘proxy self’
for psychological protection against racism in their dealings with white people in
order to secure a sense of themselves. Assuming a false self-presentation as
described by Winnicott (1964/1986), they could get by in the short term, but this
could ultimately lead to psychological splits, incurring later damage (Thomas
1995). Whilst identi¿cation by proxy can be a useful childhood defence that affords
the child some ability to function, the inability to separate this from the real self can,
as Winnicott indicated, lead to mental health problems in adolescence and adulthood.
Both GPs and school psychological services were reluctant to refer black people
for therapy and many were treated with anti-psychotic medication or were
sectioned under the Mental Health Act. Littlewood and Lipsedge (1997) had
found from ¿gures collected in 1977 that West Indian men and women were more
than two and a half times more likely to be admitted to hospital for schizophrenia
than people of English and Welsh backgrounds. Eaton and Harrison (2000) found
this ¿gure to be between two and eight times more likely in parts of the United
Kingdom. The over-representation of Caribbean people in the mental health
statistics led to suspicions of discrimination. Black people’s mistrust of the
medical establishment was at its height after the exposure of the Tuskegee syphilis
experiment (Jones 1981). In order to understand the progress of the disease,
medical practitioners left over 300 African American men untreated without their
knowledge for over forty years. Consequently many died, wives were infected
and children born with congenital syphilis. That such unethical practices should
be conducted with white subjects was unthinkable to many. Other debates into the
1980s about intelligence and black people maintained suspicion of white
psychology. The effect of racism and discrimination in the UK, and other issues
they met with, played their own part in the dif¿culties faced by some families.
From research in the early eighties, Kareem and Littlewood (1992) identi¿ed
dedicated intercultural psychotherapy and counselling services that showed
promising results (Acharyya et al. 1989). Prior to Kareem’s work there had been
little interest in the poor showing of ethnic minorities in psychotherapy and talking
therapy in the United Kingdom. Psychiatrists Burke (1984) and McKenzie (2006)
have considered that the experience of racism and the daily grind of stress play
some part in the high numbers of African Caribbean people presenting with what
appear to be serious mental illness. The provision of culturally sensitive
psychotherapy played an important part in prevention and recovery for some of
these patients. Separation and broken attachments are an unmentionable truth in
the history of African-descended people and its ubiquity is such that it has gone
unrecognised for many years. Repeated separation and loss as a result of migration
might have impacted on psychological wellbeing (Thomas 2010). Understanding
attachment behaviour is not only important for understanding its role in the
patient’s life cycle but also for understanding affective responses to loss.
Using attachment theory

Before Bowlby’s (1951, 1958) observations of what took place between infants
and their caregivers, Melanie Klein (1951) had moved the locus of interest in
psychoanalysis from a one- to a two-person psychology. Seeing the patient in
relationship to another and being interested in the context of the developmental
history widened the scope for therapy.
Technique used in attachment therapy has been developed for use in all
relationship-based therapies, with individuals, couples and families. The practice
of attachment based psychotherapy is relatively new and has come about in the
light of developmental ¿ndings by attachment specialists and the work done by
psychotherapists on early development such as Winnicott (1960), Spitz (1945),
Fraiberg (1980) and latterly, relational psychotherapists.
From neuroscience, Schore (2002) teaches about the importance of reciprocal
bonds between infants and their primary caregivers, which act to ‘switch on’
important brain functions for the baby. Early bonding with babies begins before they
are born and develops with feeding, holding and attunement to the babies’ cries.
Infants in secure attachment relationships with caregivers have pre-verbal
‘conversations’ with them that help with the co-construction of their personality and
with their ability to make sense of the world around them. This is part of their lifelong
quest for understanding others, themselves, and themselves in relation to others.
Beyond the biologically determined need of bonding for survival, the infant’s
connection with its primary carer cements their relationship and is the ¿rst
opportunity for the child’s learning. Generally, families transmit attachment and
child-rearing styles and, of course, this is set in a cultural context. Therapy is
relationship focused and lends itself well to the work of social workers,
psychologists, psychotherapists and others. Attachment based therapies do not
just rely on making what is unconscious conscious, but endeavour to repair the
individual’s relational systems that might have led to dif¿culties in their emotional
or psychological functioning. The experience of the therapist as an accessible,
sympathetic ¿gure will be helpful to the patient in engaging with their past and the
process of change. Transference and countertransference resemble an object
relations use of the concepts, covering the broad span of both the patient’s
developmental and contemporary relationships.
The following case explores the dif¿culties that arose between a teenager and
his mother when he came to join her in the United Kingdom after a separation of
nine years. Steve had been in the care of his parents and grandparents until he was
left in the care of grandparents at the age of three years. The case illustrates the
usefulness of the attachment skills employed by the psychotherapist in helping the
patient to deal with his despair and isolation. He began therapy after developing
mental health problems many years later.
Steve, a very formal 42-year-old hospital lab technician, came to therapy. His
depression had resulted in absences from work. He was given sick leave and
the phone number of a therapy organisation by human resources. Suspicious of
therapy, he felt that it was important to attend because he was sent by work.
He told Jan, the therapist, that he had recently separated from his partner and
children and had experienced a death in his family. Steve began to tell his story
to Jan. He was born in the Caribbean to professional parents and raised by
paternal grandparents when his parents left for the United Kingdom. He said
that he had a good life, enjoyed school, church and the small town life. He
remembered that his mother arrived one day to take him to England when he
was 12. His grandfather told her that he needed permission from his son to
allow this to happen. It was a very unpleasant incident and it was not until that
point that he learnt that things were not good between his parents. He made
his reluctant farewells two days later and said that his ‘first’ meeting with his
mother gave him the impression that she was an unfeeling person. In
London he met a younger brother, an infant sister and a new father. A capable
student, he settled well in school and he got on well with his stepfather, who
played cricket and took Steve with him to matches. He was not happy to be in
England and wanted to go back to St Vincent. When Steve was 16 his grandfather
died and he felt a mixture of sadness and anger. He had an argument with his
mother and she threw him out of the home. Steve slept in the park for several
nights until a friend’s parents allowed him to stay so that he could complete ‘O’
levels. After 18 months he left the Gilberts, shared a flat for some years and
attended night school. He had become very close to the Gilberts who had
taken him in and was very affected by the death of Mr Gilbert just a year before
he began therapy. He was never reconciled with his mother but secretly saw
his step-brother, who had attended school a short bus ride from Steve’s place
of work. At 26, Steve moved in with his girlfriend and they had two sons. For
many years until he left the home he found that he and his girlfriend were
incompatible. His depression and loneliness had grown in these past few years
and he moved into a studio flat. Jan realised quite early in her work with Steve
that he had numerous losses and broken attachments in his life and wrote a
formulation along these lines.
Progress of the therapy
Steve came to therapy because he had been isolated and depressed, his
relationship had broken down and he had lost someone a year earlier who had
been in a fatherly role to him. He had not made connections with his separations,
lost relationships and his general distress. His referral was to a service that was
well known for working with black and ethnic minority patients. He settled
well with Jan, his white female therapist, after an uneasy start. Steve was asked
if he had a preference of gender or ethnicity of therapist. He said that he had
none, but he was surprised that he was not given a Black or Asian therapist.
Never openly questioning her ability to help him, Steve was just cautious in the
early sessions with Jan. He was very aware of Jan’s whiteness and wondered
both about her degree of experience and knowledge of working with Black
people and about how racist she might still be. It was only after she asked him
about his relationships at work and whether or not he had any difficulties with
racism from colleagues in the past, that he decided she was an ‘OK person’.
This acknowledgement helped Steve to feel appreciative of his therapist and
helped him to begin to explore his past relationships.
Steve was cared for by his grandparents. He knew that his parents lived in
London but their absence did not have a great deal of meaning to him and he
did not remember the event. He felt loved, and was happy with his life in St
Vincent. On arriving in London, Steve felt that his mother expected him to be
grateful for giving him a new life in England. He regretted not making it difficult
by crying or refusing to leave his grandparents. He wondered if it was his
curiosity about London that had made him comply with the arrangements that
left such a hole in his emotional life. He said that after leaving the Caribbean he
was never hugged and nobody wanted to know how he felt. His mother, he
said, had no time for him and his father, who lived not too far away, made little
effort to have a relationship with him. He felt that his stepfather took an
interest in him but he could not comment on his mother’s decisions in the
home. He said that coming to England was the worst thing that had ever
happened to him. He later came to understand that leaving his grandparents
was his second broken attachment. Jan told Steve that he seemed to have lost
trust in relationships with others and had increasingly found it difficult to let
people into his life. He agreed, saying that he had learned to be a self-sufficient
person over the years but was not always this way. Jan explained that sometimes
being in therapy might feel uncomfortable and he might feel that she was
intrusive because he had become so self-reliant.
Being taken in by his friend’s parents was a very positive experience for
Steve and the death of Mr Gilbert had affected him in an unexpected way. He
described the family, their two sons and daughter as loving and warm. Steve
wondered what it was about his family that made them so very different from
the Gilberts, who were also a Caribbean family. They were affectionate, jolly
and interested in what their children were doing at school. He said that his
recurrent dream since coming to England, of rushing to catch a plane or train
only to see it pull away, had gone away whilst living with the Gilberts. Steve had
not been able to understand this dream, which always left him feeling sad on
waking and recalling it. From his work with his therapist he came to understand
this as a preoccupation with loss. Jan had avoided making interpretations and
waited to understand the feelings that dreams evoked in Steve. Mrs Gilbert had
encouraged him to keep in contact with his family and was keen for his mother
to ring. Steve said angrily, ‘Not once did my mother ring to check that I was
OK, or how my exams went’. He believed that his mother was more affectionate
to the younger children, but from his contact with his brother learnt that she
continued to rule with an iron fist. He said that he could never understand his
mother, as if she was unreadable, and that when she looked at him she saw
someone else.
Jan and her supervisor were left to speculate on Steve’s early attachment
with his mother. After she left the Caribbean he seemed to have had a secure
relationship with his grandmother, she was an early attachment figure. It is not
uncommon in some communities, particularly in developing countries, to find
examples of multiple attachments (Thomas 1996). Infants in these circumstances
have their needs met by more than one member of their household or kinship
group. This evolved style, developed centuries earlier in human development,
was clearly important during the period of enslavement for survival of the
infant in the event of permanent separation or maternal death. Steve had
become attached to his grandparents with whom he had an uninterrupted
relationship until reluctantly leaving them at 12.
Steve came to a session and said that he realised that all that had happened
to him had made him unhappy. He said that his emotional state had left him
stuck in a corner and he could not respond to his partner’s kindness and
warmth. He feared that his unhappiness might be passed on to his sons and he
did not want them to live with the emptiness that he felt. He wanted to get
better and to be more involved with them. Steve’s description of being stuck
in a corner reflected his temporarily lost ability to self-sooth. Jan’s constancy
enabled him to work through the difficult feelings of abandonment and rage. As
well as her reliable presence, Jan provided Steve with a sounding board for
feelings that he had dared not express before. The therapeutic relationship is
unique, co-constructed, and is a foundation to engage with what will take place
in the therapy. Childhood incidents, or emotional wounds that could not be
understood or thought about, can be powerfully enacted in therapy (Wallin
2007).
From his good relationships with his grandparents and the Gilberts, it
seemed that Steve had been capable of secure attachment. Jan took care to be
an emotionally available person in order to help him to talk about those first
months in London when he so missed his grandfather and grandmother. Loss
of Mr Gilbert was experienced as twofold, echoing the loss of his grandfather
and the row that led to his leaving home. Jan helped him to construct a coherent
narrative out of confusing and damaging experiences in his life.
Indications of attachment issues do not only rely on the fact that the patient has
problems making and keeping relationships, but also having false self presentations
(Winnicott 1960, 1964/1986). ‘Ego distortion in terms of true and false self’
describe what happens when there are problems with very early bonding and the
infant gives up on getting what they need and develops a caretaking part of
themselves. Whilst this can be an indicator of very early disturbance in the
developmental relationship, it is more likely to be observed in the patients with

avoidant dismissing attachment styles. This was not an aspect of Steve’s early
life; his withdrawal occurred later in his life when he had bricked up his feelings.
His ability to engage well with Jan offered some corroboration of her view that
Steve had experienced a secure early relationship. Jan was very aware of working
at Steve’s pace to avoid the risk of him leaving therapy to regulate emotional
proximity to her. For the ¿rst time he was able to ask somebody what it was about
him that made him unlovable to his mother and father. As a secure base, Jan was
able to help him to explore his past to ¿nd an understanding of the course his life
had taken and the relationships that have shaped it. After some time, Jan was able
to ask Steve if his mother had ever spoken to him about how it was for her to have
left her three-year-old son behind in St Vincent. He replied that neither one of
them ever made reference to their leaving, but both behaved as if it was he who
had left her.
With attachment problems, the therapist is actively involved in helping the
patient to restructure their proximity to others. With the alleviation of his
depression and improved relationships, therapy helped with the modi¿cation of
Steve’s internal working models. The therapist becomes an important ¿gure by
picking up a similar role previously occupied by primary caregivers. Through the
experience of a good therapeutic relationship, the patient will begin to resume
some functions of self-care and self-soothing, following the cues of the therapist.
From this position Steve was able to repair his relationships. He had made good
progress in his therapy and was able to return to work to deal with his losses and
to re-establish good relations with friends and his children, and develop an
appreciation for his former partner.
Conclusion
Attachment based psychotherapy is a relatively new therapeutic modality with
adults and families. The value of this approach lies in its ability to trace problematic
relationship footprints in families and to help patients to consider their options to
repair and not repeat. Professionals who have closely observed infants will attest
to the importance of good early attachment. A child’s bond to its parents is
important to it, as we have frequently seen in child protection cases where abused
and neglected children will repeatedly give their parents chances for them to get it
right. It is important for professionals and policy makers to make the connection
between early parent–child relationships and adult psychopathology. Working
therapeutically can help in many ways by assisting the patient to connect up
problems from early life with adult relationships and functioning. Attachment
techniques in therapy lend themselves well to working with family relationships
and what happens between family members over several generations. In the case
of Caribbean people, this poses a particular challenge to mental health
professionals. Change would entail remembering and discovering generations of
damaging separations and loss. People of African descent from the Americas and
the Caribbean have endured signi¿cant trauma and survived. The cost of survival
has been signi¿cant not only to individual wellbeing but also to the group as a
whole, and different challenges face each generation. Therapists and clinical
social workers in the USA have been drawing attention to how help can be
provided for those caught up in the cycle of social failure. Many of the social and
psychological problems of black people often represent the maladaptive behaviour
of a people who are still in the process of surviving the pernicious effects of
slavery. Working with attachment and loss will help patients from Caribbean
backgrounds to appraise present problems and relationships, and how these have
been affected by past family attachment styles. Professionals are required to be
suf¿ciently trained and skilled to recognise traumatic loss or attachment disorder
that has been transmitted from one generation to another. By breaking these
damaging patterns, therapeutic work can help to prevent dif¿cult relationships
from blighting the lives of future family members.
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Chapter 13
Meeting the mental health

needs of older adults using the
attachment perspective
Cecilia Yee Man Poon
Attachment theory has been recognised as a relevant conceptual framework for

clinical practice with older adults for more than a decade (Bradley and Cafferty
2001). Clinical work with older adults may be informed by the attachment
perspective for several reasons. Firstly, theory and research have both emphasised
the enduring and powerful impact of attachment across the lifespan. Secondly,
late adulthood is ¿lled with experiences of separation and loss that may activate
the attachment system. Finally, attachment security is associated with better
psychosocial adjustment among older adults. This chapter illustrates how the
attachment perspective may inform geriatric mental health care. A brief review of
attachment across the lifespan is followed by a discussion on how attachment
inÀuences the treatment process. Speci¿c aging-related challenges are presented
to illustrate the usefulness of the attachment perspective when working with older
adults and their caregivers.
Attachment across the lifespan

Bartholomew and Horowitz (1991) conceptualised four attachment styles along
two continuous dimensions of anxiety and avoidance: secure, dismissing-avoidant,
preoccupied-ambivalent, and fearful-avoidant. With low attachment anxiety and
avoidance, secure older adults may possess more psychosocial resources, such as
greater self-esteem and effective help-seeking skills, to cope with stress. Dismissing
older adults low in anxiety and high in avoidance may minimise their attachment
needs and be overly self-reliant. Preoccupied older adults high in anxiety and low
in avoidance may be excessive care-seekers. Fearful older adults high in both
anxiety and avoidance may withdraw from others due to fear of rejection.
Despite some methodological limitations, a growing body of research supports
Bowlby’s claim that the inÀuence of early attachment may last ‘from the cradle to
the grave’ (1969/1982: 208). For example, individuals who were separated from
their families or experienced poor family nurturing in childhood because of World
War Two were more likely to report an insecure attachment style in late adulthood
in a British sample (Rusby and Tasker 2008). Although research suggests that
attachment styles are quite stable in adulthood, some aging-related and cohort-
184 Cecilia Yee Man Poon
based differences have been observed. In a community sample of young adults

aged 18 to 34 and older adults aged 60 to 94, older adults were less likely to report
a fearful or preoccupied style compared to younger adults, possibly because of
better emotion-regulation in late life and social norms that discourage the
expression of negative emotions among earlier-born cohorts (Segal, Needham and
Coolidge 2009).
Regardless of one’s prevailing attachment style, the attachment system is more
likely to be activated in times of perceived threat (Bowlby 1969/1982). Many
individuals in old age will experience the threat of losing their functional abilities
or their loved ones due to illness and death. Instead of regarding the ensuing
emotional turmoil and interpersonal dif¿culties merely as signs of personal defect
or pathology, the attachment perspective can help frame these problems as
manifestations of a universal need for proximity to protection and care in times of
distress. Rather than encouraging an absolute reliance on oneself and treating the
acceptance of help from others as a sign of weakness, the ability to trust and to ask
for assistance are considered to be indicators of secure attachment. By framing
older adults’ increasing dependency in a positive light and legitimising their
attachment-related concerns, interventions informed by attachment theory may be
less stigmatising and more appealing.
Despite having a weaker inÀuence on psychotherapy outcomes among older
adults than with younger adults (Levy et al. 2011), attachment style continues to
be an important concept in treatment because of its association with various
psychosocial outcomes in late adulthood (Bradley and Cafferty 2001). In one
study, Israeli older adults with secure attachment reported less ageism against
themselves and better quality of life (Bodner and Cohen-Fridel 2010). In an
ethnically-diverse sample in the United States, the positive impact of emotional
support was much stronger among securely-attached older adults (Merz and
Consedine 2009). Therefore, by examining older clients’ attachment history,
beliefs, behaviours and needs as part of the intervention, therapists may promote
better psychosocial outcomes in late adulthood.
Therapeutic relationship as a foundation of treatment

The attachment perspective brings to light the interpersonal dynamics between
therapists and their older clients, thus allowing the therapeutic relationship to be a
powerful stage for their respective attachment styles to play out and engender
change. An awareness of ongoing attachment processes in older adults, family
members and treatment providers may strengthen the therapeutic relationship at
every stage of treatment, sustaining older clients’ willingness to remain engaged.
Conceptualisation
Older adults who are referred for mental health treatment often have a myriad of
concerns that are not explicitly interpersonal in nature, such as recurring panic
Meeting the mental health needs of older adults 185
attacks post-surgery, or depressive symptoms associated with physical disability.

