The Routledge Handbook of Attachment: Implications and Interventions

Paul Holmes, Steve Farnfield, Paul Holmes, Steve Farnfield

• Publisher: Routledge
• Year: 2014
• Topic: Psychology
• eBook ISBN:
  9781317653813
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Routledge Handbook of Attachment: Implications and Interventions offers an introduction to therapies produced as a result of the popularity of attachment studies. These therapies can be divided into two categories: those that are 'attachment-based', in that they use evidence-based attachment assessments in their development, or 'attachment-informed', in that the theories of attachment have been integrated into the practice of existing schools of therapy.

The book reviews the field and provides a range of interventions for children, adults and parents, beginning with a detailed review of both evidence-base and evidence-informed interventions including individual psychotherapy, family therapy and parenting. The remaining chapters provide accounts, from the practitioner's perspective, of interventions that address issues of attachment from the level of one-to-one therapy, family and social work to social interventions involving courts and Care Proceedings, illustrated with examples from day-to-day practice.

Discussing how an understanding of formal assessments of attachment can be used to inform therapeutic, social and legal interventions to assist and protect children, The Routledge Handbook of Attachment: Implications and Interventions is an indispensable guide for clinical psychologists, psychiatrists and social workers working with children and families, clinicians in training and students.

Chapter 1

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Introduction

Steve Farnfield and Paul Holmes

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A great deal of work needs doing before we can be confident which disorders of attachment and care-giving behaviour are treatable by psychotherapy and which not and, if treatable, which of various methods is to be preferred.

(Bowlby 1979/2005: 171)

John Bowlby, the founding father of attachment theory and research, trained both as a psychiatrist and as a psychoanalyst. His early seminal book Child Care and the Growth of Love (1953) grew out of a report he wrote for the World Health Organization commissioned to study the needs of ‘children who are orphaned or separated from their families for other reasons and need care in foster homes, institutions or other types of group care’ (Bowlby 1953: 7).

Bowlby’s interest in developing a research-based understanding of the consequences of childhood trauma, loss and separation was always linked to consideration of effective and logical therapeutic interventions. He struggled with his own personal psychoanalytic heritage and always intended his contribution as ‘an up-to-date version of psychoanalytic object relations theory, compatible with contemporary ethology and evolution theory, supported by research, and helpful to clinicians in understanding and treating child and adult patients’ (Ainsworth & Bowlby 1991: 9).

Clinical applications of his theory were slow to materialise and more has been achieved since his death, at the age of 83 in 1990, than during his lifetime. It is impossible to provide a comprehensive over view in a book of this length on all the implications and treatments associated with issues of attachment. However, the authors contributing to this volume open windows onto the wide range of therapies and interventions which use attachment theory and/or research to inform their practice.

Attachment theory

This book does not aim to provide a detailed account of attachment theory but a brief summary may be useful.

Attachment is first and foremost a relational theory. It has given us a way of describing what we do when we are anxious and how we use past experience to make predictions about what is most likely to keep us safe in the future. Bowlby described this information as being stored as Internal Working Models (Bowlby 1973/1985; Bretherton 2005) whereas Crittenden uses the term Dispositional Representations (Crittenden & Landini 2011). These memories of attachment-based experiences are not things we have in our heads so much as the sum of expectations of future situations, especially those involving danger, developed in interaction with attachment figures in the past.

The consequences of this process for an individual infant were neatly captured by Mary Ainsworth and her work on the Strange Situation procedure (SSP) (Ainsworth et al. 1978) which explored an infant’s responses to a brief separation from their mother. Ainsworth’s analysis of these observations provided the ABC notation on which much of the subsequent empirical work has been based.

• Type A Carers of infants in Type A are predictably rejecting of ‘unnecessary’ signals of attachment from their child and tend to be protective but not comforting. Consequently the infant inhibits the display of anxiety; tries to fit in with the expectations of the outside world; takes responsibility for what happens; and finds intimacy in close relationships makes her defensive. Type A uses cognition as a source of information, i.e. there is a reliance on cause and effect at the expense of arousing feelings such as anger or desire for a cuddle.

• Type B Carers of infants in Type B are predictably protective and comforting and attuned to their child’s needs. The infant comes to learn that the expression of arousing negative feelings can lead to resolution of problems after which attachment-seeking behaviour can be terminated and he can go back to exploration. Children and adults in Type B develop a high level of emotional literacy.

• Type C Carers of infants in Type C are inconsistently available to meet their infant’s needs and may reinforce behaviour in the infant that they say they do not want, for example smiling approvingly when telling the child off for doing something ‘wrong’. Life in Type C is never clear: the child’s feelings and own perspective are a better guide to how he should proceed than the perspective of other people. He uses affective logic to solve relationship problems and force others to feel what he feels; finding the right distance in close relationships is a problem.

One starting point – two theories of attachment

Not all infants and children assessed in the early SSP samples fitted into one of these three types. Scrutiny of anomalous examples led to a divergence of theory by two of Ainsworth’s students, Mary Main and Patricia Crittenden. Main and her colleagues developed a fourth category, disorganised-disorientated (Main & Solomon 1986), setting in motion the development of the ABC + D model of attachment. Crittenden interpreted the same data in a different way: as alternating A and C strategies and then early signs of more complex A and C strategies which she was later to describe in the Dynamic-Maturational Model (DMM) of attachment (Crittenden 1985, 1995), which integrates all types of strategic attachment behaviour under the three broad headings of A, B or C.

