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Attachment Research, Developmental Implications, and Clinical Interventions with Children, Adults, and Couples

Abstract and Keywords

This review summarizes contributions to attachment theory and research by John Bowlby, Mary Ainsworth, Mary Main, and many other researchers. It addresses contributions from the Adult Attachment Interview to the understanding of loss and trauma as well as the intergenerational transmission of attachment patterns from parent to child. The review describes current findings from infant research, and the implications of attachment theory to clinical interventions with children, families, adults, and couples.

Keywords: Attachment, Adult Attachment Interview, infant studies, mentalization, affect regulation, trauma

Since its inception in the mid-20th century, attachment theory has had a significant influence in the field of child development. Attachment research contributed to a better understanding of the familial environment and its impact on child development, and how early attachment experiences affect adult personality and subsequent relationships. Though attachment theory emphasizes the child/caregiver bond, we now know that genetics, epigenetics, and sociocultural events are important influences on human personality and behavior that should be taken into consideration. This review summarizes the historical, social, and scientific context in which attachment theory was founded and presents major figures in the attachment field and their contributions to attachment and infant research. Included are John Bowlby, the founder of attachment theory; Mary Ainsworth, who pioneered international attachment research and the laboratory experiment of the Strange Situation; Mary Main, who with her collaborators created the Adult Attachment Interview; and Allan Sroufe who developed groundbreaking longitudinal studies with children and adolescents. Second generation researchers and clinicians whose work will be discussed and who were strongly influenced by attachment research are Fonagy, Stern, Beebe, and Lyons-Ruth. This review will address contributions related to the Adult Attachment Interview and the intergenerational transmission of attachment patterns from parent to child, as well as factors associated with unresolved loss and trauma. Finally, the implications of clinical interventions with children, families, adults, and couples will be discussed.

John Bowlby and the History of Attachment Theory

Attachment theory developed in the context of social, cultural, and scientific developments in both human and animal research. In the world of biological science, Konrad Lorenz, an ethologist, discovered the imprinting behavior of ducklings, who were observed to follow the first moving object they saw when they were hatched, even if that object belonged to a different species (Lorenz in this case). This experiment, one in a series of animal studies concerned with attachment needs, showed that the motivation to bond with a caregiver was a powerful factor in the survival of offspring. Following Lorenz, Harlow experimented with baby rhesus monkeys (Harlow, 1958), also finding that the offsprings’ need for a bond with the parent was fundamental for their survival. In Harlow’s experiment, infant monkeys who were separated from their mothers at birth and raised in isolation became attached to a wire mesh simulation of a mother covered in terry cloth. When faced with the choice of a wire mesh mother with milk bottles, and a wire mesh mother covered in terry cloth without milk bottles, the baby monkeys grabbed the milk bottles but went back to nestle with the terry cloth mother. They found a way to meet their survival needs but also their need for warmth and nurturing.

Along with scientific advances in the natural world there were important developments in the understanding of the child/caregiver relationship. Renee Spitz, who coined the terms hospitalism and the failure to thrive, observed that children he visited in orphanages seemed listless and depressed, and failed to grow and develop although their basic needs for food and shelter were being met (Spitz, 1945). John Bowlby, who was a member of the British psychoanalytic society, the leading form of mental health treatment at the time, observed childrens’ response to separation from their parents during hospitalizations, as well as during World War II, when many British children were evacuated from London (Bowlby, 1959). Until that time, there was little recognition of the impact of parental separation on young children, or of attachment as a primary developmental need. For example, the customary approach in psychotherapy was to treat children separately from their mother, even if their problem was directly related to disturbances in the maternal bond (Bowlby, 1988). Bowlby, however, observed that parental behavior, absence, or death had a powerful impact on the child and had to be addressed in the treatment (Bowlby, 1963). Similarly, D. W. Winnicott, a child therapist and psychoanalyst, also recognized the significance of the powerful bond between children and their mothers (Winnicott, 1965).