When therapists decide to formulate a case from the attachment perspective, they
have to evaluate how the presenting problem is related to themes of separation,
loss and dependency; how one’s internal working model of self and others, and
existing attachment behaviours, may contribute to the problem; and how one’s
attachment is shaped by past and current relationships within a speci¿c
sociocultural context.
Assessment
To establish rapport, therapists may intersperse the assessment process with
empathic validation of their older clients’ distress and psychoeducation on the
basic tenets of attachment theory. For example, an older client stepped into the
¿rst session expressing a desire to acquire coping skills to manage her health
problems but spent most of the time venting about her daughter. The therapist
reÀected on the client’s concerns and gently moved towards an assessment of the
client’s attachment history:
‘Major illnesses often make us feel vulnerable and helpless. It is only normal
that you want someone to reassure you that you will be cared for. What seems
to upset you the most is that you don’t believe you’re getting any support
from your daughter. You feel that the more you call, the less concerned she
sounds. I understand that you’d like to learn to cope with your illness. For
many people, social support is an important coping resource. I wonder if you
could tell me how you’ve coped with situations that made you feel vulnerable
in the past, and whether someone was there to support you …’
Some clients have been ignored or rejected by their attachment ¿gures when they
expressed their emotional needs. By acknowledging the legitimacy of older
clients’ concern and normalising their desire to be protected, therapists may
nurture a different kind of attachment experience in the therapeutic relationship.
An assessment of the attachment style of older clients’ current attachment
¿gures will also inform treatment. Preoccupied clients may have a greater need
for support from their attachment ¿gures. Their constant need for reassurance may
create a much bigger challenge with a dismissing spouse. Conversely, dismissing
clients may be less aware of their partners’ emotional needs and become frustrated
if they have to deal with someone who demands excessive reassurance. Although
the attachment style of older clients’ signi¿cant others may not be the focus of
intervention in individual therapy, clients will bene¿t from psychoeducation on
how attachment style inÀuences behaviours in relationships. Clients may come to
appreciate the common and intrinsic need for safety within them and their partners,
in spite of differences in their overt attachment behaviours. They may develop
greater empathy for their signi¿cant others and become more ready to adapt
accordingly.
Sociocultural considerations
Older adults’ beliefs and behaviours are shaped by their sociocultural experiences,
which may in turn inÀuence the treatment process (Knight and Poon 2008). The
activation of attachment behaviours may vary across cultures. When working with
older clients from a different cultural background, therapists have to be mindful of
the presence of within-culture differences in attachment history, beliefs and
behaviours. Within the United States, some ethnic minority older adults may be
more likely to endorse a dismissing attachment style because of their experience of
socioeconomic hardship in childhood (Magai 2008). Their parents may have been
less physically available as they had to work very long hours away from home to
support the family. Thus, these individuals may have become extremely self-
reliant. In general, active intervention may not be necessary when an older person’s
level of dependency or emotional distancing is within the limits of what is culturally
sanctioned and is not causing subjective distress or objective impairment.
Older adults from certain cultures may be more sceptical and weary of the
discussion of early attachment. Psychotherapy has previously been portrayed by
the media as a way to blame one’s parents for every problem in life. In many
cultures this goes against the social norm of revering one’s elders, especially
among earlier-born cohorts. Therapists may introduce the concept of attachment
to their older clients by highlighting how it may inform treatment, while
emphasising that the goal is to change the present, not blame the past.
Therapists are encouraged to guard against trivialising or pathologising non-
traditional attachment relationships that may become more common in late life
after the deaths of same-age partners, siblings and elderly parents. To replace lost
attachment ties, older adults may identify their adult children, deceased loved ones,
God and animals as attachment ¿gures (Cicirelli 2010). An examination of these
relationships may facilitate the assessment of current attachment needs. A smaller
social network in old age does not always warrant immediate intervention. Research
has shown that securely-attached older adults were able to maintain their most-
valued social relationships and experienced less depression during life transitions,
despite having a smaller social network than younger adults (Gillath et al. 2011).
Instead of assuming that all older clients who endorse feeling lonely need to expand
their social network, therapists may focus on how these clients’ attachment style
has kept them from experiencing adequate affection in existing relationships.
Intervention
Just as an older person is not de¿ned by his or her attachment style, treatment is
not dictated by attachment theory alone. When the presenting problem is primarily
poor self-esteem and feeling unworthy of love, an appreciation of how one’s
attachment experiences have inÀuenced one’s view of self may inform case
conceptualisation. Speci¿c strategies can then be Àexibly drawn from different
approaches. Cognitive-behavioural strategies may be used to highlight faulty
expectations about oneself, and how these beliefs may inÀuence attachment
behaviours. Taking an attachment perspective does not negate other ways of
approaching a presenting problem. For example, instead of dismissing the role of
neurobiological and psychosocial changes in the development of post-stroke
depression, attachment-informed treatment may focus on helping older clients
cope with these changes by examining and potentially changing maladaptive
attachment behaviours with their family caregivers and healthcare providers. This
may result in better adherence to pharmacological interventions and a greater
willingness to engage in behavioural activation and rehabilitation.
Regardless of how case conceptualisation is informed by the attachment
perspective, an understanding of basic attachment concepts will strengthen the
therapeutic relationship. There are parallels between the roles of parents and
therapists, in that caregivers who promote secure attachment may enhance care
recipients’ desire to engage in physical and cognitive exploration (Bowlby 1988).
When therapists are consistent and responsive, older clients may be more ready to
participate in therapy. As attachment is built upon a mutual relationship, a healthy
awareness of therapists’ own attachment needs may also reduce the likelihood of
problematic countertransference in treatment.
Consistency
The ability to remain consistent in the therapeutic relationship contributes to the
development of trust. One practical way to maintain consistency is to schedule
appointments at a regular time as much as possible. Cancellations and changes in
scheduled appointments should be brought up in a neutral manner, with the
intention of reassuring the older client of the therapist’s availability. During a
session, insecurely-attached older adults may suddenly become hostile or withdrawn
to protect themselves from emotionally-charged topics, or to test their therapists’
reliability and competence. When therapists remain empathic and supportive
despite their clients’ inconsistencies, it will promote trust and facilitate change.
Responsiveness
Therapists’ ability to respond appropriately to their older clients’ emotional
needs is important within and across therapy sessions. Some anxiously-attached
older clients may be reluctant to open up because they have been maintaining
their attachment relationships by being excessive caregivers. Their tendency to
take care of everyone ¿rst may fuel a desire to protect their therapists by not
overburdening them with strong emotions. Older clients’ reluctance to share
their thoughts and feelings may be expressed in a subtle manner. They may
suddenly jump from topic to topic or repeatedly tell a speci¿c personal anecdote.
Although the possibility of dementia is a valid concern, disinhibition and
perseveration may be a way to mask one’s attachment insecurity and avoid
discussing an attachment concern.
One way to work through these situations is the use of process comments.
Therapists who do not work with older adults on a regular basis may ¿nd this to
be challenging at ¿rst, because interrupting an older person may be viewed as a
form of disrespect in many cultures. Judicious use of non-judgemental process
comments may prove to older clients that their therapist is actively listening.
Passively allowing older clients to digress may undermine the perceived emotional
presence and responsiveness of the therapist. Because insecurely-attached older
adults may have a tendency to interpret process comments as threatening, it may
be prudent to ask for permission at the beginning of therapy and regularly discuss
how they feel about these comments. A similar strategy to highlight the therapist’s
responsiveness is to have an ongoing discussion on therapy goals and progress.
An emphasis on goal-setting and progress-monitoring may help older clients
realise that their therapist is mindful of their improvement and evolving needs.
Counter-transference
Therapists’ attachment style can help or hinder psychological interventions. Counter-
transference may be a normal reaction to an older client’s attachment behaviours, or
a reÀection of the therapist’s unresolved attachment needs. Clinical staff’s personal
experiences with aging and caregiving responsibilities may set off counter-
transference that interferes with assessment and intervention. It is not uncommon for
long-term care staff to become angry at family members for not doing more for their
elderly relatives, especially when staff are dealing with similar situations at home.
Consultation, referral or supervision may be necessary for clinical staff who are
confronting personally challenging aging-related circumstances.
Some therapists may have dif¿culty approaching therapy termination because
of the assumption that their older clients will be lonely when therapy ends.
Although treatment termination may amplify the fear of abandonment, most older
clients are quite resilient and glad to ¿nd out that they have made suf¿cient
progress and no longer need therapy. When reviewing an older client’s treatment
progress, therapists have to consider whether their own attachment needs are
distracting them from a realistic appraisal of their client’s readiness to leave
therapy, or from the need to refer a client to another provider for a different level
of care such as medication management. If an older client does present with mild
concerns about being rejected by other providers, the therapist may problem-solve
with the client during the pre-termination phase and practise initiating contact
with new providers.
Separation, loss and dependency in late adulthood

In the following section, several aging-related experiences that may heighten
one’s personal vulnerability and fear of dependency are presented to illustrate
how treatment may be informed by the attachment perspective in different clinical
settings.
Physical illness and decline

Major illness often results in potential loss and separation, thus triggering greater
attachment needs even among older adults who have been previously well-
adjusted. Decline in physical functioning may result in a need to rely on others for
assistance. This may be particularly challenging for dismissing individuals
because of their reluctance to seek help. Psychoeducation on human beings’
innate need for security may Àow from an expression of strong attachment
emotions, such as fear of abandonment.
Bill was an older widower who had recently had a stroke. Despite regaining
most of his physical and mental functioning, he could no longer return to his
job as a factory manager. He experienced profound hopelessness and attempted
suicide. His physical and emotional condition stabilised soon after he was
admitted to the psychiatric unit. When the attending psychiatrist evaluated Bill
for possible discharge, Bill admitted that he could not find any purpose or
meaning in life and would continue to look for ways to kill himself. Bill decided
to give therapy a try only because ‘There’s nothing else to do on the unit’.
Based on reports from the psychiatrist and staff, Bill appeared to have a
dismissing attachment style. Given his perceived lack of purpose in life and
hopelessness, life review was used as a tool to keep him engaged in therapy by
allowing him to reflect on his personal accomplishments and how he might find
meaning in his life again. The use of life review also generated a discussion about
Bill’s childhood attachment experience. Bill shared that after his father left, his
mother was so busy with his younger siblings that she had no time for him. He
explained that he was ‘always very independent anyway’. As Bill described his
self-reliance to overcome adverse situations in the past, his tendency to minimise
his relationship needs was also brought to the surface.
Because of the huge age difference between Bill and the therapist, as well as his
dismissing attachment style, Bill often questioned the therapist’s abilities by
making belittling or patronising comments. The therapist used these examples to
help Bill explore his attitude towards concepts such as weakness, dependency
and trust. It dawned on Bill that he had a strong desire to be invincible because
he did not trust that anyone would be capable of helping him. As an adult, his
suspicious attitude encouraged others to keep a distance from him, thus
strengthening his belief that nobody was available to help him. During one session,
Bill reported that therapy was a ‘pleasant surprise’, as he had never imagined how
good it would feel when someone actually listened to him as a person, especially
after he became ‘crippled’ and unemployed. Bill began to embrace the possibility
of establishing some social relationships. He later wrote to the therapist that
although he still preferred to spend most of his time alone, he had begun to
volunteer at a local school several hours per week. He found it quite fulfilling to
mentor students from immigrant families who yearned to be heard and accepted.
Relocation
Physical illness, caregiving responsibilities and ¿nancial dif¿culties often force
older adults to leave their home. Whether it is moving to an adult child’s home,
a long-term care facility or another part of the country, relocation may represent
a major loss and intensify one’s sensitivity to potential danger. For those who
have already experienced multiple losses, relocation may trigger a fear of
becoming completely helpless. Cognitive restructuring and problem-solving
techniques may be useful in these situations, such that the older person may
learn not to catastrophise the situation, and to take practical steps to establish
new relationships.
Linda was feeling overwhelmed about managing the five-bedroom house she
had lived in since she was born. When her son suggested that she move to a
retirement community, Linda became extremely resentful, accusing him of
scheming to steal her property. Linda was reluctant to enter therapy because
of a fear that information shared with the therapist would be used against her.
When the therapist commented on Linda’s mistrust of people and wondered
out loud with Linda why anybody could be trusted at all, Linda became more
engaged in therapy and went on a tirade about how her son left home two days
after his high school graduation and never came back until his father’s funeral.
Behind Linda’s suspicion and hostility was an intense fear that she would not
be able to adjust to a new environment on her own, especially when she had
little faith that people in the community would be willing to help her. The
therapist challenged Linda’s rigid expectations by helping her identify
experiences that did not support her mistrust in others. Linda finally agreed to
visit a few retirement communities. She was surprised by her pleasant
encounters with residents and staff. In the meantime, Linda continued to
wonder if others would be willing to help her in the future.
Treatment then focused on Linda’s strengths in managing her life in the past
seven decades and how she might be able to manage her new environment
through a combination of self-reliance and help-seeking. To prepare for the
relocation, help-seeking was role-played in therapy and later practised in real
life when she spoke to her son. As Linda became more confident in herself and
others, she gradually realised that her resentment was driven by a sense of
extreme helplessness. This allowed Linda to work through her experience as a
child abuse survivor, achieve greater inner peace, and become more forward-
looking as she prepared for the move.
Long-term care settings

Older adults often have to depend quite heavily on the assistance of staff in most
institutional settings. Constant shift changes and staff turnover may heighten
feelings of insecurity. Mental health professionals may assist clinical staff in
creating an environment that supports secure attachment, as well as teaching
insecurely-attached residents how to effectively express their needs to minimise
staff burnout. An awareness of counter-transference and its impact may help staff
develop more positive interpersonal relationships with residents. An awareness of
residents’ attachment styles may prepare staff for potential behavioural challenges
and encourage the use of person-centred interventions to manage these behaviours.
Anne lost her husband of 50 years a month after he was diagnosed with cancer.
When Anne moved to a nursing home because she could no longer take care
of herself and her husband’s farm, she presented with extreme anxiety. She
was hypervigilant that she was in danger. Efforts to reassure Anne soon became
emotionally draining to staff. Attempts to walk away from her only exacerbated
her anxiety.
An examination of Anne’s life history revealed a longstanding preoccupied
attachment style. Her husband was the only one who was able to withstand her
anxiety and reassure her that she could turn to him for help. The therapist
brought up how Anne had framed herself as an ‘eternally vulnerable’ individual
who needed constant protection. Instead of punishing or pathologising any
clingy behaviours, the therapist normalised these behaviours as Anne’s reaction
to her attachment needs. Treatment focused on refining Anne’s behaviours
and challenging her feelings of extreme vulnerability. Whenever Anne exhibited
ineffective attachment behaviours, such as crying incessantly and accusing the
therapist of being uncaring to turn down her request for more frequent
sessions, the therapist would highlight Anne’s desire to feel taken care of, while
encouraging Anne to ponder on whether her behaviours had brought others
closer to her or drawn them away in the past.
Anne eventually calmed down when she realised that the therapist remained
responsive and supportive despite standing firm with her professional
boundaries. The therapist met with staff to discuss Anne’s attachment style and
the importance of consistency in staff behaviours. A fixed schedule of staff-
initiated 10-minute interactions with Anne after each meal was proposed.
Appropriate help-seeking behaviours were praised. When Anne calmly
requested and waited for staff to fill out a form for her, instead of demanding
everyone in the hallway to help her immediately, staff would compliment her
for being patient. Staff were encouraged not to promise to meet with Anne or
perform specific chores for her unless they were certain they would be able to
honour the promise. As staff’s behaviours became more predictable, Anne
reported less anxiety. She began to develop a more positive sense of self that
made her more self-reliant. Staff became more empathic and confident in their
ability to deal with Anne’s dependency and reported a much better relationship
with her.
Caregiving
Secure attachment has been associated with a less subjective sense of burden and
a greater commitment to provide care among the adult children of ailing parents
(Crispi, Schiaf¿no and Berman 1997), whereas avoidance and anxiety have been
associated with lower levels of wellbeing (Perren et al. 2007). When individuals
assume the role of caregivers to an attachment ¿gure, such as their elderly parents,
anticipatory grief and previously unresolved grief may exacerbate their attachment
needs because of an augmented feeling of helplessness and vulnerability. Some
caregivers may minimise or dismiss their care recipient’s concerns to guard
against these negative feelings. Others may engage in excessive caregiving
because of an intense fear of separation and loss.
Insecurely-attached older care recipients may impose ¿lial responsibilities on
family caregivers to preserve their relationship with their adult children, combat
feelings of poor self-worth, and ful¿ll their need for reassurance and validation
(Karantzas, Evans and Foddy 2010). Preoccupied older adults may be more
demanding to their caregivers as a result, whereas dismissing older adults may
be unwilling to seek help because of conÀict-avoidance. It may be confusing
when care recipients express their attachment needs through rejection, hostility
or paranoia.
Although it is not always possible to change a family caregiver’s prevailing
attachment style when the intended client is the older adult, therapists may help
caregivers become more aware of their own attachment needs. It is important to
help caregivers recognise how insecure attachment may inÀuence their
understanding of their loved one’s end-of-life care wishes. In one study, individuals
with attachment-related avoidance or anxiety made less accurate prediction of
their loved ones’ wishes for life-sustaining treatment (Turan et al. 2011).
Therapists may intervene by normalising caregivers’ tendency to become
overwhelmed or withdrawn, before addressing how this may affect the quality of
care given to the care recipient.
Raul had been caring for his terminally ill 90-year-old mother for several
years. Despite his own failing health, Raul continued to travel a long distance
to visit his mother daily. Raul would make multiple requests that were
inappropriate given his mother’s medical condition, thus alienating support
from staff. After a family conference, a therapist mentioned how common it
was for caregivers to experience great fears about their own future when a
loved one was dying. Raul broke down in tears and stated that his mother was
the only reason for him to live. Although the therapist only briefly touched
upon Raul’s fears about losing his last surviving attachment figure, the
opportunity for Raul to vocalise his fears helped him reconsider whether he
was making the best decision for his mother and himself. He warmed to the
idea of in-home hospice care. With encouragement from the therapist, Raul
agreed to join a caregiver support group to address his attachment needs and
anticipatory grief.
Dementia care
Dementia does not only strip individuals of their memory but also of their identity,
making it a terrifying experience of loss of control over a once familiar world. As
stated in an earlier section, the attachment system is activated when there is
perceived threat in the environment (Bowlby 1969/1982). While a secure pre-
morbid attachment style has been shown to predict more positive emotions after
the onset of dementia (Magai 2008), less securely-attached individuals are more
likely to express their attachment needs through agitation, aggression, panic and
paranoia (Perren et al. 2007). The attachment perspective may shift caregivers’
attention from overt behavioural challenges to underlying attachment needs of
comfort and security. This may increase caregivers’ empathy and ability to
maintain a soothing presence when interacting with someone afÀicted with
dementia. Caregivers’ attachment avoidance has been found to be associated with
more behavioural problems among care recipients (Perren et al. 2007). The less
anxious or angry the caregiver is, the more likely it is that the person with dementia
will be able to calm down. Behavioural interventions that promote consistency,
structure and the availability of familiar ¿gures, such as the use of previously
recorded voices of familiar individuals (Browne and Shlosberg 2006), may foster
a sense of security and reduce agitation.
After being diagnosed with dementia, Julia moved in with her daughter Carol.
When Carol had to move to another country for work, she planned to move
Julia to a nursing home. To promote a smooth transition, they visited with
residents and staff several days per week a month before the move. Carol
provided staff with family photos, items Julia had used for decades, and a list of
her favourite activities. To maintain a sense of consistency in the mother–
daughter attachment, Carol continued to call Julia on a regular basis. Being
securely-attached, Julia was usually easily soothed when she became disoriented
and began to wander. Staff would ask Julia what was bothering her in order to
understand the emotional meaning of her agitation, reassure her that she was
in a safe place, redirect her to participate in her favourite activities, or invite
Julia to talk about a familiar object such as her wedding photo. Because staff
responded to Julia’s distress in a prompt and calm manner, a sense of security
was fostered. To manage staff’s potential frustration towards difficult residents,
the nursing home regularly scheduled training to highlight the attachment
needs of individuals with dementia, to elicit greater empathy and to discuss
behavioural strategies that could enhance attachment security. The facility also
obtained behavioural observation data to illustrate the benefits of being
responsive, consistent and calm when dealing with challenging behaviours.
Although Carol encouraged staff to call her if Julia remained agitated, staff
seldom had to call Carol for help.
Concluding comments
This chapter illustrates how the attachment perspective can inform
conceptualisation, assessment and intervention when working with older adults
and important individuals in their social network. Aging-related challenges in late
adulthood are often characterised by separation, loss and increasing dependency,
making the attachment perspective an appropriate conceptual framework in
clinical practice with older adults. An examination of older clients’ attachment
history, beliefs, behaviours and needs can strengthen the therapeutic relationship
and promote change. Interventions that are informed by the attachment perspective
allow for a Àexible selection of strategies from different approaches.
Clinical work with older adults often involves a diverse range of professionals,
settings and interpersonal systems. One of the most important contributions of the
attachment perspective is that it accentuates a common and universal need for
protection and care in times of distress and danger. Its intuitive appeal renders it a
relatively simple concept to teach and accept. There may be a greater readiness to
empathise and collaborate among older adults, family members and service
providers when this common pursuit of comfort and safety is emphasised, thereby
fostering successful aging and personal growth even in the face of multiple aging-
related challenges.
Note: All examples are informed by the author’s experience but do not concern
speci¿c individuals in real life.
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Section 4
The organisation and the

