Attachment Theory in Adult Mental Health

A guide to clinical practice

Adam N. Danquah, Katherine Berry, Adam N. Danquah, Katherine Berry

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134675319
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychothérapie

In the fifty years since its inception, John Bowlby's attachment theory has been powerfully influential 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 which 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, among others, the treatment of depression, anxiety disorders, psychosis, personality disorder and eating disorders. Section Three addresses the needs of specific populations, discussing the influence of sociocultural factors like 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 field, Attachment Theory in Adult Mental Health is ideal for psychologists and psychological therapists, counsellors, psychiatrists, occupational therapists, social workers and mental health service managers and commissioners.

Section I

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Attachment theory and practice – the basics

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Chapter I

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Introduction

Katherine Berry, Adam N. Danquah and David Wallin

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Background

In the fifty 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 influence 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 field (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 find it difficult 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.

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 defined as an affectional bond that a person forms with a ‘differentiated and preferred individual’ or attachment figure who is approached in times of distress (Bowlby 1979). The attachment bond is conceptualised as persistent and emotionally significant, and is associated with a desire for close proximity to, and distress following involuntary separation from, the attachment figure (Bowlby 1969, 1973, 1980). The attachment figure 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 figure 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 influence – 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 figure. 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 significant 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 reflect 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 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 classified as secure or insecure, with the insecure category subdivided into ambivalent or avoidant categories (Ainsworth et al. 1978). Infants classified 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 classified 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 difficult to soothe upon reunion, seeking contact with the caregiver while also resisting angrily or with upset. Infants classified 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 (Weinfield 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 classified 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 figures 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 classified 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 identification 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 figure 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 figure 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 reflects a breakdown in attachment organisation, as a result of their profoundly disturbing and fundamentally irresolvable conflict about whether to approach or avoid the attachment figure (Fraley and Shaver 2000).

The initial research sparked by Bowlby's theorising led to the identification of the attachment classifications of infancy, as summarised above. Subsequent research has led to the classifications 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 first group – Main, Fonagy, Sroufe and others with a developmental or psychoanalytic orientation – rests on findings that suggest that individual differences in attachment relate to the organisation of mental representations of earlier attachment figures. 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 reflect upon their own attachment relationships (Main, Kaplan and Cassidy 1985). The AAI classifies 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 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 influence 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 classified 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-sufficiency 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...