Bowlby’s observations and writings had a significant impact on hospital and mental health policy. Prior to his studies, hospitalized children were separated from their parents, who were not allowed to visit overnight during their children’s hospital stay. However, following Bowlby’s findings regarding the deep impact of parental separation and loss, parents were allowed to spend the night next to their children during hospitalization. The growing understanding of the need for love, affection, and bonding between children and caregivers also contributed to fundamental changes in childcare practices. Rigid behaviorist techniques during the 1970s and 1980s that encouraged parents to ignore their children’s cries and adhere to a strict schedule of feeding, napping, and sleeping became more flexible, emphasizing holding and connection over strict disciplinary attitudes (Bowlby, 1970).

Bowlby’s wide-ranging interests in evolutionary science, biological research, child mental health, and psychoanalysis contributed to the development of attachment theory as a naturalistic inquiry rooted in everyday experience and observations, rather than a theoretical paradigm divorced from daily life. In his work with Robertson, a social worker, Bowlby observed childrens’ response to separation from their parents for a limited amount of time, as well as children in orphanages whose parents were deceased or who had abandoned them. Bowlby realized that separation and loss had a profound psychological impact. Bowlby observed that children responded to separation in sequential stages that included protest, despair, and detachment. Even a brief separation could impact the child’s ability to trust and temporarily disrupt their bond with their mother. Bowlby also observed that childrens’ response to loss was associated with the quality of safety and security they experienced in their family. Bowlby also observed children’s grief response to the loss of a parent. He noted that this reaction normally occurred in four stages. During these stages, children as well as adults reorganize their sense of self and learn how to function in the world without their loved one (Thomson, 2010). The first stage of the mourning process is a period of numbness, when it is still difficult to accept the loss. The second stage is described as a period of longing for the deceased, similar to the protest experienced during separation from the caregiver. The third stage is a period of disorganization, and in the final stage, reorganization, the child or adult begins to accept the loss and reorganize their lives around it. If the child lacked a fundamental sense of safety and security, the normal grief process did not take place, and the child either responded to the loss with a prolonged grief response that could recur throughout their lives, or else they failed to mourn altogether. Such failure to mourn could manifest in somatic symptoms or depression later in life (Bowlby, 1980). Failed mourning was demonstrated on the Adult Attachment Interview (to be discussed later on) when subjects seemed to dismiss and minimize their loss and its impact on their development.

Bowlby’s observations of children’s fundamental need for attachment bonds with their caregivers and the profound impact of separation and loss of significant figures in their lives had a powerful impact on mental health practices with children and families, hospital policies, and clinical practice in general. Bowlby also paved the way for more extensive and systematic attachment research that was taken up by his assistant and later researcher in her own right, Mary Ainsworth, as well as several of her students including Mary Main, Allan Sroufe, Bob Marvin, and others.

Mary Ainsworth, International Attachment Research, and the Strange Situation

Mary Ainsworth turned to research in order to develop a more systematic categorization of children’s attachment patterns. She was curious to see whether discrete patterns could be identified in young children’s response to situations of separation and reunion with their primary caregivers. Ainsworth first undertook a naturalistic research project in Uganda, observing mothers and their toddlers during daily situations of separation and reunion, and she identified three distinct patterns that she called securely attached, insecurely attached, and not yet attached (Ainsworth, 1963). When Ainsworth replicated this protocol with Baltimore mothers and their children, she identified similar patterns, though she recognized that cultural customs played a role in how children expressed their joy at reunion or their expression of distress at separation. For example, during reunion Ugandan children clapped their hands while Baltimore children reached out and wanted to be held by their mothers.