individual practitioner
Chapter 14
Four pillars of security

Attachment theory and practice in
forensic mental health care
Gwen Adshead and Anne Aiyegbusi
John Bowlby’s ¿rst published study was a forensic one: a study of the early
attachment histories of juvenile thieves (Bowlby 1944). Forensic psychiatry did
not then exist as a clinical speciality, only emerging in the UK during the last
thirty years. In that time, extensive research based on attachment theory, in both
clinical and non- clinical populations, has produced data that has proved valuable
to forensic practice, both theoretically and clinically (PfäfÀin and Adshead 2004).
In this chapter, we explore four key areas of research and practice from
attachment theory that are relevant to forensic mental health care. They are:
• Attachment theory, the development of the personality, and disorders of

personality
• The relevance of attachment insecurity to the risk of violence
• Attachment and thinking about victims
• Attachments within residential care: relational security and insecurity
between staff and patients.
We suggest that a thorough understanding of these domains provides theoretical

‘pillars’ of knowledge that can underpin the ‘secure bases’ that are essential to
forensic practice. We also discuss implications for training and supervision.
Throughout, we refer mainly to male patients; not because there are no female
offender patients, but because they are a minority of service users. We are also
linguistically explicit about the nature of the psychological challenges faced by
the patients; especially the struggle to master the feelings of cruelty and violence
that have resulted in their offences. Everyone struggles with such feelings from
time to time, but forensic patients have acted on them and have to live with the
consequences.
Attachment theory, the development of the personality

and disorders of personality
Attachment theory is useful not only for understanding how personality develops
but also for understanding how personality disorders develop. This is particularly
200 Gwen Adshead and Anne Aiyegbusi
relevant in forensic services where the prevalence of personality disorder

diagnoses is 60–80 per cent, which is considerably higher than the community
prevalence of 4 per cent (Coid et al. 2006; Duggan and Howard 2009).The most
common type of personality disorder in forensic practice is ‘anti-social’: i.e. a
personality that lacks the qualities of the ‘social mind’ that allow us to interact
fruitfully with others in groups (Dunbar 2003).
We assume a basic knowledge of categories of attachment style derived from
research. These categories are not types of people or ‘symptoms’ of disorder, but
rather ways that people think about attachment relationships. Bowlby (1969)
theorised that insecure attachment representations are based on internal working
models (IWMs) of relationships that are built up in the mind over time. These
models develop in response to attachment-related stressors and are (in effect)
‘defences’ (cognitions and affects) that help to reduce arousal and distress. These
IWMs have both conscious and unconscious elements and may be revealed in
behaviour and language (Hesse 2008).
Children who are exposed to high levels of attachment distress may develop an
avoidant/dismissing attachment IWM, which reduces distress through hypo-
arousal and reduced affect; or they may develop an ambivalent/enmeshed
attachment IWM, which is associated with hyper-arousal and unstable, high
amplitude affect states (Schore 2001, 2003). Children exposed to chronic fear and
chaotic home environments may develop a ‘disorganised’ IWM, which is
characterised by rapid oscillations between different states of mind with regard to
attachment, and odd behavioural manifestations of anxiety (van IJzendoorn and
Bakermans-Kranenburg 2003). Insecure and disorganised attachment styles tend
to persist into adolescence and adulthood, and are associated with more
interpersonal dysfunction and severe clinical disorders (Dozier, Stovall-McClough
and Albus 2008; Sroufe et al. 2005; Steele and Steele 2009; van IJzendoorn and
Bakermans-Kranenburg 2003).
Early childhood attachment insecurity is highly inÀuential on the development
of the ‘Big Five’ personality traits or dispositions that also seem to develop in
childhood and then persist into adulthood (Bartholomew, Kwong and Hart 2001;
Mikkelson, Kessler and Shaver 1997; Shiner and Masten 2002). Early attachment
experience is likely to be as inÀuential as genetic vulnerabilities or other
environmental stressors in terms of risk of developing personality dysfunction
(Brennan and Shaver 1998; Dozier, Stovall-McClough and Albus 2008) and early
attachment insecurity is an established risk factor for the development of
personality disorder (Bartholomew, Kwong and Hart 2001; Crawford et al. 2006,
2007; Livesley 1993). We argue that personality disorder might be best understood
as the adult sequelae of profound attachment disorder in childhood. Such an
approach is supported by those researchers who argue that personality disorders
should be rede¿ned as ‘relational disorders’ or disorders of interpersonal function
(First et al. 2002; Skodol et al. 2011).
The studies of the inÀuence of early attachments on personality dysfunction
would suggest that forensic clinical assessment of people with personality disorder
Four pillars of security 201
will be incomplete without a detailed developmental attachment history, one that

provides a clear account of the attachment environment in which the forensic
patient grew up and his or her ¿rst behavioural or affective responses to stress,
threat or perception of threat. Detailed attachment histories will allow us to make
much better predictions of the type of emotional responses our patients will make
under stress; especially stress that arises in the context of relationships, both
personal and professional (Sarkar and Adshead 2006).
Mentalisation based therapies help patients manage negative emotions when
they are activated by attachment-related situations, such as perceived threat,
abandonment or unmet need. Mentalisation based therapies have been used to
good effect with personality disorder in non-forensic settings, and are the focus of
current treatment trials in forensic settings (Bateman and Fonagy 2008).
The relevance of attachment insecurity to the

risk of violence
There have been a variety of studies of attachment insecurity in a range of violent
offenders; including rapists, sex offenders, child abusers, homicide perpetrators
and offenders who score highly on psychopathy (Adshead and Bluglass 2001;
Bogaerts, Vanheule and Declerq 2005; Frodi et al. 2001; Levinson and Fonagy
2006; Marshall, Serran and Cortoni 2000; van IJzendoorn et al. 1997).
It is worth noting the low prevalence of attachment security compared to non-
clinical populations. It is also worth noting that some offenders appear to have
secure attachment representations, which suggests that security of mind with
respect to attachment is therefore not an indicator of safety (Bakermans-
Kranenburg and van IJzendoorn 2009; Van IJzendoorn and Bakermans-
Kranenburg 1996). This data serves as a reminder that every act of violence is a
complex phenomenon, and attachment security (or lack of it) is only one of a
number of risk factors that may be operating at the time of a violent act.
There is evidence that the dismissing style is over-represented in forensic
populations (Adshead and Bluglass 2001; Frodi et al. 2001; Levinson and Fonagy
2006). If the excess of the dismissing style is a valid ¿nding, then this suggests
that the conscious psychological attitudes characteristic of the dismissing style are
risk factors for the commission of violence. As described in the Adult Attachment
Interview manual (AAI; George, Kaplan and Main 1994), these include:
• claims of personal strength and normality

• denial of need for help
• denial of pain or suffering
• dismissing of distress (in self or others) as not of interest or concern
• active derogation or contempt for distress.
A lack of concern or compassion for the self is likely to be associated with a

similar lack of concern and compassion for others, because there is a relationship
between self-reÀective function and empathy (Fonagy and Target 1997; Fonagy et
al. 1997). If your own neediness or pain is not of interest to you, then you are
unlikely to be interested in others’ pain, and this feature alone will make the
inÀicting of harm more psychologically possible and less ego-dystonic. Dismissing
attachment is also associated with avoidance of social relationships and social
isolation; a known risk factor for violence (Estroff and Zimmer 1994).
‘Active derogation’ is described as a sub-category of the dismissing style
(George, Kaplan and Main 1994). These individuals are not just dismissive about
distress or neediness, they are actively derogatory about it. The AAI manual states
that this classi¿cation is rare in normal populations, but presumably will be more
common in populations where dismissing attachment is generally more prevalent.
A derogatory and contemptuous attitude towards the distress of others would
make violence easier to commit: it also closely resembles those ‘callous’ and
‘mean’ states of mind that are characteristic of personality pro¿les associated with
high risks of violence (Hare 1999; Patrick, Fowles and Krueger 2009).
An excess of dismissing attachment has implications for clinical forensic
practice. Patients with a dismissing attachment style are harder to engage in
treatment and less likely to be treatment compliant (Dozier et al. 2001). Large
sub-groups of forensic patients are also known to be non-compliant and reluctant
to engage; and it is easy for professionals to see such behaviour as a feature of
antisocial attitudes, not a psychological issue about trust and avoidance of distress
that needs to be addressed through attempts to develop relationships and encourage
the expression of affect at a gradual pace.
Attachment and thinking about victims

Attachment ¿gures are people in our lives on whom we depend, or who depend on
us: people we go to when distressed or who come to us seeking relief from distress
and comfort (Weiss 1991). They typically include parents, children, siblings,
friends and emotional/sexual partners; and can also include professional care-
givers (Adshead 1998, 2010).
However, perpetrators of violence often attack those to whom they have had
some emotional attachment. The second most common form of violence in
England and Wales is between people who are in an intimate relationship. Of
homicide or rape perpetrators, 60 per cent are well known to their victims. Nearly
all (90 per cent) of adults who kill children are either parents or in a parenting role;
and most child abuse is carried out by family or peers (Smith and Flatley 2010).
Mental illness makes very little difference to the general risk of violence in society
but is a signi¿cant risk factor for family violence (Estroff et al. 1998). Therefore,
assessment of an individual’s attachment relationships may be highly relevant to
the assessment of their risk.
In a vulnerable person, loss or potential loss of an attachment relationship can
be a powerful trigger for violence because the pain and fear of loss stimulates
defensive anger (Bowlby 1984). An angry mental state, which is then further
aroused by substance misuse or affected by the reality-distorting effects of

psychosis, is a potent risk factor for violence (Fazel et al. 2009). Vulnerable
individuals include those who rely on the attachment ¿gure to regulate their own
feelings, i.e. what is sometimes described as co-dependence on the attachment
¿gure. If the attachment ¿gure leaves (or appears to be leaving), this stimulates
intense anxiety, then panic, and then rage, which can be manifested as violence.
Such unstable violence in response to perceived abandonment by an attachment
¿gure is characteristic of borderline personality disorder, and has been commonly
described in perpetrators of intimate partner violence (Holtzworth-Munroe et
al.1997).
There are other forms of toxic attachments that give rise to violence, such as
highly abnormal care-giving behaviour (as found in Factitious Illness by Proxy
behaviours). Mothers who perpetrate such atypical and risky care-giving
behaviours on their children have high levels of insecure attachment patterns
(Adshead and Bluglass 2001). In addition, it is plausible to speculate that toxic
attachments exist in those families where a father (or rarely, a mother) kills their
children and then themselves, usually after the break-up of the parental relationship.
It is also important to consider paranoid attachments that may result in stalking
behaviour. The most famous example of this is the case of Tatiana Tarasoff, who
was killed by a young man who had formed a psychotic attachment to her and
killed her in response to a perceived rejection. We know now that anyone who has
a paranoid attachment to another presents a risk to them, and the size, degree and
time-span of the risk may be hard to assess.
Finally, attacks on professional caregivers can be understood as a form of
dysfunctional attachment behaviour. To recap, attachment theory states that
when in distress, the securely attached child elicits care from their attachment
¿gure, who is then able to give care successfully. However, there are sub-groups
of psychiatric patients who attack caregivers, either psychologically or
physically, on a regular basis. Such attacks may represent maladaptive
attachment behaviour in response to perceived rejection or neglect and/or an
attempt to get attention for distress. Some patients seek care, but then are hostile
to it, or seem to be unable to make use of the care that is offered (Norton 1996).
Serious and repetitive attacks on healthcare staff quickly result in admission to
higher and higher levels of security; with huge associated costs; there is
anecdotal evidence that one third of admissions to high security are as a result
of severe violence to staff in medium security. However, little attention is paid
to the attachment histories of these patients, or the exploration of how and why
a professional attachment ¿gure should provoke such rage and distress. It would
seem sensible to add routine questions about attachment relationships, both in
childhood and adulthood, to risk assessment, both in terms of clinical enquiry
and formal assessment tools.
Attachments within residential care: relational

security and insecurity between staff and patients
An awareness of attachment issues can help staff establish therapeutic relationships
that really act as a ‘secure base’ for therapeutic engagement and clinical
improvement. Engagement is a particular problem for forensic patients (Glorney
et al. 2010), so understanding that insecure patients may appear dismissing or
demanding because of their attachment disturbance helps staff not to react
inappropriately, but to tailor their interventions accordingly.
We assume that any professional who delivers long-stay residential psychiatric
care is effectively in an attachment role with patients because of: (a) the length of
time; and (b) the dependence and intensity of the contact between staff and patients
in this context. Unlike community or general in-patient work, where the length of
stay is measured in weeks, forensic patients may stay more than ¿ve years on a
forensic ward and may be ‘living’ with the same nursing staff all that time.
One of the authors has been involved in qualitative research exploring the
attachment narratives of nurses working in secure settings, and their therapeutic
relationships with patients, especially those with personality disorder.1 Below are
themes arising from the complexity of relationships between nurses and patients
in these settings, some of which are supported by quotes from this study.
Childhood history and help seeking

Insecure attachment representations mean that forensic patients may not know
how to make use of the staff care; and they may ¿nd it hard not to repeat
dysfunctional attachment behaviours or to relate to the staff as dangerous carers
from the past. Given that most forensic patients have histories of abuse at the
hands of carers, they are naturally suspicious of authority ¿gures, or those who
claim to be carers. In most forensic services, each ward may have as many as
¿fteen or twenty people like this, but perhaps only six nurses to manage their
needs and prevent them from harming themselves or each other.
Nursing staff report that patients often secure care by behaving in a disturbed
way and are also unable to accept care when it is offered. Here is an example of a
patient rejecting care when offered:
And there is a particular patient who when they are very distressed, they will
say ‘I don’t need you’ when they really need you … so by not understanding
the communication that is coming from them you are more likely to miss out
certain important things … So it’s a bit like working opposite, like taking
their no as a yes.
This relational pattern, in attachment terms, suggests ambivalence about asking

for help and is due to prior experiences of rejection when vulnerable (Adshead
1998; Fonagy 1998).
Understanding attachment-related aggression

In some patients, the anxiety about asking for help may be so great that the patient
becomes aroused, angry and aggressive, and may then act out in a threatening
manner that can often alienate those who might be able to care. Disorganised
attachment experiences in early life are particularly associated with later
controlling behaviours towards carers. Using an attachment approach, staff can
understand the arousal and hostility as a hyper-aroused response to threat and the
experience of being in need. The nurse can acknowledge how dif¿cult it sometimes
is to ask for help, and gently but ¿rmly remind the patient that hostility tends to
make it dif¿cult for others to help effectively. Such an approach can discon¿rm
patients’ negative expectations; and can lay the foundation for a more ‘secure’
nurse–patient relationship.
Nurses’ ambivalent feelings about relationships

Within these complex relationships, nurses also report that they may have to
manage ambivalent feelings about the patient, who can simultaneously elicit both
caring and angry, fearful and rejecting feelings in staff, as described below by a
nurse:
She evoked in me quite a lot of mixed feelings. She was a fragile woman who
wanted to be taken care of. At the same time I was always quite wary: she was
a woman who on some occasions could be quite rigid in her views and racist
and that to me threw me back to the environment that I grew up in at the time
in [country].
Managing fear
Managing fear is a key issue for forensic nursing staff. Children who have been
abused by their caregivers face an intolerable dilemma because they are frightened
by the very person from whom they are meant to seek help (Fonagy 1998). As
discussed previously, many forensic patients are profoundly fearful of seeking
help from caregivers on whom they depend, often for their most basic needs. At
the same time, the nursing staff may also fear the patient; either directly because
of the way they present or because of their offending history.
Oh, oh dear. For starters she scares me, she scared me a great deal, she really
did scare me a great deal. Erm … on a lot of occasions I avoided having one
to ones with her, I avoided confronting her. She could be very kind, very
considerate, certainly considerate but it was almost, it was her menacing way,
that was the most dif¿cult, it is certainly almost impossible to have a
relationship with someone you are afraid of and working with someone who
has those kind of defences.
Sexualised attachment
A particular type of problematic attachment in forensic settings is a sexualised or
eroticised attachment (Thomas-Peter and Garrett 2000). A signi¿cant sub-group
of forensic patients have experienced sexual abuse as children; and a further sub-
group are admitted for sexual offending, i.e. breaking legal boundaries around
sexual behaviour. It is therefore not surprising to ¿nd that a sub-group of forensic
patients (male and female) see the nursing staff in sexual terms and eroticise the
nurse–patient relationship.
Forensic patients may openly compare notes with each other regarding who has
the best or nicest primary nurse and sometimes behave in a way that suggests they
are infatuated with members of nursing staff, including primary nurses. Through
projection, patients may wrongly perceive that the primary nurse or other member
of the nursing staff is attracted to them or even loves them, proclaiming that if
they had met under different circumstances a romantic attachment would develop
between nurse and patient.
These highly idealising attitudes are characteristic of the dismissing attachment
style. They are defensive because they do not admit that the loved object has any
weaknesses or Àaws. Nurses who are the object of an idealised attachment by a
patient are at high risk of being the victim of assault when they (inevitably)
disappoint the patient, or if the patient fears to lose them (as described above in the
section about victims). Highly idealised or enmeshed attachments can also lead to
sexual boundary violations by staff in forensic settings (Thomas-Peter and Garrett
2000). Female staff have been found to be at risk of engaging in sexual boundary
violations with male patients; possibly because they are targeted by predatory male
patients; but if they are experiencing personal dif¿culties at home this can also
make them vulnerable to ‘special’ attention from a patient (Gabbard 1989).
A key feature of relational security is the making and maintaining of professional
boundaries in the relationships between staff and patients. Understanding
everyone’s need for attachments at times of stress may help senior staff and
managers to understand why staff who are undergoing personal loss or stress at
home might behave inappropriately with patients or colleagues. Sexual boundary
violations are also known to commonly involve patients with histories of sexual
abuse in childhood; suggesting that these patients may be particularly vulnerable
to this maladaptive attachment pattern (Kluft 1990).
Professional and personal boundaries