Other related theories

Neither the ABC + D or DMM model offers a phenomenology of attachment. Yet it is the feeling of being insecurely attached, and how this affects other people, which may bring people to therapy and interest professionals when trying to understand individuals or families.

Object Relations Theory (ORT) provides one way of trying to give subjective meaning to the internal processes that underpin Bowlby’s ‘inner working model’ of the world or, to use different language, Crittenden’s ‘dispositional representations’. Concepts such as splitting or projective identification are useful in explaining not just the internal defences employed in the Type A and C strategies but also their effect on other people. ORT can flesh out the meaning attachment strategies have for specific individuals and the impact on their relationships. It is thus of considerable clinical use in attachment-informed treatments with both adults and children (Holmes 1992; Steele & Steele 2008a; Steele et al. 2007; Fonagy 2001).

The work of Peter Fonagy and colleagues has added the theory of mentalisation to the classical theories of psychoanalysis and has shifted attention from the classification of strategies to how people process information. Mentalising refers to the peculiar human ability to take an intentional stance with regard to our own and others’ behaviour; our ability to read the minds of other people and think about our own thought processes. This can happen at a conscious or non-conscious level and high-level mentalising is associated with secure attachment; the parent–child relationship is a meeting of minds in which mentalising/secure attachment in the parent is transmitted to the child (Fonagy et al. 2004; Allen et al. 2008).

What are ‘attachment-based’ interventions?

Writing on clinical work with adults, Obegi and Berant (2009) make the useful distinction between attachment-informed and attachment-based psychotherapy. The former refers to the use of attachment theory and research to aid with assessment, formulation and aspects of treatment but with a reliance on established therapeutic modalities in terms of approach and technique. The latter attachment-based therapies make explicit use of attachment theory as a conceptual and operational framework for intervention and use validated assessment procedures to establish whether changes in attachment behaviour or representations of behaviour have occurred following a particular treatment. At a minimum this requires pre/post research designs and at best randomised controlled clinical trials.

The first reaction to reading the above might be that we should be striving for attachment-based interventions that meet the demand for evidenced-based practice. Certainly if increasing attachment security in our clients is the primary aim of our treatment then we should be able to give an account of our success. However, the progress in establishing formally attachment-based interventions is patchy at best. This is partly due to both the difficulty and the cost of mounting studies of effectiveness. But, a more central reason is that, as Music observes in Chapter 2, attachment theory and research cannot provide a whole theory about therapeutic work.

Do we need specific attachment-based treatments?

The chapters in this book are a testament to the likely balance between attachment-informed and attachment-based interventions in present clinical practice. In our opinion only one chapter (Juffer and colleagues in Chapter 5) describes a formal attachment-based intervention, while all the others are attachment-informed. In the other chapters the authors have used their training as therapists and their professional experiences to integrate the concepts of attachment into their work using their clinical judgement and creativity rather than following ‘evidencebased’ procedures. However, we would hope that therapeutic interventions that are ‘felt to work’ will result in the establishment of proper evidence-based outcome studies.

A prominent view, and one that we share, has been that attachment theory should be used to inform the use of existing interventions rather than create new ones (see Slade 1999: 577). The authors in this book discuss a number of therapeutic and social interventions informed by attachment studies in this way.

‘Holding therapy’

Even a cursory search of the internet reveals all manner of ‘attachment therapies’ and cures for ‘attachment disorders’ together with other sites devoted to people complaining that they have suffered at the hands of intrusive and abusive therapists. These sites are reminders of an issue that came to a head in professional circles around 2005 regarding ‘therapy’ which included enforced holding and eye contact to reconfigure the social brain of traumatised children. This produced an outcry in professional circles (e.g. BAAF 2006; Chaffin et al. 2006; Prior & Glaser 2006). Our impression is that in this country the use of overt holding and other forms of enforced ‘therapy’ has now abated or indeed ceased.

‘Holding’ was certainly the antithesis of a ‘secure base’ and it also reminds us that psycho-social therapies are not neutral; if they can benefit people then they can also do damage. Doctors and therapists can do harm (Fonagy & Bateman 2006: 1–2).

Wheels within wheels: systems within systems

This book considers interventions from a wide perspective, moving from one-to-one individual psychotherapy through family therapy and parent training to the input of social workers and the interventions of society through legal activity.

Attachment can be conceptualised as an intra-personal, inter-personal and a social psychological theory which considers different spheres of existence or systems that all have an interlinked and hierarchical relationship to each other.

System
Genetic	That which is inherited but which is open to change after birth through the epigenetic process.
Biological	The nervous, neurobiological, system which grows and adapts over time from infancy consequent upon life experiences.
Intra-personal	The individual’s psychology.
Inter-personal	Th...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Dedication
• Notes on contributors
• Preface
• 1 Introduction
• 2 Attachment theory and its uses in child psychotherapy
• 3 Where the child is the concern: working psychotherapeutically with parents
• 4 The marriage of attachment theory and systemic family therapy practice: an invitation to join the wedding party
• 5 Attachment-based interventions: sensitive parenting is the key to positive parent–child relationships
• 6 Attachment-focused therapeutic interventions
• 7 Clinical implications of attachment in immigrant communities
• 8 Attachment: a British lawyer’s perspective
• 9 The applications of attachment theory in the field of adoption and fostering
• 10 Attachment and social work
• Index