Next, Ainsworth and her assistants developed a more systematic laboratory experiment that she called the Strange Situation (Ainsworth & Bell, 1970; Ainsworth, Blehar, Waters, & Wall, 1978). In this well- known experiment, children from 6 to 18 months are placed in a room with their mothers. The child is exposed to several situations of separation from the mother, first with a stranger in the room, then alone. The child is also observed during two situations of reunion with the mother. Ainsworth found that children behaved in three distinct patterns that she and her collaborators called: secure attachment, anxious ambivalent attachment, and anxious avoidant attachment. Children who were securely attached engaged in attachment behaviors, seeking proximity to the mother or asking to be held, but also seemed comfortable engaging in exploratory behaviors, playing with toys, and engaging the stranger in the room. Though they cried when their mother left the room, they were able to recover quickly. In contrast, children who were anxious and ambivalent (or resistant) in their attachment style, seemed to cling to their mother, showed insecurity when exploring the room or playing, and were not able to recover from the separation. They continued to cry and refused to explore their environment and be separated from their mother. When she returned, they engaged in alternately asking to be held and pushing their mother away. Finally, children who were categorized as avoidant seemed to engage primarily in an exploratory behavior, showing no interest in the mother or in being close to her, even when the mother left the room. However, later research that measured cortisol levels in these children showed that these levels were significantly increased during separation from their mother. Though these children seemed to be self-reliant and unaffected by their mothers’ leaving, their higher cortisol levels clearly showed that they were upset but had learned not to show it.

Further observations indicated that the children’s response was closely linked to their mothers’ parenting style. Secure children had mothers who were consistent and comfortable with their child’s attachment-seeking behavior as well as with their need to explore and move away. These children knew that their mothers would be their secure base to be held and nurtured, but also a safe haven they could return to when they wanted to explore on their own and needed soothing and reassurance. Anxious ambivalent children had mothers who showed an inconsistent responsiveness, at time hovering and protective, at times absent. The child could not rely on the mother’s consistent attunement and therefore tried a variety of strategies to seek her attention. Rather than exploring the environment, secure in the knowledge that their mother would be there when needed, the child would become hypervigilant to the mother’s presence and emotional availability. The mothers of avoidant children seemed rejecting and uninterested in them. The child learned that their mother would not welcome their attachment signals, and therefore learned to hide their distress and maintain a facade of autonomy and self-reliance. In some cases, the mother was controlling and intrusive, and the child learned to minimize their attachment behaviors so that they could maintain some measure of autonomy. The Strange Situation showed that children’s attachment behaviors were closely related to the child/caregiver system, and that in many cases, attachment patterns were transmitted from mother to child (Bretherton, 1992; Sable, 2008).

A fourth attachment pattern was later identified by Mary Main and her collaborators, who noticed that some children responded to their mother’s leaving and returning with bizarre, repetitive, and confusing behaviors. They seemed frozen and dissociated, afraid of their mother, and at time trying to hide when she returned. They engaged in repetitive movements or alternated between the three attachment patterns. The researchers determined that fear was a fundamental emotion in this attachment system (Main & Goldwyn, 1984). The children feared their mother, who may have been abusive, mentally ill, or suffering from her own unresolved trauma. The children may have also perceived that the mother was timid and insecure, afraid to handle them. These children demonstrated no coherent strategy for attachment, unlike the previous three types who developed a predictable, consistent response elicited during separation and reunion experiences. Fear is a primary emotion in disorganized attachment as young children, who depend on their caregivers for most basic needs, experience anxiety and fear when their very survival is at stake (Slade, 2014). Main and her colleagues also understood that disorganized children experienced the dilemma of needing and depending for their survival on a caregiver, who was also the source of fear and abuse. These conflicting agendas created affective fragmentation and dissociation, and interfered with the child’s ability to develop a functional stress regulatory system.