Attachment theory may also aid understanding of other, more egregious, failures
in residential forensic care. All professionals working in these settings will
themselves have IWMs of attachment that affect their own care-giving and care-
eliciting behaviour, and the normative data from non-clinical populations would
indicate that insecure attachment representations will be found in as much as 40
per cent of the workforce (Bakermans-Kranenburg and Van IJzendoorn 2009; see
Adshead 2010 for review).
Therapist attachment style has an impact on the outcome of therapy (Rubino et

al. 2000) and has been shown to inÀuence therapeutic relationships in forensic
care (Zegers et al. 2006). Staff with insecure attachment styles may (without
realising it) become hyper-aroused and agitated when faced with threat or need; or
may become avoidant or hostile to patients. They may also be at increased risk of
stress reactions, burn out, sexual boundary violations and other types of
inappropriate relationship.
For example, we may consider the two different sets of inquiries into institutional
failure of care in Ashworth hospital (Department of Health 1990; Fallon Report
1999). In the ¿rst Ashworth Inquiry, there was evidence that staff had been
physically abusive to patients; in the second it became clear that staff had either
colluded with patients in rule-breaking behaviour, turned a blind eye to it, or not
noticed it.
These might seem like different kinds of problem, but in reality they are not.
They are sad examples of how the IWMs of attachment that are present in both
staff and patients can be activated by the stresses of life in long-term residential
care. The activation of IWMs in staff results in conscious emotional reactions to
the patients, such as hostility, rage, contempt and fear, which may be dif¿cult
enough to manage. But activation of these models can also trigger unconscious
reactions to the patients, derived from unresolved distress from past traumatic
relationships with the patients or someone else from their personal history.
In the incidents mentioned in the ¿rst Ashworth inquiry, we can guess that the
staff must have perceived the patients as especially provocative and threatening;
given that they used violence against patients (as opposed to organised restraint or
some other socially sanctioned response). It may be that there was something
about the presentation of the patients that unconsciously triggered in staff fears
about their own capacity to become disorganised; and anxiety about their capacity
to contain the patients. It seems likely that the attachment relationships between
staff and patients were highly insecure, with the patients looking to the staff to
contain anxiety and the staff feeling increasingly anxious about their capacity to
do so. As anxiety rose, the staff seem to have adopted a dismissing style in which
they rejected the neediness of the patients and responded with derogation and
anger. They may also have become angry and abusive in response to their own
distress and fear that they were not in control.
If in reality staff numbers are down, or the ward is particularly stressed, then the
chance of staff feeling helpless and panicky is increased, which in turn may
increase the risk of staff acting in a hostile way to patients. None of the above is
an excuse for unprofessional behaviour, but it does provide a framework for
understanding what happened and how it might be prevented.
Conversely, in the set of incidents recorded in the second inquiry, we might
speculate that the attachment relationship between staff and patients was an
enmeshed one, in which there was an abolition of boundaries between staff and
patients and some degree of role reversal. Such enmeshment may be a defence
against feeling overwhelmed and helpless in the face of the patients’ capacity for
cruelty and hopelessness. It is possible that staff failed to notice what was going
on and/or failed to take action because they felt there was no point in noticing or
acting. In this way, they may have unconsciously identi¿ed with the victims of
their patients and also the victim part of each patient’s history. Victims of violence
characteristically ‘freeze’ and become passive in the face of danger; they can also
experience overwhelming hopelessness and helplessness, which further increases
passivity (van der Kolk 1989).
What happened in Ashworth were examples of violations and erosion of
professional boundaries as a result of highly disorganised attachment relationships
between staff and patients. The staff lost sight of their therapeutic goals by the
gradual erosion of their professional identities. Boundary violations happen in all
forms of health care, but they are particularly common in places where staff and
patients have to engage in long-term relationships. The point here is not that the
staff in Ashworth were ‘bad apples’ who need to be rooted out. Rather, we would
argue that what happened at Ashworth is a professional hazard of long-stay
residential forensic care. Forensic institutions need to face this head on and make
working with these issues part of everyday clinical practice.
Implications for training and supervision

Attachment theory is an accessible theory of psychological development and
interpersonal functioning that provides a useful base for the training and support
of forensic nursing staff (Aiyegbusi and Clarke-Moore 2008) and other
professionals such as occupational therapists and psychologists. Much traditional
mental health training may leave staff unaware of the interpersonal aspects of
their relationship with patients (especially if those relationships are dif¿cult), and
with a tendency to attribute relational problems to ‘mental illness’, personality
disorder or ‘evil’ (Bowers 2002). It may be hard for staff to appreciate that
medication may improve symptoms of mental illness but does little to change
attitudes to caregivers. They may also be unprepared for the fact that they will
experience emotional reactions to the patients, both positive and negative, which
may be evoked in them by the patient’s attachment behaviour. Attachment based
‘supervision’ can provide a space for reÀection on the emotional demands of the
job (Winship 1995) and the complexities of relating to people whose attachment
history is highly insecure. Identi¿cation of a vulnerable sub-group of staff with
insecure attachment styles could lead to the provision of extra support; but could
also place staff at risk of stigma and unfair employment practice.
Conclusion
In this chapter, we sought to set out why attachment theory is of particular practical
relevance to services for forensic patients, whether in prison or secure mental
health settings. We described the impact of attachment on the development of
personality and how insecure attachment patterns can increase risk for the
development of personality disorders. We have described the high prevalence of

insecure attachment styles in forensic populations, compared to non-clinical
populations; and the impact this may have on risk assessment. We have also
considered how attachment ¿gures can be potential victims of violence and how
threats of loss of attachment ¿gures can trigger violence. Finally, we have also
explored how insecure attachment patterns in both patients and staff impact on
therapeutic relationships in long-stay residential secure care; and looked at ways
of managing interactions to help people become more psychologically ‘secure’.
Note
1 Aiyegbusi, A. (2011). Managing the nurse – patient relationship with people diagnosed
with personality disorders in therapeutic community and secure mental health settings.
Unpublished doctoral thesis, Middlesex University, Tavistock Clinic.
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Chapter 15
Using attachment theory to

inform psychologically minded
care services, systems and
environments
Martin Seager
Attachment and the human condition

The ¿rst attachment relationship between a dependent infant and an adult caregiver
lies at the heart of what it is to be human. Indeed, attachment appears to be one
concept that most scientists of the human condition can agree about. Observing
newborn babies with their caregivers shows that bodily, psychological and social
development are interwoven and get started together.
For example, breast or bottle feeding at the very start of life does all of the
following:
• nurtures the body, supplying the energy for physical growth

• provides a foundation for the development of a secure self and identity in the
infant as the caregiver ‘mirrors’ the feelings and mental states that are
embodied in hunger, satiation, distress and comfort
• creates an initial blueprint for social relationship.
Because human youngsters remain dependent and vulnerable for a much longer
time than the young of other species, this means that the attachments formed
between developing humans and those that care for them are a protracted, complex
and also potentially risky affair if those attachments are disrupted or violated in
any way. In 30 years of clinical practice with people experiencing severe and
complex mental health problems, I cannot recall a single such case where early
childhood attachments were not seriously violated or disrupted. It should be
obvious that where early attachments are traumatic, abusive or neglectful, the
development of a healthy adult personality cannot happen. ‘Scienti¿c’ research is
only belatedly looking at these issues, which have long been understood by our
greatest artists and novelists, most obviously Charles Dickens, whose most
famous works (e.g. Oliver Twist) are fascinating studies of the damage done to
developing children when care-giving attachments go wrong, coupled with
uplifting accounts of how emotional damage can be repaired through new and
loving attachments.
214 Martin Seager
If attachments go wrong, therefore, a child can grow physically into an adult

form but remain emotionally damaged or undeveloped. This is not to split the
brain from the mind. After all, the human brain as a biological entity has evolved
mainly as a learning machine. Recognising this fact makes the nature versus
nurture debate largely redundant. We now have increasingly hard evidence to
show that love attachments shape our lives and even our very brain development
(Gerhardt 2004; Schore 2001). From an evolutionary perspective, an 18-year
childhood would indeed be pointless in a species whose essential personal
characteristics (including something as vital as ‘mental health’) were largely pre-
con¿gured at birth.
The theory of attachment provides a powerful framework for integrating our
scienti¿c understanding of how human mental health is developed, and yet this
universal concept is largely forgotten in the design of our adult mental health
services, based as they are upon a default, bio-medical model where attachment
and relationship processes are seen at best as vague ‘facilitators’ or ‘stressors’ that
simply increase or decrease the risk of triggering underlying ‘conditions’.
However, one powerful example will clearly show that it is better science to
view attachment factors as fundamental building blocks of the ‘human condition’
in which all individuals evolve a unique personality that reÀects their early care-
giving environment, and that in turn helps to shape the way that future environments
and relationships are experienced and managed.
In the TV documentary Help me love my baby1 (Channel 4, 2007) a six-month-
old girl is shown clearly, consistently and actively avoiding eye contact with her
mother (whilst at other times being able to maintain eye contact with other adults).
Correspondingly, the mother’s face when she is holding the baby is shown to be
signalling intense fear and resentment. It is clear that the attachment is going
wrong. The baby has already learned to look away to protect herself from
overpowering feelings that are experienced as threatening and intrusive rather
than as nurturing and supportive. It emerged later that the mother herself had not
been ‘mothered’. Because her own mother had been unavailable emotionally and
had struggled with alcohol addiction, the daughter had learned to switch off or
ignore her own dependency feelings. This meant that she could not now easily
relate to or ‘tune in with’ a child of her own that was highly dependent and in need
of intensive mothering. This baby had indeed been vulnerable from birth and had
required a period in a Special Care Baby Unit. However, after a period of parent–
infant therapy, when both the mother’s and the baby’s feelings were being ‘tuned
into’ by the therapist, the attachment between the two was repaired and developed
to a point where it could be said that this mother and baby truly ‘loved’ each other.
This difference was visible just by looking at the mother, whose eyes now seemed
to twinkle when she looked at her baby. It was clear that this mother was now
emotionally available, not only to her own child but also to herself. She was no
longer switching off her own feelings and could now therefore more accurately
identify with her child’s needs and feelings.
Using attachment theory to inform 215
This striking example, along with other developing research evidence (e.g.
Svanberg, Mennet and Spieker 2010), raises a number of vital questions, most
importantly: ‘If early attachments are this powerful and formative in human
personality development, why is our society so blind to attachments when
designing its mental health care systems?’
This blindness to attachment is even more striking when it is considered that
attachment relationships are also perhaps the core and universal ingredient of all
effective psychotherapy, whatever the brand (Norcross 2002). This qualitative
aspect is commonly referred to in the therapy literature as the ‘therapeutic
alliance’, ‘collaborative relationship’, ‘working relationship’ or ‘rapport’. Even
lay people call it ‘chemistry’. Given these universal ¿ndings and patterns, rather
than seeing attachments simply as a vehicle for treatment techniques it is probably
better science to see therapy models as different languages in which to deliver
therapeutic and empathic attachments.
The concept of ‘mentalisation’ (e.g. Fonagy et al. 2002) has also expanded our
understanding of how human attachment operates in psychological terms and how
the mind of the adult caregiver impacts upon the developing mind of the dependent
child. It shows that attachment is even more vital than previously thought,
providing the original vehicle for empathic ‘mirroring’ and infant personality
development. It helps us to see that it is only the accurate emotional attunement
and responsiveness of caregivers to the emotional signals of infants that enables
infants to build up an accurate internal map of ‘self’ in relation to ‘other’ or
‘identity’.
By expanding attachment theory in this way, three robust scienti¿c assumptions
can therefore be made about the status of early attachment in human mental well-
being.
1 A human being’s ¿rst non-verbal attachment experiences lay down the ¿rst
pattern or blueprint of ‘self in relation to other’ onto which subsequent
language-based experience must be mapped and through which subsequent
relationships are interpreted.
2 A baby cannot healthily develop an internal sense of its own feelings and its
own mind (self, identity) unless an available (securely attached, emotionally
invested) external adult caregiver is able accurately to empathise with,
identify with, recognise, ‘mirror’ or ‘read’ the communications of the baby.
3 Adults with severe, complex and enduring mental health problems tend to
have experienced insecure, damaging, neglectful or broken attachments
during their earlier developmental years. This means that they will need
services that can provide stable and consistent therapeutic attachments to
unlock emotional defences, repair past damage and address unmet needs.
216 Martin Seager
Attachment-blindness and mind-blindness 2 in adult

mental health service provision
Given our implicit scienti¿c and cultural knowledge of the centrality of the ‘love
bond’ to the human condition, it is perhaps strange that still to this day our society
organises even its mental health services in a very medicalised and un-psychosocial
way, making an unquestioned assumption that people are afÀicted by a range of
speci¿c illnesses that require speci¿c ‘evidence-based’ treatments in speci¿c
‘doses’. Within this bio-medical framework, the age-old human activity of
forming compassionate attachments and empathic relationships with our fellow
human beings can itself only be viewed as another kind of ‘treatment’ that must
be quanti¿ed as somehow being equivalent to mood-altering drugs and rated
against them for comparative effectiveness. The example of parent–infant therapy
described above, however, makes it clear why attempting such ‘drugs versus
psychotherapy’ comparisons is poor science.
Perhaps inevitably, therefore, ‘talking therapies’ as they have come to be known
are still to this day researched and marketed as distinct brands that are presumed
to be quanti¿able in terms of dose-effects. This framework or paradigm, by
contrasting ‘bio-’ and ‘psycho-’ models, leaves very little room for genuinely
integrated bio-psycho-social thinking about the human condition, and it also
makes it very hard for a theory such as attachment theory, which is more
developmental than clinical, however universally accepted, to gain a foothold in
the shaping of wider mental health service culture. Within a paradigm that says we
need to test speci¿c treatments separately for speci¿c conditions, attachment
theory can only readily be evidenced and implemented as the basis for its own
brand of ‘talking therapy’, and this probably explains why we do indeed now have
speci¿c ‘attachment-based therapy’ for speci¿c ‘attachment-based disorders’.
This is a valuable development, but ignores the greater truth that nearly all serious
mental health problems are attachment disorders of one kind or another.
In 2007, at the request of the Health Secretary, I set up a national advisory
group on mental health and well-being (Seager et al. 2007). Our aim was to
identify universal underlying concepts that linked all the different brands and
approaches to psychological therapy and human mental well-being. The group did
indeed achieve a consensus and it was agreed that secure attachment was a core
and universal factor underlying well-being for all humans.
The group arrived at ¿ve universal psychological principles:
1 Human well-being depends on meeting universal psychological needs as well

as physical and social needs.
2 All mental health service provision and policy – not just specialist
psychological services – should be informed by psychological principles and
standards.
3 Attachment theory provides a universal evidence base that has not yet been
fully recognised or utilised in general mental health policy and service design.
4 In mental health, it is misleading to claim that relationships merely provide a

setting or a set of values within which treatment is delivered. Relationships
are the essence of the treatment and are the ‘baby, not the bath water’.
5 Choosing between medical and psychological approaches to mental health is
bad science and based on a Cartesian body–mind split – there is always a
psychological aspect and a psychological impact arising from every human
intervention, even so called ‘pure’ medical treatments; there is no such thing
as a psychological or relational vacuum.
Whilst principle 3 is clearly the most relevant for our present purposes, the central
implication of all ¿ve principles is that care-giving attachments directly shape and
dynamically maintain the health and well-being of the human personality. Under
principle 1, the primary universal psychological need was also de¿ned as follows:
To have a secure and stable attachment to at least one signi¿cant other person who
knows us well and whom we can trust.
According to these principles, attachments and other relationship factors are
always vitally operative in any human care situation and should therefore inform
the overall design of all mental health services, systems and cultures. However,
what is striking about our adult mental health services to this day is that they are
run in ways that remain blind even to the basic concept of attachment. This
contrasts with the fact that there is at least some implicit acknowledgement of
attachment in the design and delivery of child and family mental health services,
if only because children are by de¿nition still dependent on adult caregivers.
In our current mental health service culture we generally think of drugs as a last
resort for children but a ¿rst resort for adults. This ‘apartheid’ between our service
cultures for adults and children cannot be explained in terms of biological science.
After all, we do not deny life-saving drugs to children with cancers and other life-
threatening physical diseases.
What this massive difference in the cultures of our mental health services for
children and adults truly shows us, therefore, is a failure of a coherent scienti¿c
hypothesis relating to the real nature and causes of mental well-being. We know
implicitly that children need love bonds for their well-being but we somehow
forget or ‘turn a blind eye’ to this in our services for adults.
When faced with an unhappy child, it is usually impossible to medicalise the
issues. Children are more transparent in their distress and their dependency on
care-giving relationships is all too obvious. In trying to achieve scienti¿c
coherence in our approach to mental health services, therefore, the real question
must be:
Should we change our child mental health service culture to be more medical
or make our adult service culture more developmental and psychosocial?
The answer to this question is surely self-evident. In a medical service culture,

however, where psychological approaches are seen merely as an alternative
218 Martin Seager
treatment ‘technique’ rather than as tapping into a universal human need for love,
relationships and psychological nutrition, the possibility of establishing effective
therapeutic attachments is severely restricted by:
1 a false assumption that psychological approaches are only relevant to selected

