Attachment in Mental health and Therapy

Proximity seeking as primary drive
Secure base
Internal Working Model to replace structural
Later theorists:the attachment system as the
site for formation of the self, of agency and
of affect regulation
An “internal working model” contains our
expectations for how current and future
relationships will unfold, and for how we will
experience ourselves and others in that
relationship. These are symbolic or
representational mud-maps that determine
how we perceive, edit, and interpret our
relationship experiences. Because these mudmaps shape our response to others, they also
shape the actual relationship dynamics, and
so become self-reinforcing.
McLeod’s “if-then” contingencies
Stern’s “RIGs”
Symbolic Attachment (Wallin)
“drama triangle” (Liotti):
Internal Working Models are not intra-psychic:
they are intersubjective
The Strange Situation
Categories of Infant Attachment Behaviour
Secure Infants
Anxious/Avoidant Infants
Anxious/Resistant Infants
Disorganised Infant Attachment
Adult Attachment Inventory
Adult Attachment Styles:
- Autonomous/Free/Secure
- Dismissing/Avoidant
- Preoccupied/Enmeshed/Ambivalent
- Unresolved (for Loss or Trauma)
Earned Security
Fonagy et’al “reflective function”, “mentalizing
Comfortable in relationship settings. Readily
contribute to interdependent relationships
as a springboard for engaging in the wider
Less distressed by interpersonal conflict.
Able to engage in productive, task-oriented
Less preoccupied with the need to elicit
positive regard from others or the need to
avoid closeness with others.
Desire closeness but become anxiously preoccupied
by how others regard them. This can limit their
ability to explore the outside world, other
relationships or even work and hobbies.
Their ability to develop interdependent and
cooperative relationships can also be limited.
Have a need for experiencing acknowledgement,
praise, being valued, acceptance, support and
being included.
On the other hand, can tend to dislike intrusiveness
by others and can mistrust positive relatedness as
phony or unreliable. (ambivalence)
Compulsively self-reliant, dismissing needs
for closeness for selves and others.
May naturally engage in negative or
unproductive conflict.
Efforts to develop inter-dependant
relationships at work and in community
compromised by the need to avoid group
Likely to interpret efforts for closeness by
others as intrusive and demanding.
The person is not the
“We’re all individuals” (Brian)
“I’m Not”
The act of reflecting on one’s own mental
representations of self and other (and
associated feelings); AND – at the same time
– being able to reflect upon the other
person’s mental representations, feelings,
and intentions.
Moreover, it involves perceiving the connection
between one’s mental state and that of the
other person.
A series of studies show that 72% have same
attachment classification at 18 months (SS)
and at 21 years of age (AAI)
(David,Kaplan,Mayes 2010)
Unresolved for loss or
Prompt responsiveness to distress, NonIntrusiveness, Interactional Synchrony, Warmth
Mid-Range Tracking of Child’s Affect (Beebe and
Lachman 2002)
Contingent and Marked Mirroring
Containment – understand the cause of distress
- do not join in their distress
- recognise their intentional stance
Mirroring Meta-Cognitive Capacity
Repeated cycles of attunement, misattunement, and
reattunement (Schore 2008)
REPAIR –GOTTMAN and couples
This involves exquisite synchronisation of facial
expressions, mirroring of emotions and
anticipation of each other’s intentions.
“Mirror neurones” (Johnson, 2009; Rothchild 2000) allow each
person to know the other from the inside out
through associated stimulation of the autonomic
nervous systems.
Oxytocin is released creating a cascade of
pleasurable and comforting body experiences.
“Each person’s mind and emotion are attuned to the
other’s. Each person knows the other’s mind and
recursively knows that he or she exists in this
mind.”(Johnson, 2009,p273)
Individuals categorised as “secure” are 3 to 4
times more likely to have securely attached
children (van Ijzendoorn1995; Ward & Carlson
80% of children with Disorganised Attachment
(SS) have parents with Unresolved Attachment
Style (AAI)
Genetics and child temperament are only minor
determinants of attachment pattern (Belsky et,al
1995, Liotti 2005)
Slade 2005, Arnott & Meins 2007: Attachment
style of caregiver and metacognitive ability of
caregiver are predictive of child’s attachment
style and meta-cognitive capacity
Secure attachment (AAI) coorelates with greater intimacy in close
relationships (Hazan & Shaver 1993, Borelli&David 2004)
Insecure attachment (AAI) results in less effective stress
management (Scheidt et,al 2000)
Adult attachment behaviour shapes one’s experience of, and
behaviour in, group contexts generally. (Markin & Marmarosh,
2010; Rom&Mikulincer 2003).
Feeney (et,al 2008) demonstrated that a person’s attachment
style determines how they engage in and shape new
relationships with people – in both social and work
Secure attachment (AAI) protects adolescents from risk-taking
behaviour (Wills & Cleary 1996)
Adolescents with secure attachment patterns with their
parents are more able to launch and create interdependent
adult relationships (Allen&Land 1999, Noom et,al 1999).
Adults who experience secure and reliable dependence with their
spouse are more able to explore and perform independently
away from their spouse (Feeney,2007; Elliott, 2003).
Disorganised (SS) and Unresolved (AAI) Styles are strongly
correlated to disorders of both axes, especially BPD (Schore
2002, Fonagy et,al 2006) and PTSD (Liotti 2005) and eating
disorders (david et’al 2010)
Avoidant Attachment is associated with obsessional, narcisistic
and schizoid problems (Bouchard et,al 2008; Wei et,al 2005)
Preoccupied/Ambivalent Attachment is asscociated with
borderline and hystrionic difficulties (Schore 2002, Slade 1999,
Sable 1997, Shorey & Snyder 2006))
Improvements in attachment relationships protect people from
and reduce symptoms of Post Traumatic Stress Disorder (Muller
& Rosenkranz 2009; Mills,2008; Verhaeghe et,al 2005).