The Strange Situation was replicated in Western countries as well as in non-Western cultures such as Japan, China, and several African countries. The researchers found that levels of security, ambivalence, and avoidance were similar across cultures, where most children were securely attached (66%), with approximately 18% avoidant, and 13% anxious ambivalent. The remaining 3% could not be classified. They also found that the pattern held even in countries were children were raised by people other than their mothers, and where the Western nuclear family was not the cultural paradigm and grandparents, fathers, aunts, or other relatives could be the primary caregivers. However, there were cultural variations in terms of temperament and behavior. For example, Ainsworth’s students went to Nigeria (Marvin, van Devender, Iwanaga, LeVine, & LeVine, 1977), where they found that cultural differences affected attachment patterns, and that children were more passive and less exploratory than Western children. As well, they were attached to more than one caregiver in the extended family. There were additional attachment studies with the Dogon in Mali (True, 1994), with the Pygmies of Northeastern Zambia (Morelli & Tronick, 1991). Studies in China (Posada et al., 1995; Lin & Fu, 1990) showed Chinese mothers preferring more independent, exploratory behaviors by their children modeled after Western cultural values. Studies in Japan (Posada et al., 1995; Vereijken, 1996), suggested that cultural traditions encouraged dependency on the mother, though here, too, the mothers seemed to prefer a more Westernized exploratory and independent behavior. Clearly, cultural influences, whether locally or through the media, had a significant impact on attachment behaviors.

Ainsworth and her colleagues paved the way to a better understanding of how parental behaviors could have a significant impact on the child’s personality development and capacity to engage in social relationships. The Strange Situation helped create parenting training programs that helped parents learn more adaptive ways to interact with their children, and that taught parenting skills to young and inexperienced parents.

Allan Sroufe, a student of Ainsworth, is an important attachment researcher who conducted a number of longitudinal studies looking at the development of attachment patterns at different developmental stages (Sroufe et al., 2005). Sroufe wanted to study whether attachment styles observed during the Strange Situation continued in later developmental stages and in other social contexts, such as school. In one of his studies, Sroufe followed 48 children to see if their early attachment styles stayed constant during social relationships with peers and teachers (Sroufe, Egeland, Carlson, & Collins, 2005). Sroufe found that secure children seemed better adjusted, and more academically successful both in play and in their studies. Their secure behavior correlated with their mother’s support and responsiveness, in contrast with avoidant mothers who could be impinging or rejecting, or ambivalent mothers who were inconsistent. In another study, Sroufe and Egeland recruited 267 pregnant women from low socioeconomic status, and followed them and their children for twenty years. Among these subjects, 80% were white, 14% black, and 6% Hispanic or Native American (Sroufe, Egeland, & Kreuzer, 1990). Sroufe and his colleagues found that the mother’s personality and responsiveness were more predictive of the child’s attachment style than the child’s temperament or genetics. Sroufe and his colleagues found that secure children were independent and empathetic to other children, as well as more motivated in their academic work. Anxious children, including the avoidant ones, were more dependent. However, while the ambivalent children expressed their dependency needs, avoidant children behaved in an oppositional or self-reliant manner to mask their insecurity.

The Adult Attachment Interview

The Adult Attachment Interview was developed by Main, Goldwyn, and Hesse to identify the relationship between the attachment patterns of children and parents (2002). Main, Goldwyn, and Hesse conducted the interview with parents whose children’s behavior was observed by the researchers during the Strange Situation. Unlike the Strange Situation experiment, in which researchers observed children’s behavioral response to experiences of separation and reunion, the AAI classifies adults’ attachment categories based on their subjective state of mind in regard to experiences of attachment, separation, loss, and trauma. Rather than focusing on the experience itself, the questions examine the subject’s state of mind in regard to attachment experiences, and this determines their attachment category. The Adult Attachment Interview is comprised of 20 questions designed to explore the subject’s memories and states of mind in regard to early experiences of attachment, separation, loss, and trauma (Hesse, 2008). Much like the attachment patterns identified in the Strange Situation, three organized attachment classifications were identified in adults based on their answers to the AAI. These categories are the secure/autonomous, the dismissive, and the preoccupied, which roughly correlate to the secure, avoidant, and ambivalent attachment patterns that were identified for children in the Strange Situation. Main, Goldwyn, and Hesse also identified two disorganized attachment categories. These were the unresolved/disoriented pattern in relation to loss and the same pattern in relation to trauma. The interview usually lasts about one hour, and since the questions are not ones that most speakers have encountered before, they usually answer authentically, without the opportunity to prepare or censor their answers beforehand. It has been remarked that the AAI protocol has the potential to present as a surprise to the unconscious (George, Kaplan, & Main, 1996). While the interview relies on linguistic cues only, it does predict the speakers’ attachment category with a high rate of consistency (Hesse, 2008).