‘conditions’;
2 prescribing relationships in predetermined ‘doses’ and ‘courses’ like drugs;
3 discharging and transferring patients based on symptom counts rather than
relationship and personality developments;
4 staff rotations and changes to staff availability that are based on organisational
considerations rather than the attachment needs of service users;
5 a lack of recognition that a psychologically-informed stance is the business of
all care professionals and that all care should meet fundamental psychological
standards (particularly relating to care-giving attachments);
6 a failure to recognise that all attachments, including those formed with
families, friends, colleagues, other service users or non-clinical staff (e.g.
domestics, receptionists), can have a critical value and a therapeutic (or
negative) impact on a person’s mental health.
Given that attachment and empathy are intertwined at the root of the health of the
human mind, this ongoing ‘mind-blindness’ in our adult mental health services is,
therefore, potentially quite harmful, especially when it is considered that these
services are dealing with the very people for whom early attachments have already
gone badly wrong.
From mind-blind to psychologically minded services

How then can the concept of attachment be introduced into the design and culture
of adult mental health services to render them more psychologically-minded and
to improve their safety and effectiveness? The following list is not exhaustive, but
provides some obvious examples.
Reducing the risk of attachment breakdown for in-patients

There is strong evidence that a time of signi¿cantly heightened risk for suicide is
the period immediately following discharge from psychiatric hospital (e.g. King
et al. 2001). Such a ¿nding de¿es medical explanation. After all, aren’t people
discharged because they’re better? However, this evidence can readily be
explained in terms of attachment theory (Seager 2006). Vulnerable in-patients at
a time of distress can feel more secure as they start to build certain attachments to
individual staff, to fellow patients and even to the system as a kind of ‘professional
family’. Discharge from hospital, which might seem a positive move in medical
terms, can therefore represent a major rupture of attachments, prompting feelings
of rejection, abandonment and intense emotional insecurity (ironically provoking
what in medical terms would look like a ‘relapse’). Even a basic application of
attachment theory, therefore, would mean that the medical concept of ‘discharge’
from in-patient units is at best misleading and should perhaps be replaced by a
more developmental concept of ‘transition’. Such transitions would be safer if
some measure of attachment was factored into the care planning. If a signi¿cant
drop in available attachments would result from leaving hospital, then the timing
would not be right for such a transfer. Using attachment theory in this way would
constitute safer practice and potentially save lives. Of course, this sort of thinking
and practice can and does take place in our mental health services already, but it
is sporadic, precisely because it is not explicitly part of the service model.
The explicit use of attachment theory would of course clearly demand a change
in the whole culture of in-patient care. In-patient units would be designed to
promote consistent and therapeutic relationships between staff and service users.
The recruitment, deployment and training of all mental health professionals would
need to be informed by some knowledge and understanding of attachment issues.
Longer and more therapeutic stays involving the explicit and systemic use of
attachment principles, with better planned transitions to community care, would
improve outcomes, save lives and in the longer term save money through a
reduction both in the suicide rate and in the all too familiar ‘revolving door
syndrome’.
Attachment theory as a basis for personalisation of services

The term ‘personalisation’ (e.g. Mind 2009) is becoming fashionable in mental
health circles but it lacks an underlying theory. Attachment theory is well placed
to provide such a theory along with clear service standards such as:
• Who is there in the care system with a consistent and stable emotional
investment in the service user?
• Who is there in the system that knows who the service user is, remembers
their individual life story and ‘holds them in mind’?
• Who is there in the system that the service user can trust and get hold of
quickly?
• How many different people in the system are relating to the service user? Is
this pattern insecure because there are too many to really get to know the
person or too few to cope with their needs?
One obvious and simple application of these standards is to appointment systems.

To this day, psychiatric appointment systems remain relatively impersonal. It is
still common practice to give outpatient appointments to adults on a ‘clinic’ basis,
where the identity of the clinician is not consistent or even predictable. The same
applies to ‘ward reviews’ in psychiatric hospitals, where it is also routine for
different professionals to come and go on the basis of organisational needs rather
than relationship considerations. Because the system is built on the assumption
220 Martin Seager
that it is ‘conditions’ that need to be reviewed and treated, not people in

relationships, little or no primary consideration is given to personal attachments
formed between the patient and caregivers either as individuals or as an overall
professional ‘family’ system. This means that it is often a ‘hit and miss’ affair
whether stable and continuous attachments do ultimately get formed within our
adult psychiatric care culture.
Whilst service brochures and mission statements often aspire to ‘personalised’
or ‘client-centred’ services, this failure to take account of attachment theory in
something as basic as the appointment system speaks for itself. This indeed is the
theme of many complaints that services receive: ‘I never saw the same person
twice and I had to keep telling my story over and over again’.
Depersonalisation is, of course, one of the key causes and symptoms of poor
mental health in the ¿rst place. It can, therefore, be argued that the traditional
mental health care culture risks reinforcing rather than reducing problems.
Factoring attachment into the appointment system is therefore one obvious step
that would help to create genuine personalisation in practice by ensuring a standard
of continuity of relationship in the booking of appointments. Similarly, whilst
service users are increasingly offered ‘key workers’ or ‘care co-ordinators’ in our
adult mental health system, this is not based on attachment theory or indeed on any
relationship model so much as a ‘pragmatic’ belief in the value of co-ordinated
care. This means that much of the potential therapeutic bene¿t of ‘key working’
may be lost or even violated when key-workers and care co-ordinators are blindly
transferred, replaced or substituted for ‘pragmatic’ reasons. Informing key working
and care co-ordination with even the most basic understanding of attachment
theory, therefore, could help to make mental health services signi¿cantly safer.
From physical safety to ‘psychological safety’

Our ‘health and safety’ culture even in mental health care remains heavily focused
upon the physical environment. I have elsewhere (Seager 2006) described a
concept of ‘psychological safety’, rooted in the science both of attachment theory
and of psychodynamics. Putting this simply, psychological safety means that
people are much more at risk from failures of relationship than they are from
de¿ciencies in the physical environment, in the sense that an environment can be
seen to be only as safe as the security of emotional attachments that it can provide
for service users.
Attachment theory can therefore provide a framework for de¿ning and measuring
the psychological safety of care environments. Goodwin and colleagues (2003)
have developed the Service Attachment Questionnaire (SAQ), which assesses the
extent to which services meet the attachments needs of service users. Questions
cover six key areas: being listened to; consistency and continuity; being given time
– ending and leaving; safe environment; enabling relationships; contact and comfort.
This information, along with measures of service users’ individual attachment
styles, could create an audit tool for service safety (Berry and Drake 2010).
One other obvious application of this idea is to the prevention of suicide in

psychiatric units. When suicides and other ‘serious untoward incidents’ (SUIs)
occur, psychiatric units are frequently investigated in terms of physical safety for
the presence of ‘ligature points’, but no real attempt is made to investigate breaks
in the security of the attachments between service users, professionals and others,
especially at times of transition (e.g. discharge from hospital, see above). The
relevant emotional attachments of those involved are not measured or even
considered, and therefore psychological lessons are rarely learned. Creating even
the crudest of attachment measures for use at key points in the care pathway could
therefore potentially save lives.
Availability and accessibility of the service system as an

attachment issue
The failure of early care-giving attachments is inevitably one of the greatest
sources of emotional damage. It follows from this that emotionally vulnerable
people will ideally need a mental health system that can provide stable, consistent
and accessible attachments if this emotional damage is ever to be repaired. Putting
it crudely, services need to provide some experience of healthy ‘re-parenting’.
However, even the working hours of traditional mental health services in the
UK still follow the normal ‘business’ hours of 9.00 am to 5.00 pm. Some ‘out of
hours’ services are provided but these are limited. Again, even the most basic
application of attachment theory indicates that care-giving relationships do not
work in this way. With vulnerable, insecurely attached and emotionally damaged
service users, it should be evident that there is a need for a Àexible, accessible and
available care-giving system based on psychological time rather than physical
time. It is precisely ‘in the wee small hours’, at those very times when normal
facilities are shut down, that vulnerable people would be predicted to feel most
alone, most in need of help and most at risk.
The very design of statutory community mental health services can therefore be
experienced as alienating and this partly explains the popularity and value of 24-
hour alternatives in the voluntary sector, particularly the Samaritans. Within
statutory services the only routinely available 24-hour access-point for mental
health service users is ‘A and E’, which is primarily geared for physical
emergencies and is certainly not informed by attachment theory or by any
psychological model. Using attachment theory, all mental health services would
need to be designed in such a way that attachment ¿gures did not conspicuously
fade away after 5.00 pm. To avoid creating a culture of neglect, statutory services
need some redesign, using the concept of attachment, to ensure that there is at
least one accessible professional caregiver at any time of the day. This might
involve closer collaboration with the voluntary sector.
222 Martin Seager
Honouring human dependency needs rather than stigmatising them

Attachment theory helps to explain why children need a critical period of
dependency within a stable home environment if they are to develop into healthy,
independent adults. To become self-reliant a human being has ¿rst of all to be able
to rely on at least one external caregiver.
Dependency, including the basic human need for love and attention, is all too
often stigmatised as a problem (‘attention-seeking’) or as a symptom to be
eradicated rather than as a need to be understood and met. Public mental health
services are also increasingly focused on low cost, time limited ‘quick ¿xes’
rather than on wider notions of human attachment and development. An
attachment-blind system therefore can become self-defeating, creating a ‘revolving
door’ culture of dependency, rejection and abandonment. This is perhaps most
obvious within the homelessness sector where, ironically, service users are
provided only with housing, hostels and brief hospital admissions rather than
genuine homes. Even the simplest application of attachment theory, however,
should lead us towards designing more homely environments based on ‘family’
relationships, so that such damaged people could begin to let down their defences
and address their unmet universal needs. After all, no human being can ever grow
up, move out or move on from a home that they have never had (Seager 2011).
Creating a secure family atmosphere and environment

Attachment theory supports the common-sense view that where a mental health
service (like any other human system) is organised in ways that support a healthy
‘family atmosphere’, the well-being of both staff and service users is promoted.
The recent notion of a ‘psychologically informed environment’ (PIE) (Johnson
and Haigh 2010) represents some movement in this direction and is perhaps a
revival of the older concept of the ‘therapeutic community’. I have referred
elsewhere (Seager 2006) to the concept of a ‘professional family’ (as distinct from
the concept of treating the family system). Implicit in such a model is the idea that
mental health is promoted by a containing framework of secure attachments to a
limited and consistent number of professionals who work together and who get to
know their clients and help them develop over time. In a recent paper (Seager
2011) I argued for the concept of ‘re-parenting’ to be expanded to that of ‘re-
homing’. Essentially, this highlights that no human being can develop without a
sense of roots and of ‘home’. The core part of any home is the attachment
relationships within it. If our mental health services were designed on this
personalised principle, they could only work better.
Caring for the mind of the care-giver

Attachments between staff and their own caregivers (supervisors, managers) are
also vital in creating therapeutic conditions. If care professionals are not securely
attached to their place of work then they cannot transmit that security and stability
to the service users, in the same way that a chaotic family will undermine the
healthy development of its children. If our service users are forming attachments
to professionals who are themselves not feeling a sense of secure attachment and
belonging to their place of work, a culture of deprivation will be created.
Attachment theory, extended by the more recent concept of mentalisation, makes
it clear that an attachment is only as good as the mental state of the caregiver. It is
equally clear therefore that the mental state of the caregiver must in turn rely upon
empathic back-up and support.
Leaving aside issues of psychological training, aptitude and skill, caregivers
can lose their empathic stance through fatigue, burnout, ‘vicarious trauma’,
negative counter-transference, stress, overload, poor managerial support, limited
supervision, bureaucracy and other distractions (see Figley 1995; Seager 2006).
‘Minding the baby’ is the essential task of any caregiver but so many things can
get in the way. An organisational culture can foster empathy in its staff or impair
it. Supervision, for example, is not just a skills issue but a necessary way of
detoxifying the emotional impact on professionals of caring for society’s most
vulnerable individuals. A fatigued and stressed General Practitioner (GP) or
psychiatric nurse (however highly trained and motivated), who is coming to their
twelfth clinical encounter of the day but who has not had the chance to reÀect on
and process the impact of the previous eleven, is unlikely to be in any state of
mind to listen. Good supervision, therefore, (whatever the model: group/
individual, peer/expert, face to face/telephone) can be a vital emotional ‘reviver’
that can prevent emotional neglect and potentially save lives. In healthier service
cultures, informal conversations can also often ful¿l this function. Given that all
human beings have a limited emotional capacity to listen and engage with their
fellow human beings, perhaps the single most simple and vital safety test that
could be applied across the care system is ‘How many attachments of a given
intensity can any one professional caregiver hold in mind at any time before
empathy breaks down?’ Such an attachment-informed approach to caseload
management could in itself and at a stroke improve the safety of our adult mental
health services for the future.
Conclusion
Attachment theory is widely recognised and there is implicit acceptance that
attachment is a fundamental factor underlying human well-being. And yet the
attachments formed between service users and their professional caregivers
remain almost totally neglected in the design of our adult mental health services.
In this chapter it has therefore been argued that this continued neglect of attachment
amounts to a kind of ‘mind-blindness’ that can only increase risk and impair
therapeutic effectiveness. Practical ideas for introducing attachment theory into
the future culture and design of adult mental health services have been proposed.
224 Martin Seager
Notes
1 Broadcast on Channel 4, 3 December 2007.
2 Broadening Simon Baron-Cohen’s autism-related concept.
References
Berry, K. and Drake, R. (2010). The relevance of attachment theory for psychiatric
rehabilitation and implications for practice. Advances in Psychiatric Treatment 16,
308–15.
Figley, C.R. (ed.) (1995). Compassion Fatigue: coping with secondary traumatic stress
disorder in those who treat the traumatized. New York: Brunner/Mazel.
Fonagy, P., Gergely, G., Jurist, E.L. and Target, M. (2002). Affect Regulation, Mentalization
and the Development of the Self. New York: Other Press.
Gerhardt, S. (2004). Why Love Matters: how affection shapes a baby’s brain. Hove:
Routledge.
Goodwin, I., Holmes, G., Cochrane, R. and Mason, O. (2003). The ability of adult mental
health services to meet clients’ attachment needs: the development and implementation
of the Service Attachment Questionnaire. Psychology and Psychotherapy: Theory,
Research and Practice 76, 145–61.
Johnson, R. and Haigh, R. (2010). Social psychiatry and social policy for the 21st century
– new concepts for new needs: the ‘psychologically-informed environment’. Mental
Health and Social Inclusion 14, 30–5.
King, E.A., Baldwin, D.S., Sinclair, M.A., Baker, N.G., Campbell, M. and Thompson,
C. (2001). The Wessex Recent In-Patient Suicide Study 1. British Journal of Psychiatry
178, 531–6.
Mind (2009). Personalisation in Mental Health: a review of the evidence. London: Mind
Publications.
Norcross, J.C. (ed.) (2002). Psychotherapy Relationships that Work: therapist contributions
and responsiveness to patients. New York: Oxford University Press.
Schore, A. (2001). The effects of secure attachment relationship on right brain development,
affect regulation and infant mental health. Infant Mental Health Journal 22, 7–66.
Seager, M. (2006). The concept of ‘psychological safety’ – A psychoanalytically-informed
contribution towards ‘safe, sound and supportive’ mental health services. Psychoanalytic
——(2011). Homelessness is not houselessness: a psychologically-minded approach to
inclusion and rough sleeping. Journal of Mental Health and Social Inclusion 15, 183–9.
Seager, M., Orbach, S., Sinason, V., Samuels, A., Johnstone, L., Fredman, G., Antrican,
J. and Hughes, R. (2007). National advisory group on mental health, safety and well
being – towards proactive policy: ¿ve psychological principles. (Unpublished paper
commissioned by the Health Secretary, Patricia Hewitt.)
Svanberg, P.O., Mennet, L. and Spieker, S. (2010). Promoting a secure attachment: a
primary prevention practice model. Clinical Child Psychology and Psychiatry 15,
363–78.
Chapter 16
We are the tools of our trade

The therapist’s attachment history as
a source of impasse, inspiration and
change
David Wallin
Please note that an earlier version of this chapter was published in the book
Clinical Pearls of Wisdom edited by Michael Kerman.
For the past ¿fteen years, my work – practising, teaching and writing about
psychotherapy – has been inspired by a mixture of curiosity and conviction about
the power of attachment theory to enhance clinical practice. That work culminated
in a book, Attachment in Psychotherapy (2007), in which I identi¿ed three research
¿ndings that appeared to have the most profound and fertile implications for
treatment: ¿rst, that co-created relationships of attachment are the key context for
development; second, that preverbal experience makes up the core of the
developing self; and third, that the stance of the self toward experience is a better
predictor of attachment security than the remembered facts of personal history
themselves. Accordingly, my approach as a clinician has focused on the therapeutic
relationship as a developmental crucible, the centrality of the nonverbal dimension,
and the transformative inÀuence of reÀection and mindfulness. Within this
framework, attending to the attachment history and patterning of the therapist is
of vital importance.
In the pages that follow, I will discuss the advantages and vulnerabilities that
arise from the therapist’s characteristic career trajectory, with its roots in a history
of trauma and adaptation to trauma. I will go on to explore how, as therapists, we
can identify our own states of mind with respect to attachment and the implications
that Àow from recognising that our state of mind is presently secure, dismissing,
preoccupied, and/or unresolved. Then I will describe how mindfulness and
mentalising can be enlisted to help us recognise and work with the enactments of
transference/countertransference that take shape where our own attachment
patterns interlock with those of the patient. Finally, I will present an illustrative
clinical vignette.
Attachment and the therapist