Interrelationship between insecure attachment patterns and
mood disorders (Wei et,al 2005) (West 2002)
Correlation between Reflective Function, Mentalizing capacity
and disorders of both axes (Fonagy et,al 1997, 2006)
Psycopathy and autism have been described as disorders of
menatalization (Fonagy et’al 2006)
Mentalized Affect - Jurist
Interpersonal Affect Regulation
The Dependence-Independence Paradox
Positive Dependency – Solomon
Poor emotion regulation, poor impulse control,
volatility of relationships and self-image, psychotic
Fragile mentalizing capacity vulnerable to social
Primary difficulty is a loss of mentalizing arising from
failures in early attachment (Schore, Fonagy et,al;
BPD is strongly associated with insecure attachment
(only 6-8% are classified as secure) and most strongly
associated with Disorganized Attachment (Levy 2005)
Causes are abuse, neglect and gross failures in
mentalizing responsiveness by parents (Fonagy &
Primary Focus is on emotion regulation – immediate threat to treatment
Containment – validate their distress
- manage your own reactions
- validate their intentional stance
Reinstate mentalizing when it is lost or to help maintain it when loss is
Maintain an active, collaborative, not-knowing stance
Ask “what” questions rather than “why”
Match intervention to mentalizing capacity, de-prioritise insight and
interpretation and cognitive-based prescriptions
Actively manage enactments and schisms in the alliance
Introduce alternate representations tentatively and collaboratively
Be up front about your own thoughts and feelings as a way of
introducing alternative constructions
Tight-rope of workable tension and emotion storms
Switching focus between mental states of self and other
Developmental Thread from Disorganised
Attachment (SS) to Unresolved Attachment (AAI)
and Dissociative Disorders (including DID) and
vulnerability to PTSD after a traumatic incident
(Liotti 2004, Steel & Steele 2003)
Dissociative phenomena found from childhood
through adulthood in Disorganised Attachment
Traumatic experiences trigger the attachment
system: all insecure attachment types more
vulnerable to PTSD
in unresolved attachment, attachment traumas are
triggered and vulnerability to dissociative
symptoms are amplified including peri-traumatic
Qld Ambulance policy
 Fonagy et,al: attachment trauma includes abuse and neglect but also
failures of responsive mirroring
 Viscious Cycle of Traumatic Symptoms and current Attachment
dynamics – implications – one context of trauma reinforces the other
context of trauma
 Attention to attachment system must take primacy over exposure
 i.e. heuristic attention to :
 a) material from childhood attachment traumas
 b) material from current attachment traumas
 c) optimising secure attachment experiences in the current
therapeutic setting
Supporting Mentalizing when it is at risk, reinstating mentalizing when
it is lost.
 Liotti: delayed memories and delayed dissociation when significant
change in relational
Secure Base
The primacy of emotions
Mentalizing Emotions
Interpersonal and Personal Affect Regulation
The tight rope of working with Attachment Systems
Managing Enactments,Managing Affect Storms, Transference
Providing Experiences of Secure Attachment – Mirroring,
Containment, Intersubjectivity as opposed to Re-Parenting
Focussing on Enhancing Mentalizing Capacity
Modifying Interventions to match their Mentalizing Capacity
Keeping an eye on the Systemic
Principles of Containment
Softening (Johnson) Responses
crucial with severe disturbance (Schore 2008)
“Not only is the therapist being unconsciously
influenced by a series of slight and, in some
cases, subliminal signals, so also is the patient.
Details of the therapist’s posture, gaze, tone of
voice, even respiration, are recorded and
processed. A sophisticated therapist may use this
processing in a beneficial way, potentiating a
change in the patient’s state, or in a addition to,
the use of words.” Schore, 2008
David is a 55 year-old ambulance driver , 25 year career
He has not previously had trouble with traumatic experiences until recently.
He is being troubled by fragmented memories from various jobs over the
He is experiencing depression and a difficulty in maintaining concentration.
He has stopped going to his woodworking club and dreads going to work
and feels antipathy toward managers and supervisors. He particularly resents
heaving to bear the brunt of his work while he is required to constantly
“babysit” new paramedics.
He feels a pervading sense of being on his own with his experience,
believing no one cares about his plight. He feels the ambulance service is
oblivious to his experience. He deplores the loss of camaraderie and support
that had come with years of organisational restructuring and emphasis on
The event that appears to have triggered his difficulties was a job where he
attended the death of an elderly woman from a heart attack. He remembers
vividly the scene: Beside the body was her adult son, crying uncontrollably,
begging for him to help.
This scene exposed David’s grief for the loss of his mother 12
months before - grieving he had deferred because of his
ambivalence toward his mother (indicating attachment
Therapy familiar approaches such as titrated exposure, unpacking
his complicated grieving and boundary marking between his and
other people’s trauma
what David reported to be most useful was including his wife in
therapy sessions and working on the way difficult emotions were
dealt with in that relationship
Once he had re-established this relationship as a secure base and
as a context for affect regulation, David was psychologically
available for working on his issues of traumatic stress and
unresolved grief.
He was able to reengage in his workplace, was less preoccupied
by the responsiveness of colleagues and the organisation in
general. He was able to access more benign representations of
others at work – that they too were just trying to get by with
demands and new realities in their own way.

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