The speaker’s state of mind in regard to their early attachment experiences, and the coherence of their narrative are closely correlated with their level of attachment security. As the AAI is a complex measure, it requires highly trained and certified coders and significant time to analyze and classify. Therefore, it is not as widely utilized as other more quantitative attachment measures, especially in large research studies. However, the AAI has been subjected to several rigorous psychometric tests of stability and discriminant validity (van Ijzendoorn, as cited in Hesse, 2008). Some important findings were that the ratio of secure (58%), dismissive (24%), and preoccupied (18%) in a non-clinical sample were similar across a number of studies (van Ijzendoorn & Bakermans-Kranenberg, 1996). Another finding was that the speaker’s attachment classification could not be attributed to the influence of the interviewer (Sagi et al., 1994). Due to its complexity and focus on the subject’s relationship to early developmental experiences and attachment figures, the AAI can be a useful clinical tool in clinical assessment and evaluation.

Main, Goldwyn, and Hesse used the French linguistic philosopher Grice’s four maxims to help them analyze and code the interviews (Grice, 1989). Grice formulated these principles as underlying conditions for a rational conversation, and called them the Cooperative Principle. The four maxims which are the foundations of rational discourse are as follows: 1. Quality: be truthful, and have evidence of what you say. 2. Quantity: be succinct yet complete. 3. Relation: be relevant or perspicacious. 4. Manner: be clear and orderly (Main, Goldwyn, & Hesse, 2002, p. 44). Based on these overarching principles, the researchers identified the following attachment categories: Subjects with the secure-autonomous category are characterized by a coherent, collaborative narrative, the ability to recall relevant memories, a lively authentic personality, forgiveness and empathy for caregivers, and the ability to present oneself as fallible. Subjects with the dismissive category present a narrative characterized by idealization of their attachment history and of their primary caregivers’, usually their parents’, idealization that is not validated by their memories. These speakers can also present an attitude of dismissiveness toward their attachment experiences and attachment figures. Dismissive speakers may also show lack of memory for attachment-related experiences, low coherence of the interview narrative, and lack of collaboration, or resistance, with the interviewer and with the interview process itself. Finally, the preoccupied subjects are characterized by a quality of vagueness and tangential narrative details, or by active anger at the speaker’s caregivers. The speakers seem preoccupied with their early history and lack an autonomous, independent sense of self (Main, 2000).

Along with the three organized categories, the researchers identified two disorganized categories on the AAI (Hesse, 2008; Hesse & Main, 2000). These relate to expressions and behaviors that convey disorientations in regards to experiences of loss or trauma. The subjects who are identified as unresolved/disoriented in relation to loss are characterized by disorientation in regards to cognitive functions (such as disbelief in the death, or belief that the subject was causal in the death); disorientation in regard to time (such as lack of consistent account of the time of the death); disorientation in regards to space (such as lack of consistent account of where the death or funeral took place). Other indications include an overly detailed account of the circumstances leading to the death or funeral scene, irrational beliefs about the dead. The subject may describe an extreme behavior during the time of bereavement, such as suicidal attempts or hospitalization (Hesse, 2008). These are clues that the grief response is disoriented and, in fact, parents’ unresolved/disoriented response to loss and trauma has been linked to disorganization in the subjects’ children, so that unresolved events in the parents’ life are transmitted to their children and have a significant effect on their subsequent attachment relationships (Lyons-Ruth, Dutra, Schuder, & Bianchi, 2006). The unresolved/disoriented category in regards to trauma follows similar indices to that of loss. Not surprisingly, AAI research shows that lack of resolution in regard to loss or trauma is highest in clinical populations, such as clients with Borderline Personality Disorder (Patrick et al., as cited in Hesse, 2008), and that the caregiver’s disorientation is directly related to their child’s disorganized attachment pattern (Lyons-Ruth et al., 2006).