Despite the reality that ‘we are the tools of our trade’ (Pearlman and Saakvitne
1995), the impact of the therapist’s own psychology upon his or her clinical
226 David Wallin
effectiveness is a topic the psychotherapy literature has largely ignored. From the
attachment perspective within which I work, this omission appears very
problematic. At the heart of the matter is my assumption that, in childhood and
psychotherapy alike, the relationship is where the developmental action is. Just as
the child’s original attachment relationships make development possible, it is
ultimately the new relationship of attachment with the therapist that allows the
patient to change. But development, of course, takes (at least) two. For this reason,
the ¿nding of attachment research that the parent’s security, insecurity or trauma
is regularly transmitted to the child must surely catch our attention. For it suggests
that not only as parents but also perhaps as therapists, our ability to generate a
secure attachment relationship will be profoundly affected by the legacy of our
own attachment relationships – a legacy that is, for many of us who choose this
work, marked by trauma. Regardless of our theoretical orientation, then, our own
attachment patterns may well be the single most inÀuential factor in shaping – that
is, enhancing but also constraining – our capacity to create with the patient a
genuinely therapeutic relationship.
Let me be more speci¿c. Attachment history is ‘engraved’ in the psyche. It
takes the form of internal representations and rules for processing information that
derive from our experiences of what has and has not ‘worked’ in relation to
particular attachment ¿gures. These ‘rules of attachment’ are quite literally rules
to live by, given that they initially emerge from interactions with caregivers upon
whom we depend for our very survival. The key issue here is what has been ruled
in and what has been ruled out in the relationship with our original attachment
¿gures. Put differently, the question is: What have we been able to integrate
(because it elicited an attuned response from attachment ¿gures) and what have
we needed to defensively dissociate (because it threatened the survival-critical
attachment bond)? The answers to this question shape our attachment patterns,
determining not only how we relate to ourselves and to others, but also what we
allow ourselves to know. For what in infancy began as behavioural ‘strategies’ for
optimising the relationship to attachment ¿gures soon become emotional,
cognitive and attentional strategies that determine how freely we can feel, think,
sense and remember. As therapists, then, our own (more or less troubled)
attachment history – marked by the dissociations it has imposed and the integration
we have managed to achieve, often with the help of personal therapy – is always
both an asset and a liability.
On the one hand, we know others most profoundly on the basis of what we
know about ourselves. Such self-knowledge can be a therapeutic resource to the
extent that we have been able to recognise, tolerate and make meaningful sense of
the painful aspects of our own history – that is, to integrate them. Then our
personal experience may confer a heightened capacity for empathic understanding
grounded in our partial identi¿cation with the patient’s own dif¿cult experience.
Moreover, the freedom we have won to think deeply and feel fully can equip us
well to kindle or strengthen the patient’s capacities for reÀection and emotion
regulation. Finally – because of the mutual reciprocal inÀuence therapists and
We are the tools of our trade 227
patients inevitably exert upon one another – our real-time awareness of the ways
our attachment patterns are presently being enacted with the patient can help to
illuminate the patient’s own attachment patterns.
On the other hand, the impact of the therapist’s history – particularly experiences
that have yet to be integrated – can have adverse effects on treatment. To begin
with, our view of the patient can be clouded by what we are unable or unwilling
to know about ourselves. Additionally, our own attachment-derived skew toward
thinking at the expense of feeling – or vice versa – can undermine our ability to
upgrade the patient’s ability to think and feel in an integrated fashion. Most
problematically, impasses in treatment can arise out of the need to keep at bay our
own unbearable, and hence dissociated, experiences of self or other. These
impasses can take the form of collusions or collisions (Goldbart and Wallin 1996).
In keeping with our own attachment rules and patterns, we may ¿nd ourselves
colluding with the patient to avoid experiences that are troubling to us and, not
infrequently, to the patient as well. Alternatively, disowned aspects of ourselves
– not only our dissociated experiences and our dread of them, but also our wish to
work them through – can be defensively ‘relocated’ in the patient. Then we may
¿nd ourselves caught in collisions with patients who evoke reactions in us that
initially arose (but often had to be suppressed) in response to our original
attachment ¿gures. Or we may ¿nd ourselves embroiled in conÀict when we
unconsciously push our patients to take on developmental challenges that we have
only ambivalently or incompletely addressed ourselves. As therapists, in short, we
need to be aware of the ambiguous relationship between what we recognise in the
patient on the basis of overlapping experience and what we project onto the patient
on the basis of what we have yet to fully integrate in ourselves.
For many therapists, I would propose, this un¿nished work of integration
involves a history of early trauma to which we have adapted with what attachment
researchers call a ‘controlling-caregiving strategy.’ Longitudinal studies (Main
and Cassidy 1988; Wartner et al. 1994) show that many infants assessed at twelve
months as ‘disorganised’ – presumably as a result of growing up with attachment
¿gures whose own unresolved trauma made them frightening to their babies –
have by age six developed a distinctly solicitous role-inverting strategy. Like
these children, I would suggest, many future therapists have learned to take control
of scary parents by taking care of them. Put differently, many of us are ‘wounded
healers’ who in the role of ‘parenti¿ed’ children ¿rst acquired many of the skills
– but also the constraints – we now bring to our clinical work.
Identifying and working with the therapist’s

attachment patterns
From an attachment perspective, therapy heals when the quality of the therapist’s
presence and interventions can help patients both to deconstruct the attachment
patterns of the past and to construct fresh ones in the present. From a slightly
different angle, the therapist aims to create a relationship within which the patient
228 David Wallin
may be able to integrate experiences that have previously had to remain dissociated.
But our deliberate efforts to offer the patient a new and healing attachment
relationship are invariably complicated, if not undermined outright, by the hidden
pressures and constraints of our own attachment patterns.
For research purposes, identifying the attachment patterns of adults with
singular descriptors (secure-autonomous, dismissing, preoccupied and unresolved)
has been shown to have enormous value. For clinical purposes, however, it may
be both more useful and true to the facts to assume that therapists in the course of
their work can inhabit more than a single ‘state of mind with respect to attachment’.
In particular, therapists who have had a lot of therapy – and consequently a breadth
and depth of self-knowledge and experience – will likely be well acquainted with
a multiplicity of such states of mind in themselves. These states of mind are
developmentally determined, to be sure, but they are also context-dependent. By
this I mean that the therapist in the clinical setting may ¿nd herself or himself in a
secure, dismissing, preoccupied or unresolved state of mind depending on the
particular moment in the particular therapy of the particular patient.
Recognising the state of mind in which, as therapists, we are presently lodged
can be especially important when that state of mind is dismissing, preoccupied or
unresolved – and thus imposes limits on our awareness and effectiveness.
Advantageously our very effort to notice and identify our state of mind can begin
to loosen its grip – for then that state of mind may become an experience that
needs to be understood rather than a fact that de¿nes (and con¿nes) us. Through
such a process of attention and reÀection, the constraints associated with particular
states of mind can be transformed into therapeutically productive questions. For
example, having noticed that we seem to be in a dismissing state that leaves us cut
off from our feelings, we can ask ourselves, ‘What might be the feelings we don’t
now wish to feel?’ Scrutinising our experience in this fashion helps us to get out
of our own way. And because our state of mind is always determined in part by
the relational context, our efforts to grasp the nature of our own experience often
wind up illuminating aspects of the patient’s experience as well.
The therapist in a secure state of mind

Two key words describe our experience when we can inhabit this much-to-be-
desired state of mind: freedom and Àexibility. We have the freedom here to reÀect,
to feel, and to be aware of bodily sensations. We also have a kind of ‘binocular
vision’ which permits Àexible access to a wide range of experience both in ourselves
and in our patients. Consequently, we are able to value, recognise and manifest in
our conduct the balanced capacity for attachment and exploration that is the
hallmark of secure attachment. Put differently, we are able in a secure state of mind
to experience our relationship with the patient as a context in which there is room
for two – two voices, two perspectives, two centres of desire and initiative. In an
insecure state of mind, by contrast, we tend to experience the therapeutic relationship
as a setting in which there is only room for one. In a dismissing state of mind, as I
will explain, that one is the self; in a preoccupied state of mind that one is the other.
The therapist in a dismissing state of mind

The key word here is isolation. As therapists in a dismissing state of mind, we tend
to be isolated both from the patient and from our own internal experience.
‘Compulsive self-reliance’ was Bowlby’s shorthand to describe this drift toward
disconnection and emotional shutdown. Sustaining such a stance may require us
to think too well of ourselves and too little of the patient. It may lead us to be more
involved with conveying our own perspective than in empathising with the patient,
or deepening the patient’s experience. In such a state we are gripped by the
‘deactivating’ attachment strategy characteristic of avoidant infants and dismissing
adults alike. This means that rather than feeling comfortable with the primary
biological attachment strategy – which is to turn to others when in distress – we
are prone to tune out, in ourselves and from the patient, whatever cues might
activate the attachment behavioural system. Clues to the therapist’s deactivating
strategy may be found in the research showing that infants classi¿ed as avoidant
have usually been raised by controlling attachment ¿gures who reject their
overtures for closeness. In other words, therapists who become distant from their
feelings and from their patients may unconsciously be protecting themselves from
the threat of being rejected and/or controlled – which threats may also carry the
potential to activate the therapist’s feelings of shame.
Against this backdrop, it should come as no surprise that in a dismissing state
of mind we tend to be dissociated from attachment-related emotions, impulses,
memories and vulnerabilities. In particular, we may be ‘allergic’ to experiences of
need and shame. More broadly, we may be cut off altogether from the world of
feelings and bodily sensations – especially in ourselves, but often in our patients
as well. From a certain angle and with certain patients – especially, perhaps, those
in a preoccupied state of mind – these liabilities can be seen as assets (see Dozier,
Cue and Barnett 1994), in that they allow the therapist to focus in a disciplined
fashion, to analyse (albeit with limited empathy), to establish boundaries and,
ultimately, to cope.
Primarily, of course, we need to be aware of the constraints to which we are
vulnerable when we ¿nd ourselves in a dismissing state of mind. In the overview,
we are likely to pay inadequate attention to attachment-related experience, may
analyse the patient’s experience rather than deepen it, may think rather than feel,
and may focus too much on behaviour and too little on internal states. ‘Merger
wariness’ (Goldbart and Wallin 1996) in the dismissing state of mind can lead to
withdrawal rather than intimacy. There may also be a tendency to externalise, so
that the patient rather than the therapist is regularly felt to be responsible for
whatever problems arise in the relationship.
Rather than wear these constraints like an invisible straitjacket, we can, ideally,
use our awareness of them as information that may allow us to correct our course.
230 David Wallin
Whenever I ¿nd myself in a dismissing state of mind – isolated from my feelings

and distant from the patient, engaged in a conversation between ‘talking heads’,
bored and sometimes drowsy – I try to take a step forward in the direction of the
patient and my own internal experience. I also try to remember to ask myself,
‘What is it that I don’t want to experience now?’ Or alternatively, ‘What is it in
myself and/or in the patient that I have needed to isolate myself from?’ Finally, I
tend to wonder if I may be involved in a collusion with the patient to avoid
emotional experience that is troubling not only to me, but to the patient as well.
The therapist in a preoccupied state of mind

The preoccupied is in many ways the polar opposite of the dismissing state of
mind. In the latter, we inhabit a ‘left-brain’ world in which thinking prevails over
feeling and the self, rather than the other, is the centre of gravity. In the former,
we are in a ‘right-brain’ world in which strong feelings can drown out thought,
and the other is the centre of gravity – the partner in the relationship with
inÀuence and importance. To capture our experience as therapists in a preoccupied
state of mind, the key word is accommodation. We accommodate to the patient,
or try very hard to, out of the fear that if we do not, the patient will leave us.
While we may feel very connected to the patient, we have little solid sense here
of our own value, our ability to be of real help, or our potential signi¿cance to the
patient. As a consequence, we can ¿nd ourselves reÀexively attempting to please
and reassure the patient in any number of ways. We may bend over backwards to
communicate our empathy. We may disclose our identi¿cation with the patient’s
experience. Or we may yield to the temptation simply to say what we think the
patient wishes to hear.
Our surplus insecurity and fear of losing the patient, as well as our compulsive
accommodation, can be understood in the light of certain aspects of the
‘hyperactivating’ strategy common to ambivalent infants and, of course,
preoccupied adults. This strategy arises out of repeated experiences of abandonment
by unpredictably responsive attachment ¿gures (now you see them, now you
don’t) upon whom we are dependent and from whom we learn that our best hope
for securing the support and attention of others is to make our distress too
conspicuous to ignore. In the context of this strategy, our helplessness and
vulnerability are felt to foster connection, while our strength and autonomy are
felt to threaten it. The problem with this solution is that our need to keep the
attachment system chronically activated can undermine our potential to feel
emotionally balanced, con¿dent about ourselves, and trusting in relation to others.
As therapists, this preoccupied approach is clearly constraining. On the other
hand, it also enables us to resonate with the experience of our patients and to
offer them the experience of ‘feeling felt’ (Siegel 2001) that is critical to forming
a therapeutic relationship. We have valuable resources here – particularly our
access to our emotions and intuition – but they can be hard to capitalise on
because of our fears that link autonomy to abandonment. When we have trouble
experiencing a relationship as a setting that has room for two, how are we to have
a mind of our own?
Among the consequences of this quandary for the therapist in a preoccupied
state are the following: expressions of our authentic autonomous self can too
easily be suppressed or dissociated, in which case it will be hard to have – and still
harder to convey – views that differ from the patient’s. This means that as we
relate to the patient our freedom to interpret – that is, to recognise and articulate
alternative perspectives – can be very constrained. Much the same is likely to be
true when it comes to appropriately asserting, as therapists, our inÀuence upon the
patient, our needs and our desires. Instead we are vulnerable to a kind of boundary
loss or merging in which our independent experience of ourselves seems to
evaporate as we are absorbed in the experience of the patient. The other side of the
same coin may be our tendency to attribute traits of our own to the patient. Recall
in this connection the social psychological research showing that ‘anxious’ (aka
preoccupied) subjects are prone to over-identify with others through a bias toward
‘false consensus’ (Mikulincer and Shaver 2003). Thus we need to be cautious
about assuming that our own psychology and that of the patient are the same.
Needless to say, perhaps, we also need to be wary of our tendency to drift towards
conÀict avoidance, submission, self-blame and shame.
Noticing that we are caught in these kinds of undercurrents can be informative.
I can identify my state of mind as preoccupied when I feel that I am losing myself
in the patient’s experience while becoming out of touch with my own – or that I
am full of feelings but unwilling or unable to consider what these feelings might
mean. When I observe, in short, that I am too gripped by the impulse to
accommodate, then I realise that I may need to take a step back both from the
patient and from the ‘literalness’ of my own emotional experience. To this end, I
often ¿nd it helpful to ask myself questions such as these: ‘How am I
accommodating to the patient in ways that may not be useful?’; ‘What is it that I
have been afraid to say or do, out of a fear of losing or hurting the patient?’; and
‘What is it in myself, in the patient, and/or in the nature of our relationship that
might help explain my fearful inhibition?’
The therapist in an unresolved state of mind

As suggested earlier, therapists are often ‘wounded healers’ with our own history
of attachment-related trauma to which we have adapted with a ‘controlling–
caregiving’ strategy. Despite all the work we have done on ourselves – and the
‘earned security’ we hope for as the result – most of us still have elements of this
traumatic history that remain unresolved. Thus we are usually vulnerable to four
distinct experiences of ourselves in relation to others that Liotti (1995, 1999)
describes as features of an unresolved state of mind. Having been on the receiving
end of trauma, we can experience ourselves as victims. Having experienced
ourselves as both angry and responsible in response to trauma – and also perhaps
identifying with the aggressor – we can experience ourselves as persecutors.
232 David Wallin
Having experienced with attachment ¿gures the role reversal involved in being
‘parenti¿ed’ (recall that disorganised infants often become care-giving – i.e.
controlling – children), we can experience ourselves as rescuers. And ¿nally,
because as victims of trauma we have had recourse to the defence of dissociation,
we can experience ourselves as cognitively incompetent or confused. Like the
dismissing and preoccupied states of mind, an unresolved state in the therapist
confers both strengths and vulnerabilities. The strengths associated with this state
of mind include a sensitivity to the patient’s experience of trauma as well as the
potential to understand it on the basis of partial identi¿cation. On the downside,
therapists in an unresolved state of mind can tend to become too rigidly lodged in
one or more of the roles I described above – victim, persecutor, rescuer, or
cognitive incompetent.
The other day I found myself feeling apprehensive as I waited in my of¿ce for
a particular patient to arrive. I was aware of feeling anxious at the possibility that
I might be attacked by the patient or that she might experience me as attacking
her. Worried about being a victim or a persecutor, I saw that I was standing at the
edge, so to speak, of my own unresolved state of mind with respect to attachment.
Unsurprisingly, I saw this patient, too, as inhabiting (much of the time) an
unresolved state of mind. As mentioned earlier, the states of mind we experience
with our patients are both developmentally determined and context-dependent.
Thus while our potential to occupy an unresolved state is established by our
history, it is activated in a speci¿c relational context – and usually that context is
our relationship with a patient who is unresolved with respect to trauma.
Of the various states of mind with respect to attachment, it is the unresolved
state in ourselves that is usually the most dif¿cult to manage and make use of. Our
fears of being victims or persecutors can be very threatening indeed. And our
default options here – the roles of ‘space case’ and rescuer – may afford us some
protection but at the price of undermining our ability to help our patients. The
conscious and unconscious threats that hover around us in an unresolved state can
make it hard to think straight as we ¿nd ourselves becoming defensively drowsy
or spaced-out. Alternatively, we may ¿nd a modicum of security as we take charge
of scary patients by taking care of them – thus repeating in the context of clinical
work the ‘controlling/care-giving’ strategy we learned in childhood. The problem,
of course, is that consoling, soothing and/or giving advice to patients is an
inadequate substitute for the genuine empathy, limit-setting and activation/
regulation of intense trauma-related emotions and memories that are essential to
the integration of unresolved states of mind.
My advice to myself when working with such states is not to avoid them –
neither in myself nor in the patient – but instead to recognise, describe, understand
and discuss them with the patient. Of course, this advice is often easier to offer
than to implement, because the threatening roles of victim and victimiser evoke
fear and shame of an intensity that is sometimes hard to manage. But this is exactly
what we must try to do in whatever ways we can. And in this effort, as I will
shortly explain, our own mindfulness and mentalising have key roles to play.
Mindfulness, mentalising and the therapist’s self-enquiry