Though the Adult Attachment Interview was developed by researchers, and has been used for research purposes, it has also proven to be a useful clinical tool. AAI questions can be used to assess the client’s developmental history and their relationships to significant others in their lives. The questions can highlight formative experiences related to attachment, separation, and loss, and can help identify potential difficulties in processing and resolving relational disruptions in the client’s life that may impact their ability to form new relationships, facilitate conflicts with others, and parent their children. Unresolved loss and trauma on the AAI has also been linked to neuronal activity and brain structure, and to one’s capacity to regulate stress effectively.

While the AAI can be adapted for clinical purposes in investigating developmental factors, attachment disruptions, and personality disorders, it does have significant limitations as a clinical tool in social work practice. The AAI is not designed to address how factors related to the speakers’ class, culture, race, and ethnicity may shape their attachment category. While attachment researchers conducted international studies as well as studies with diverse populations in the United States (Tacon & Caldera, 2001; Barnett, Kidwell, & Leung, 1998), AAI research has not specifically focused on cultural diversity as a formative factor in subjects’ attachment narratives. In analyzing AAI transcripts, Ringel noted that several speakers with a dismissive attachment pattern grew up in poverty, or were born and raised in countries and communities where open expression of feelings was not encouraged, and life beyond daily subsistence was not possible (Ringel, 2012). These speakers’ dismissive characteristics, however, were embedded in cultural, economic and social factors that went far beyond the parent/child attachment bonds. In his studies of Kibbutz children in Israel, Sagi et al. (1994) also found that sociocultural factors were linked to Kibbutz children’s attachment styles. They were more likely to be dismissive in a society that valued independence and self-reliance and discouraged the open expression of vulnerability. In the Kibbutz society, children grew up in collective living arrangements, with primary attachment bonds to their peer group rather than parents. In conclusion, while the AAI is a nuanced and complex attachment measure that addresses significant developmental and clinical events, it does not take into consideration important environmental and contextual factors that could provide a more comprehensive understanding of clients’ sociocultural environment.

Infant Researchers and their Contribution to Child Development

Related to attachment research, developmental researchers such as Stern (1985), Beebe (2005), Tronick et al. (1998), and Lyons-Ruth et al. (2006) have found that early childhood developmental processes are closely tied to relational dynamics with patents and primary caregivers. Stern, for example, found that very young infants do possess a basic self- awareness, which develops through ongoing interactions with their caregivers (1985). Stern described three developmental stages very early in the infant’s life. The emergent self is the first stage, in which Stern observed that infants as young as two months were able to make direct eye contact and began to smile responsively at their mothers. In addition, they also turned their heads, and looked around. The second developmental stage, which Stern called the core self, occurs during ages two to three months, during which infants became increasingly more social and interactive with their environment. Finally, the third stage of the subjective self is when children seemed to express a greater sense of self-integration. In addition, Stern postulated qualities of a core self which infants could achieve, such as self agency, or authorship of one’s own actions, self-coherence, or sense of being part of a whole, self-affectivity, or experience of inner self feelings and mental states, and self-history, or sense of continuity and self-narrative.