Identifying the state of mind – secure, dismissing, preoccupied, or unresolved – in
which we are lodged at a speci¿c moment with a speci¿c patient enlists a particular
‘map’ to orient ourselves as we attempt to generate a new and developmentally
facilitative attachment relationship with the patient. But such a map is not the
territory, and certainly not the whole territory, for it may leave out the speci¿c and
personal details of our here-and-now participation in what we hope will be a
healing relationship. Scrupulously examining what in fact we are doing as we
relate to the patient can help us to access the nonverbal subtext of the therapeutic
conversation, which may in turn reveal the impact of our own attachment patterns
as they interact with those of the patient. Such self-scrutiny also has the invaluable
potential to illuminate the perceptible edge of dissociated experience in both
partners in the therapeutic couple – which is vital because accessing dissociated
experience is a precondition for its eventual integration. To make all this clearer
requires a brief turn to the realm of nonverbal experience.
All of us are profoundly affected by experiences that are dif¿cult to put into
words. Such experiences can be hard to articulate for different reasons: their
origins may be preverbal, they may be defensively dissociated, or they may have
occurred in the shadow of trauma that disabled the brain structures that underpin
speech and autobiographical memory. Though unspoken or unspeakable, these
implicit experiences – Bollas (1987) called them the ‘unthought known’ – are
nonetheless communicated. How so? In treatment, therapists and patients regularly
evoke in each other and enact with each other aspects of themselves (memories,
feelings, conÀicts, internalised images of self and other) that they are unable to put
into words. Both for better and for worse, these nonverbal communications
generate the web of transference-countertransference enactments that arises as the
attachment patterns of therapist and patient interlock. And given the inescapable
reciprocal inÀuence that helps shape such enactments, the therapist’s attachment
patterns are nearly always manifest in ways that are meaningfully, rather than
adventitiously, related to those of the patient.
Repeatedly asking ourselves what we are actually doing with the patient can
thus help us both to identify our role in these ongoing enactments and to access the
dissociated experience that psychotherapy aims to integrate. To be most effective,
the self-inquiry I advocate should pose not only the key question – ‘What am I
actually doing with this patient?’ – but also two others aimed at deepening our
understanding: ‘What are the implicit relational meanings of what I’m doing?’
and ‘What might be my motivations for doing what I’m doing?’ As I’ll explain
shortly, the ¿rst question can best be answered when the therapist mobilises a
mindful stance, the next two when the therapist mobilises a reÀective or
mentalising stance.
Recognising our role in enactments can be a considerable challenge because we
are never altogether transparent to ourselves. We remain ignorant of much of what
we do, partly because it is simply an automatic, unreÀective expression of who we
234 David Wallin
are, and partly because we tend to suppress awareness of what might trouble or
unsettle us. The latter can be a particular problem for therapists whose history of
trauma has imposed dissociations, including – almost universally – dissociated
feelings of shame.
Adopting a stance of mindfulness – the centrepiece of a 2,500-year-old Buddhist
tradition – can help to overcome these barriers, because it breaks the trance of
conducting treatment as if we were on autopilot. When we aim to be mindful, it is
as if we ‘snap out of it’ by deliberately choosing to pay attention to our here-and-
now experience with the patient as, moment by moment, this experience unfolds
– neither judging nor evaluating it, but simply pausing to notice what we are doing
while we are doing it. Moreover, cultivating mindfulness promotes acceptance, so
mindfulness can function as an antidote to the shame that constricts self-awareness.
Finally, a mindful stance not only facilitates the recognition of our role in
enactments, but may also help to loosen their grip.
Simply asking ourselves what we’re doing with the patient is a kind of
‘mindfulness in action’ (Safran and Muran 2003) that allows us to grasp – at a
literal, explicit, ‘facts of the case’ level – the details of our participation in the
ongoing enactment. Then, having explicitly identi¿ed the nature of our action
(empathising, interpreting, offering advice, making a joke), we need to understand
its implicit meaning – particularly in the light of the relationship between our own
psychology and that of the patient. For again, the clinician’s attachment patterns
as played out in the therapeutic interaction are nearly always meaningfully related
to the attachment patterns of the patient. In trying to understand our conduct both
in terms of its implicit relational meanings and in terms of our motivations, our
key resource is our ability to mentalise – that is, to make sense of behaviour by
inferring the mental states (feelings, beliefs, desires) that underlie it.
With one rather prickly patient, for example, my initial self-inquiry –
mindfulness in action – allowed me to see that what I was actually doing early in
the session was . . . nothing. At the explicit behavioural level, I was making room
for the free Àow of the patient’s spoken thoughts by making sure to share none of
my own. Privately exploring the implicit relational meanings of my silence, I
recognised my fear that whatever words I spoke, my patient would experience
them as intrusive and hurtful – and would probably become angry. Yet I felt in a
bind, for if I could not speak, I could not help. And as for the question of my
motivation? I realised that with this particular patient (and no doubt with others as
well) I was bending over backwards to avoid experiencing myself as destructive.
Eventually I broke my silence by sharing my dilemma about speaking – wanting
to say something useful, but fearing his anger in response to words of mine that he
was likely to experience as disruptive incursions on his own thoughts. This
disclosure allowed him to share with me a related dilemma of his own: Should he
risk ‘letting me in’ when his history had proven that his only safety lay in
mobilising an off-putting ‘force ¿eld’ of ever-ready anger? As he went on to
describe the ‘three-headed monster’ (narcissistic father, seductive mother, sadistic
brother) against which his force ¿eld had originally been deployed, it suddenly
occurred to me that the fear of destructiveness that had shut me up was linked with
another kind of monster: a dreaded, shame-ridden facet of myself that I had
recently come to call the ‘Bug’.
Case Example: Jacob, the ‘Bug’ and me

To begin at the middle of this story, I will say that one memorable day I was
sitting with a patient who, despite a history replete with horri¿c trauma, seemed to
bear no visible scars. Apart from some discontent with the quality of his intimate
relationships, Jacob was apparently a very happy man who lived a charmed life.
Yet he lived, I felt, on the surface. To keep safely distant from the neglect, loss
and abuse of his traumatic past, he was distant from himself while letting no one
fully know him. To offset this distance and compensate for what (I felt) was
missing in his life – the experience of being known and deeply cared for as a
whole person – he indulged in various forms of ‘acting out’ that put him at
considerable risk.
On the day in question, Jacob was telling me with pleasure about still another
stroke of good fortune that had recently come his way; he followed this with some
uncurious words about his risky behaviour, a little as if he were confessing. Such
communications from Jacob were all too familiar to me, as were my responses to
them. To today’s good news, I responded as if I shared in his pleasure; to the
confession, as if his conduct were worth exploring in an effort to better understand
its meaning and allure. Then, rather suddenly, it struck me that the words I was
speaking to Jacob had begun to have a hollow sound and that his face in response
to them was unexpressive. Plainly something was off. Deliberately attempting
now to land in the present moment, I paused to silently inquire of myself, ‘What
was it that I was actually doing as I related to Jacob?’ I became aware of the effort
I was expending in order to be there for him, for it certainly was not coming
naturally. I realised that I had been operating as if on autopilot, without thoughtful
intention, almost compulsively offering Jacob what amounted to a kind of pseudo-
therapy. If I were to talk about what was really going on inside myself, I would
have to say something about my anger and my envy that Jacob seemed to be able
to do whatever he wanted whenever he wanted to do it – with no repercussions or
even pangs of conscience! I was extremely distressed at the intensity of what I was
feeling and tried, silently and privately, with little success, to make sense of what
I was experiencing. I felt immobilised and realised that, in fact, I had been
effectively immobilised for some time. I recognised that my patient and I were at
an impasse.
Taking a step back for a moment, I would say that sometimes as therapists we
are capable – having recognised the impasses in which we are lodged – of
understanding and resolving those impasses through diligent self-analysis and
dialogue, negotiation and exploration with the patient. On the other hand, there is
often truth to the old joke that the problem with self-analysis is the
countertransference. As I have mentioned, we are never completely transparent to
236 David Wallin
ourselves, in part because we are compelled to remain blind to sights that deeply
trouble us. Moreover, our capacity for useful reÀection is always compromised
when we ¿nd ourselves gripped by intensely disturbing feelings. Hence the
necessity at times for the ‘two-person mentalising’ available in the form of
consultation and the therapist’s own therapy, both of which I made use of in
attempting to resolve the impasse with Jacob.
In a small group consultation with colleagues Susan Sands and David Shaddock,
I talked about my experiences with Jacob – and speci¿cally the problem of doing
therapy with someone who communicates as if he has no problems. With an
obvious surplus of emotion I discussed the anger and envy I had recently become
aware I felt in the presence of this man who seemed to possess the psychological
and practical wherewithal to live with nearly perfect freedom. I also discussed the
repetitious and frustrating sequence of the work with Jacob’s high-risk behaviour:
how we would approach it, seem to get somewhere, then ¿nd it slipping off the
radar screen, only to have it reappear again – and again. The patient I sketched
seemed large and strong, capable of being intimidating – though I was not aware
of feeling intimidated. What I did often feel with Jacob was a sense of lack, as if I
had much less to offer than I usually feel I do. Sometimes it was hard to think
clearly or feel fully in his presence. At worst I could feel deadened or invisible.
Rarely did I feel needed.
About all this my colleagues had many useful things to say. But what opened
my eyes and my heart was Susan saying, ‘We now know about what it’s like for
you to be with him, but can you tell us something about how he got to be the way
he is? Something about his childhood?’ I literally felt stunned to realise that I had
not said a single word about Jacob’s experiences growing up, which were largely
experiences of coping with trauma. As I began to describe this lonely story of
constant squalor and intermittent horror, I had two nearly simultaneous images so
vivid that they were like living presences: The ¿rst was of Jacob as a helpless and
humiliated little boy; the second was of myself as a similar kind of little boy. And
what felt like the superimposition of our related – though certainly not identical
– experiences, one upon the other, brought me to tears. As I sobbed, the meaning
of the impasse with Jacob crystallised for me, virtually in an instant.
In my own therapy I had recently been struggling with a profound and disturbing
set of feelings that I had come to refer to as the ‘Bug’ (think: Kafka’s
Metamorphosis). I initially experienced these utterly excruciating emotional
sensations as nearly impossible to bear and no easier to name, though the visceral
sense they carried was that I was disgusting, destructive, dangerous. Because they
were inside me, or because I felt at some primal level that they simply were me,
there seemed no escape from them save through self-destruction. Perhaps needless
to say, I never believed that the Bug was all of me, so I could feel the self-
destructive impulses without feeling compelled to act on them. What I have come
to believe is that the Bug is a residue of my preverbal experiences with a mother
who found her baby’s needs (and undoubtedly her own needs) disgusting and
dangerous.
The emotional response to being treated as a bug is probably best summed up

with the word shame – the nearly intolerable pain of feeling not just that one has
done something bad, but that one is bad. In my own therapy I had stumbled upon
this dissociated pain and I was apparently averse to dragging Jacob – who I ‘knew’
intuitively was as vulnerable to it as I was – into that particular torture chamber.
Nor, evidently, did I wish to spend any more time there myself, even vicariously,
if I could somehow avoid it.
And so I had avoided it – by colluding with Jacob in living out a relationship
between the two of us in a safer realm where need, vulnerability and shame were
relegated to the sidelines. At centre stage in that psychological Green Zone were
variations on the theme of omnipotence (and, perhaps, impotence). Rather than
experience the danger of seeing or feeling in Jacob the shamed and fearful boy (or
baby) with whom I might painfully identify, I had been focused self-protectively
– if angrily, enviously and somewhat impotently – on the man who could do
anything.
Perhaps unremarkably, when I next met with Jacob our relationship had a
profoundly different and deeper ‘feel’ – I presume because, through Jacob in a
sense, I had further integrated a disowned part of myself. This allowed me both to
be more of a whole person when I was with him and to experience him as more of
a whole person. Of course, there was no ‘miracle cure’. But shortly after the
session we agreed to meet more frequently and to address in a more deliberate and
head-on fashion the ‘acting out’ with which we had previously grappled
super¿cially, only to let it slip away. In the sessions following that pivotal meeting,
Jacob also began to talk – often pointing with his hand in the direction of his belly
– about his vague, shameful sense of inferiority and its origin in the troubling
experience of his early years.
Concluding comments
My choice to concentrate in these pages on the impact of the therapist’s own
troubling origins and attachment patterns has to do, in part, with the fact that this
important matter tends to be slighted in most of the clinical literature – as it does,
I suspect, in much of our clinical practice – despite the fact that the primary
creative instrument of the therapist is a self whose resources and liabilities are
originally forged in the crucible of personal history. And as I have mentioned, the
therapist’s personal history is liable to be one that bears the scars of trauma.
In suggesting that the therapist’s attachment patterns are often shaped by
trauma, I am departing from a conventional view that patients and therapists alike
may be tempted to embrace – namely, that the vulnerabilities in the therapeutic
couple reside primarily if not exclusively in the patient. This view is a ¿ction that
may serve the hopes of the patient and the self-protective needs of the therapist.
But it is a ¿ction that diverts attention from the important reality that it is actually
the interaction of the attachment patterns of both partners – their strengths and
vulnerabilities, their integrations and dissociations – that ultimately determines
238 David Wallin
the extent to which a new and healing attachment relationship will develop in
psychotherapy.
I am proposing that we regard the therapist’s vulnerabilities, like those of the
patient, as integral and inevitable facts of life in psychotherapy. They are not
necessarily best understood as psychopathological. Instead they may be seen as
evidence of human imperfection. These vulnerabilities – in interaction with those
of the patient – can generate dif¿culties in therapy that present obstacles, but also
opportunities. When enactments engage the core vulnerabilities of the patient and
the therapist, there is a risk of rupture, to be sure, but there is also the potential to
provide the patient with a corrective relational experience and the therapist with a
chance to further his or her own ever-un¿nished psychological work.
In concluding, let me return to the point I asserted in the title of this chapter.
The therapist’s attachment history can indeed be a source not only of impasse but
also of inspiration – for there are unique advantages potentially bestowed upon the
clinician by the experience of an unhappy or traumatic childhood. Of course,
realising these potential advantages depends upon the clinician’s working through
and integrating much (though probably never all) of the pain and dif¿culty
imposed by such a childhood. It is the ‘earned security’ achieved through
subsequent attachment relationships in therapy, analysis and elsewhere that
eventually allows ‘the clinician’s wounds to serve as tools’ (paraphrasing Harris
2009). As wounded healers many of us know the patient’s struggles at ¿rst hand.
And having made the journey ourselves – at least part way from dissociation to
wholeness – we may be exceptionally well equipped to help patients undertake
their own healing journey.
References
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Goldbart, S. and Wallin, D.J. (1996). Mapping the Terrain of the Heart: passion, tenderness,
and the capacity to love. Lanham, MD: Jason Aronson.
Harris, A. (2009). You must remember this. Psychoanalytic Dialogues 19, 2–21.
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——(1999). Disorganization of attachment as a model for understanding dissociative
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Developmental Psychology 24, 415–26.
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Pearlman, L.A. and Saakvitne, K.W. (1995). Trauma and the Therapist: countertransference
and vicarious traumatization in psychotherapy with incest survivors. New York: Norton.
Safran, J. and Muran, C. (2003). Negotiating the Therapeutic Alliance: a relational
treatment guide. New York: Guilford Press.
Siegel, D.J. (2001). The Developing Mind: how relationships and the brain interact to
shape who we are. New York: Guilford Press.
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Index
Figures are shown by page numbers in italics.
abuse in childhood, 78–92, 206 attachment, 65; medically unexplained

activation of attachment system, 120–3, symptoms (MUS), 150–1; Ms D.s case,
184, 193 59; older adults, 187; transmission
active derogation, 202 between mother and infant, 164;
adolescents, 114 treatment of patients, 106; see also
Adult Attachment Interview, 6, 96, 117, anxious-ambivalent attachment
202; ‘cannot classify,’ 117; link to Apparently Normal part of the Personality
reÀective function, 29–30, 69; narrative (ANP), 82–3, 85, 88–9
styles, 26 appointment systems, 219–20
Adult Attachment Questionnaire (AAQ), 99 Ashworth hospital, 207–8
adult classi¿cation, 7, 113–17; see also attachment-based therapy, 174, 216–18
Adult Attachment Interview attachment cry, 81
affect regulation system, 39, 41, 43, 130–1 attachment ¿gures: for adults, 148;
af¿liation, 36, 38–41 controlling, 229; forensic services,
African Caribbean families, 170–80 202–3; healthcare provider, 150, 153;
aggression, 205; see also violence as safe haven, 153; see also caregiver;
agoraphobia, 53–4 parental relationship; therapists
aloneness, 40, 70 Attachment Narrative Therapy (ANT),
ambivalent insecure attachment, 5, 133; 135–42
see also anxious-ambivalent attachment attachment styles, 5–6, 95–7; in care
anger, 59, 202–3 settings, 191–2; clinical features of,
Anne’s case, long term care setting, 191–2 100–4; cultural differences, 170; gender
anorexia, 129–43 considerations, 164–5; transmission
ANP (Apparently Normal part of the between mother and infant, 163–4
Personality), 82–3, 85, 88–9 attention-seeking, 222
antisocial personality disorder, 98, 103, 200 avoidance of attachment, 83–4, 193
anxiety, 48–60, 97; role of caregiver, avoidance of rejection, 7
49–50, 192; see also anxious avoidance strategies, 83–4
attachment avoidant insecure attachment, 5, 51, 65,
anxious-ambivalent attachment, 97, 130, 66, 97; adult classi¿cation, 7; avoidant
133–4 dismissive attachment, 164;
anxious attachment, 48, 49–51, 56–7, 66; behavioural interventions, 58; in
exposure, 58; infant link to adult caregiver, 192; change in attachment,
242 Index
107; in childhood, 50; eating disorders, relationship, 129–31; secure

133; parental relationship, 131; attachment, 5, 49–50, 69, 80; sexual
personality disorders, 98; in therapy, abuse, 206; social development, 37; see
55–6; treatment trends, 106 also early attachment relationships
children’s homes, 172
bereavement, 67 classi¿cation of attachment, 5, 6–7, 63–5,
Bill’s case, dealing with illness, 189 96–7; adults, 6, 113–17; cultural
bio-medical framework, 216–18 differences, 170; see also Adult
blindness to attachment, 214–18 Attachment Interview
borderline personality disorder (BPD), clinicians: as attachment ¿gure, 150, 153;
97–8, 118–19; change in attachment, counter transference, 188; medically
106–7; disorganised attachment, unexplained symptoms (MUS), 151–2
113–23; mentalisation-based therapy, Coard, Bernard, 173
105; preoccupied attachment, 100–2; co-dependence, 203
violence, 203 Cognitive Behavioural Therapy, 16; for
boundaries of therapists, 206–8 anxiety disorders, 48–60; failure of, 35;
Bowlby, John, 4–8, 36, 40–1, 104–5, 183; medically unexplained symptoms
on feeding, 133; on gender, 161; (MUS), 156; older adults, 186–7;
internal working models (IWMs), 50, therapeutic alliance, 53–7
64, 95; on personality disorders, 97; cognitive interventions, 58–9
theory of loss and grief, 67 collaboration, 69–70
Buddhism, 43, 234–5 collisions, 227
bulimia, 129–43 collusions, 227
communication, 71, 154–5
‘cannot classify,’ 117 compassionate capacity building, 42
care co-ordination, 219–20 Compassion Focussed therapy (CFT), 35,
caregivers, 4, 5, 17, 54–5; abnormal 41–4
care-giving, 203; adult children, 191–2; complex developmental trauma disorders,
attacks on professionals, 203; 84–91
controlling-caregiving strategy, 227; conceptualisation, 51–2, 184–5, 187
disorganised infant attachment, 113–16; conÀict avoidance, 131, 192
excessive, 187; link to anxiety, 49–50, conÀict between attachment and loss, 87–8
192; mirroring, 64; supervision for, connectedness, 18, 19
222–3; see also mothers consistency, 187
care rejection, 204 contingency, 20, 27
care-seeking, 150, 203 controlling strategies: borderline personality
care settings, 172, 191–2, 204–8 disorder (BPD), 118–19; in childhood,
Caribbean communities, 170–80 116–17; controlling-caregiving strategy,
case conceptualisation, 51–2, 184–5, 187 227; as therapists, 232
Cassel Hospital, 107 corrective scripts, 132, 134
catastrophisation, 49, 190 counselling services, 174
change: in personality disorders, 106–7; counter transference, 87, 188
promoting, 28–30 cultural biases, 173–4
childhood: abuse in, 78–92, 206; adverse cultural differences, 170–80, 186
events, 64; controlling strategies,
116–17; disorganised attachment, D-attachment: see dissociation
113–16; inÀuence on adult attachment, deactivation of attachment, 5–6, 17, 63–4;
65, 95, 97, 213–14; parental exposure to past pain, 28–9; in
Index 243
therapists, 229; see also dismissive importance into adulthood, 97, 213–14;
attachment see also childhood; infant attachment
defensive strategy, 5, 7, 36, 67, 80; eating disorders, 129–43; anxious-
dissociative attachment, 81–2; EP ambivalent attachment, 133–4;
(Emotional part of the Personality), 83; Attachment Narrative Therapy (ANT),
threats, 80–1 135–42; case study, 136–42; corrective
dementia, 187, 193–4 scripts, 134; generational patterns, 132,
dependency: co-dependence, 203; 134, 135; parental relationship, 134;
dependent personality disorder, 97; fear secure base, 135; triangulation, 134,
of, 166–8; honouring, 222; older adults, 142–3
188–94; preoccupied attachment, 100–2 ego distortion, 178
depersonalisation, 220 Emotional part of the Personality (EP), 83,
depression, 35–44, 85, 187 87; trauma-time, 85, 86, 89
developmental attachment history, 113–17, emotions: af¿liative, 36; communication,
200 72–3; Compassion Focussed therapy
dialectical behaviour therapy (DBT), 107, (CFT), 35, 41–4; connectedness, 18,
120–3 19; Emotional part of the Personality
Dickens, Charles, 213 (EP), 83, 85, 86, 87, 89; female
discharge from hospital, 218–19 attachment styles, 164–5; marking,
dismissing state of mind, therapists, 21–2, 27; motivational systems, 38–40;
229–30 positive, 37; regulation of, 21;
dismissive attachment: Adult Attachment suppression of, 50; unexpressed
Interview, 96; avoidant dismissive feelings, 28–9
attachment, 97, 164; insecure- empathy, 21, 27, 37, 73, 202; ‘mind
dismissing attachment, 65–7; link to blindness,’ 218; older adults, 185
personality disorder, 99, 100; link to endorphins, 38, 40
violence, 201–2; medically unexplained Eve’s case, Caribbean community, 171–2
symptoms (MUS), 149; older adults, evolution of attachment, 35–6, 43–4, 80–1
183, 185, 186, 189, 192; parental exploration, 17, 58, 135
relationship, 130–1; personality exposure, 28–9, 58
pathology, 102–3; treatment trends, externalising strategies, 66
106; see also deactivation of
attachment Factitious Illness by Proxy, 203
disorganised attachment, 7, 23, 63–4; family context: African Caribbean
Adult Attachment Interview, 96, 117; families, 170–80; attachment patterns,
aggression, 205; borderline personality 129–30; medically unexplained
disorder (BPD), 113–23; ‘disorganised- symptoms (MUS), 155; in therapy, 131,
disorientated’ in infancy, 6–7; infant 179; violence, 202–3
link to adult attachment, 65; role of fear, 6, 80–1, 205
caregivers, 113–16; transmission fearful attachment, 117, 149, 152, 183;
between mother and infant, 164; fearful avoidant, 97, 99, 104, 106;
treating, 72 ‘fright without resolution,’ 40–1, 115
dissociation, 78–92; dissociative feeding infants, 133, 213
attachment, 81–3, 90–1; Marge’s case, feelings: see emotions
88 female attachment styles, 164–5
feminity, 161–8
early attachment relationships, 64, 69; food, 133–4, 213; see also eating disorders
abuse in childhood, 78–92, 206; forensic mental health care, 199–209
244 Index
formulation: of eating disorders, 133–4; of staff, 206–8; see also avoidant

older adults, 184–5; in therapy, 25; insecure attachment; dismissive
treating psychosis, 70 attachment
Freud, Sigmund, 25 institutional settings, 172, 191–2, 204–8
‘fright without resolution,’ 40–1, 115 integration of personality, 90–1
internal working models (IWMs), 4–5, 49,
gender considerations, 161–8 64, 69, 200; in borderline personality
generational patterns, 132, 134, 135, 179 disorder (BPD), 120–3; comparison
genetic inÀuence, 114 to schemas, 50–1; disorganised
Goal Corrected Empathic Attunement attachment, 114–15, 116; link to adult
(GCEA), 22, 23 attachment, 50; in older adults,
grandparents, 172 184–5
Greg’s case, phobia of intimacy, 91 interventions: behavioural, 56–7, 58;
grief, 67, 192–3 cognitive, 58–9; mentalisation-based
therapy, 105; in older adults, 186–7
health and safety culture, 220–1 interview, 96
healthcare provider, 150, 153 intimate relationships: phobia of, 90–1;
Help me love my baby, TV documentary, violence within, 202–3
214 Israel, 184
help seeking, 204–5
histrionic personality disorder, 100–2 Jacob’s case, 235–7
homelessness sector, 222 Jamaica, 171–3
hormones, 36–7 Japan, 170
hunger, 133 Julia’s case, dementia care, 194
hyperactivation, 17, 18, 63–4; in
childhood, 5, 50; exposure to past pain, Kathy’s case, eating disorders, 138–42
28–9; in therapy, 55 key workers, 220
hypochondriasis, 57 Klein, Melanie, 174
illness, 185, 189 language in therapy, 25–6

imagery, 43 Levy, Andrea, 171
independence, 165 life review, 189
infant attachment, 4–7, 64–5, 163–4, lifespan attachments, 183–4
213–14; gender considerations, 161–2; Linda’s case, relocation, 190
reciprocal bonds, 174–5; see also early loneliness, 70
attachment relationships loss, 67, 72, 186, 188–94
inferiority, 36 love, 7, 19, 96–7, 98–9
in-patients, 218–19
insecure attachment, 5, 17, 50; ambivalent Main, Mary, 64–5, 96
insecure attachment, 5, 133; forensic male attachment styles, 164–5
services, 208; insecure-dismissing mammals, 35–6
attachment, 65–7; link to anxiety, 48, Marge’s case, dissociative disorder, 88
49–51; link to personality disorder, 98; marking emotion, 21–2, 27
medically unexplained symptoms masculinity, 161–8
(MUS), 152; older care recipients, 192; mastery in therapy, 24–5
organised, 23; parental relationship, maternal aspects of therapeutic
130; to perpetrator of abuse, 89–90; relationship, 24–5
professionals, 206–8; psychosis, 65–7; meaning-making, 25–8, 189
Index 245
medically unexplained symptoms (MUS), neglect, 78–92

145–56; current approaches, 146–7; neurophysiology, 38–40
managing, 152–5 nursing staff, 205; insecure attachment,
medical service culture, 217–18 206–8; personalisation of services,
memories, 89–90 219–20
men, 161–8
mental health services: availability, 221; Obsessive Compulsive Disorder (OCD),
blindness to attachment, 214–18; 55–6
criticism, 216–18; forensic, 199–209; older adults, 183–95
improving, 218–23; personalisation of organisational structure, 222–3
services, 219–20; treating psychosis, organised attachment, 23
73–4 out of hours services, 221
mentalisation, 64, 215; borderline oxytocin, 36–7
personality disorder (BPD), 123;
disorganised attachment, 116; family panic disorder, 53–4
context, 132; mentalisation based paranoid attachments, 104, 203
treatment (MBT), 105, 121, 123, 201; parental relationship, 142–3; attachment
‘mentalising,’ 6, 29–30, 42, 233–5; patterns, 129–31; eating disorders,
psychosis, 68–9 130–1, 134, 142–3; parental love, 19;
migration, 174 scripts, 132
‘mind blindness,’ 218 parent-infant therapy, 214, 216
mindfulness, 233–5 paternal aspects, 24–5
mind training, 43 perpetrator-imitating, 89–90
mirroring, 20–2, 27, 64, 215 personalisation of services, 219–20
monotropy, 121–2 personality: development, 215; dissociative
Morrison, Mary, 136–8 attachment, 82–3, 90–1
mothers: affect regulation, 130–1; personality disorders, 7, 95–108; change in
attachment styles, 163–4; empathy, 21; attachment, 106–7; forensic services,
gender considerations, 161–8; 199–201
interaction with infant, 20–2, 23; phobias: of attachment, 86–7, 119; of
triangulation, 22 dissociative parts, 88–9; of inner
motivational systems, 38–40 experience, 86; of intimacy, 90–1;
mourning, 67 trauma related, 83–4; of traumatic
Mr A.s case, panic disorder, 53–4 memory, 90
Mr B.s case, Obsessive Compulsive positive emotion, 37
Disorder (OCD), 55–6 positive priming, 28–9
Mr M.s case, dismissive attachment, 103 Post Traumatic Stress Disorder, 173
Ms C.s case, hypochondriasis, 57 prejudice, 173–4
Ms D.s case, anxiously attached patient, 59 preoccupied attachment: Adult Attachment
Ms.D.s case, histrionic personality Interview, 96; adult classi¿cation, 6, 7,
disorder, 101 97; after trauma, 99; dependency, 100–2;
Ms N.s case, narcissistic personality, 104 link to personality disorders, 98–100;
Multiaxial Clinical Inventory (MCMI), 99 medically unexplained symptoms
multi-disciplinary teams, 73–4 (MUS), 149, 151; older adults, 183, 185,
192; parental relationship, 130–1;
narcissistic personality, 97, 98, 103, 104 personality pathology, 100–2; treatment
narrative styles, 26–7, 72 trends, 106
negative affect, 72 preoccupied state of mind, therapists, 230–1
246 Index
preoccupied strategies: see safe haven, 4, 39, 42–3, 70, 153;

hyperactivation characteristics, 73
present time, 86 safety, 51, 79–80, 85, 185, 220–1
professionals: forensic services, 206–8; Samaritans, 221
support for, 222–3; see also clinicians; schemas, 50–1, 54–5, 58
nursing staff; therapists schizoid personality disorder, 97
projection, 206 schizophrenia, 68, 173–4
protest, 134 scripts, 132
proximity, 27–8 ‘sealing over’ recovery style, 67–8
psychiatric units, 221 secure attachment: Adult Attachment
psychoanalysis, 25–6 Interview, 96; adult classi¿cation, 7,
psychodynamic supportive psychotherapy 97; after trauma, 99; in childhood, 5,
(PST), 107 49–50, 69, 80; infant link to adult
psychological safety, 220–1 attachment, 65; medically unexplained
psychopathology, 7, 63–5 symptoms (MUS), 148; older adults,
psychosis, 63, 65–74 183; parental relationship, 130–1;
psychotherapy, 23, 104–5, 106, 225; within therapy, 18; transmission
Caribbean communities, 174; between mother and infant, 163–4
importance of attachment, 215; secure base, 4, 5, 17, 39, 42–3; behaviour,
mentalising skills, 30; therapists 51; CBT therapist as, 52–3, 54;
vulnerabilities, 238; treatment characteristics of, 73; eating disorders,
outcomes, 107–8 135; emotional connectedness, 19;
psychotic patients, 66–7 internal, 68; multi-disciplinary teams,
73–4; in therapy, 29; treating psychosis,
racism, 173–4 71
Raul’s case, caregiver, 193 secure state of mind, therapists, 228–9
recovery, 67–8 self, sense of, 72, 82–3, 102, 104;
referencing, 22 borderline personality disorder (BPD),
reÀective dialogue, 71 118–19; false self-presentation, 173,
ReÀective Function, 29–30, 68, 69, 178; gender considerations, 168; lack
132 of concern, 201–2; older adults, 186;
reframing, 25 personality disorders, 98
regulation of emotion, 21 self-enquiry, of therapist, 233–5
relational disorders, 200 self-esteem, 37
Relationship Questionnaire (RQ), 99 self-nurturing strategies, 73
relaxation techniques, 154 self-protection, 38
relocation, 190 self-regulatory skills, 86, 153–4
repair, 71–2 self-reliance, 7, 229
‘re-parenting,’ 222 self-report, 96–7
replicative scripts, 132 self-soothing, 179
representation, 26 self-suf¿ciency, 7, 229
residential care, 204–8 separation: in Caribbean communities,
response to therapy, 74 171–3; evolution of attachment, 35–6;
‘revolving door’ culture, 222 infant attachment, 5, 24–5, 113; older
romantic love, 7, 96–7, 98–9 adults, 188–94
rupture: discharge from hospital, 218–19; Service Attachment Questionnaire (SAQ),
and repair, 23, 71–2, 121–2 220–1
Russell, Bertrand, 29 sexual abuse, 206
Index 247
sexualised attachment, 206 meaning-making, 25–8; older adults,

shame, 40–1, 44; de-shaming processes, 184–8; positive priming, 28–9;
43; evolutionary roots, 37; link to psychotic patients, 66–7; treating
depression, 36; in therapists, 234 psychosis, 69–70, 71–2
Simon’s case, medically unexplained therapists: bene¿ts of two, 121–2;
symptoms (MUS), 145, 150, 155 boundaries of, 206–8; as caregiver,
slavery, 180 179; counter transference, 87, 188;
Small Island, 171 gender considerations, 166–8;
social attention holding potential (SAHP), ‘observing distance,’ 72; own
37 attachment type, 17–18, 225–32;
social competition, 37 personalisation of services, 219–20;
social engagement system, 79–80 providing a secure base, 54; rupture and
socialisation, 167 repair, 23; secure state of mind, 228–9;
social relationships, 66, 186 setting boundaries, 88; state of mind,
sociocultural considerations, 186 228–32; triangulation, 22;
sociopathy, 103 vulnerabilities, 238
soothing af¿liative system, 38, 39, 40, 41, therapy: attachment-based therapy, 174,
179 216–18; Attachment Narrative Therapy
space, in therapy, 24 (ANT), 135–42; Compassion Focussed
staff, 205, 206–8, 219–20 therapy (CFT), 35, 41–4; dialectic
state of mind, of therapist, 228–32 behaviour therapy (DBT), 107, 120–3;
Steve’s case, Caribbean communities, Goal Corrected Empathic Attunement
175–9 (GCEA), 22, 23; goals, 188; meaning-
stigmatising, dependency, 222 making, 25–8; mentalisation based
‘still face,’ 23 treatment (MBT), 105; parent-infant
‘strange situation,’ 5, 24–5, 113 therapy, 214, 216; psychodynamic
submission, 36 supportive psychotherapy (PST), 107;
suicide, 218, 221 systemic family therapy, 131; ‘talking
suppression of emotion, 50 therapies,’ 216; termination of, 188;
Susan’s case: depression, 18–19, 21, 25; Transference Focused Psychotherapy
psychosis, 70 (TFP), 106–7, 121, 123; see also
syphilis experiment, 174 Cognitive Behavioural Therapy
systemic family therapy, 131 threats, 4, 17, 44, 48–60; affect regulation
system, 38; older adults, 184;
‘talking therapies,’ 216 perceived, 201; see also defensive
Tarasoff, Tatiana, 203 strategy
team working, 154–5 tolerance for treatment, 85–6
terminology, gender considerations, 162 training, 208
‘Theory of Mind,’ 68 transference, 17, 19, 87, 188
therapeutic alliance, 53–7, 69, 88–9, 121–2 Transference Focused Psychotherapy
therapeutic base, 135 (TFP), 106–7, 121, 123
therapeutic community, 222 transition, in-patient care, 219
therapeutic relationship, 8, 16–25; trauma, 72, 78–92, 99; ‘trauma time,’ 85,
borderline personality disorder (BPD), 86, 89
118–19, 120–3; criticism of medical treatment: attachment styles, 105–6;
service culture, 218; establishing safety, borderline personality disorder (BPD),
85; gender considerations, 166–8; 120–3; change in attachment, 106–7;
importance of attachment, 215; complex developmental trauma
248 Index
disorders, 84–91; forensic services, unresolved state of mind, therapists, 231–2

202; gender considerations, 166–8; USA: attachment styles, 170; Caribbean
perpetrator-imitating, 90; preoccupied communities, 179–80; older adults,
attachment, 106; psychosis, 69–73; 184, 186; racism, 173
psychotherapy, 107–8; tolerance for,
85–6; see also therapy vagal nerve, 79–80
triadic perspective, 130–1 violence, 201–2, 207–8
triangulation, 22, 27, 134, 142–3
trust, 37 well-being, 215, 216–17
Tuskegee syphilis experiment, 174 West Indies: see Caribbean communities
women, 161–8; see also mothers
United Kingdom, 171–4 Women’s Therapy Centre, 166
unresolved attachment, 96; see also World War Two, 183
disorganised attachment

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Attachment Theory in Adult

Adam N. Danquah is a clinical psychologist in Pennine Care NHS Foundation

Katherine Berry is a postdoctoral research fellow at the University of Manchester,

A guide to clinical practice

Edited by Adam N. Danquah and

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

ISBN: 978-0-415-68740-9 (hbk)

Typeset in Times and Gill Sans

2 Attachment theory in therapeutic practice 16

3 Attachment theory and compassion focused therapy

4 Responding to threat: using attachment-related interventions in

5 Attachment theory and psychosis 63

6 Understanding attachment, trauma and dissociation in

7 Attachment theory and personality disorders 95

8 Disorganised attachment in the pathogenesis and the

9 Starving for affection: attachment narrative therapy

10 An attachment perspective on understanding and

11 Bringing a gendered perspective to attachment theory

12 Attachment in African Caribbean families 170

13 Meeting the mental health needs of older adults using the

14 Four pillars of security: attachment theory and practice in

15 Using attachment theory to inform psychologically minded

16 We are the tools of our trade: the therapist’s attachment

3.1 Three types of affect regulation system 39

Adam N. Danquah is a clinical psychologist in Pennine Care NHS Foundation

Katherine Berry is a postdoctoral research fellow at the University of Manchester,

Gwen Adshead is a forensic psychiatrist and psychotherapist. She trained at St

Anne Aiyegbusi is Interim Director of Nursing and Patient Experience at West

Rudi Dallos is Professor of Clinical Psychology and research director on the D

Paul Gilbert OBE is Professor of Clinical Psychology at the University of Derby

Andrew Gumley is a clinical psychologist and Professor of Psychological

Jeremy Holmes worked for 35 years as a consultant psychiatrist and

Jonathan J. Hunter is an associate professor at the University of Toronto, where

Kenneth N. Levy is a tenured associate professor in the Department of Psychology

Giovanni Liotti is a psychiatrist and psychotherapist who currently teaches at the

Brent Mallinckrodt is a professor in the Department of Psychology at the

Robert G. Maunder is associate professor in the Department of Psychiatry at the

especially the impact of interpersonal relationships on health. Since the 2003

Kevin B. Meehan is an assistant professor in the Department of Psychology and

Gail Myhr is an associate professor of psychiatry at McGill University, Canada.

group of the British government’s Campaign for Body Con¿dence. Susie is

Cecilia Yee Man Poon is a postdoctoral fellow in clinical health psychology at

Matthias Schwannauer, MA, MSc, DPsych, Ph.D, CPsychol, AFBPsS, is a

Martin Seager is a clinician, lecturer, campaigner, broadcaster and activist on

Kathy Steele, MN, CS, is clinical director of Metropolitan Counselling Services,

Christina M. Temes is a graduate student in clinical psychology at the

Onno van der Hart is Emeritus Professor of the Psychopathology of Chronic

David Wallin is a clinical psychologist in private practice in Albany and Mill

therapeutic distance, which underscores the importance of creating different

compulsive self-reliance, an estrangement from emotion and an avoidance of

infancy is an unresolved state of mind in the adult. This category is associated

Outline of the book

Brennan, K. A., Clark, C. L. and Shaver, P. R. (1998). Self-report measurement of adult

Evidence suggests that what happens in consulting rooms is at best tenuously

The therapeutic relationship

attachment/exploration cycle, in which the actuality of what the therapist offers,

Contingency and marking

vocalisations in jazz-like improvisation around them, were more security-

Rupture and repair

‘Paternal’ aspects of the attachment/therapeutic relationship

shared meanings – is in itself soothing. As in any intimate relationship – spousal,

Narrative styles and the meaning of meaning