Later studies focused on the development of affect regulation skills through observations of parent/child interactions. In her tracking of split screen, moment to moment infant/mother dyadic interactions, Beebe showed that the infant is an active agent in initiating contact (Beebe, 2005; Beebe et al., 2000). During these interactions, both members of the dyad engage in self- monitoring, as well as mutual monitoring behaviors through gaze, smile, head turning, and cooing. This interactive process requires ongoing adjustments between infant and caregiver through a range of activities, including vocalization, eye contact, touch, and facial expression. Beebe et al. (2000) described how infant self-regulation develops through bidirectional regulation with their mothers, through cycles of connection and then withdrawal as they become overstimulated and need to disrupt the connection. She called this sequence “Chase and Dodge,” a sequence that helps the infant regulate their arousal. In situations where the mother was unresponsive, intrusive, or even frightening in her expression and movements, the infant responded by withdrawing, becoming distressed, or trying to accommodate the mother in different ways. In his “Still Face” experiment, Tronick observed infants’ responses to mother’s lack of facial responsiveness (Tronick et al., 1998). The infant’s distress and dysregulation, even during a short period of time, was quite apparent. As well, infants were quite creative in trying to get the mother’s attention and engagement. These experiments showed that affect regulation is a dyadic process, where both infant and caregiver regulate themselves as well as one another. Where attunement or responsiveness from the caregiver is lacking, the infant remains dysregulated, or, as Lyons-Ruth discovered with disorganized children and their mothers, the infant learns to “control” the interaction by themselves becoming the mother’s caregiver, or by becoming aggressive (Lyons-Ruth et al., 2006). These experiments also show that infants play an active role in the relationship with the caregiver, and apply their own skills and interactive style to gain the mother’s attention and responsiveness.

Along with research related to reciprocal engagement and the development of dyadic regulation between infants and caregivers, Fonagy, Gyorgy, Jurist, & Target (2002) conducted studies that focused on the development of reflective abilities as a function of infant/caregiver interactions. In the Adult Attachment Interview, metacognition, or reflective functioning, is defined as the speaker’s capacity to reflect on their state of mind and thinking process. Further, the AAI defines metacognition as the capacity to note that events, experiences, and states of mind may not be as they appear to be on the surface, that different people may view the same experience differently, and that there are differences in self-perception over time (Main, Goldwyn, & Hesse, 2002). Fonagy and his colleagues looked at metacognition, or what they called mentalization, as a reflective function that develops over time as an outcome of parent/child interactions. They observed that the child’s mentalization or reflective capacities corresponds to the parent’s recognition and expression of the child’s state of mind, while still maintaining affective and cognitive boundaries with the child (Fonagy et al., 2002). Fonagy et al. identified three stages in the development of mentalization: from the initial stage of psychic equivalence, when the child’s internal fantasy world constitutes their reality; to the stage of pretend play, when play, both solitary and collaborative, becomes the child’s reality, an important stage for the development of creativity, playfulness, and social skills; to mentalization, when the child learns to identify and communicate their thoughts and feelings to others, as well as to read and appreciate others’ thoughts and feelings and respond to them empathically. Fonagy and his colleagues observed that if parents provided their children with material needs but could not mirror them or help them articulate their thoughts and feelings, the children did not develop mentalization skills, and lacked the ability to identify and communicate affective states to others, or to be attuned and empathic to others’ states of mind.

These studies show that parent/child interactions are pivotal to the development of affect regulation, mentalization, empathy, and social skills. These observations have been validated in neuroscientific developments as well, where it was found that child-caregiver interactions help develop and strengthen cognitive brain structure and neuronal activity. For example, Schore (2003) found that right brain to right brain interactions between children and adults, as well as in the therapeutic environment, help in the process of communicating and processing of implicit affective states.

Attachment and Developmental Trauma

From its inception, attachment research investigated the impact of attachment disruptions, separation, loss, and trauma on young children. As previously stated, Bowlby observed children in orphanages who were separated from, or who lost, their parents. Attachment disorganization was found to be related to experiences of abuse and neglect, as well as to unresolved trauma in the caregiver that was transmitted to the child, often implicitly. As stated above, Main and Solomon identified what they called a “disorganized” attachment style in children during the Strange Situation (1990). These children’s behavior indicated fear and apprehension toward the parent during reunion, including running away and hiding (Hesse, Main, Abrams & Rifkin, 2003; Lyons-Ruth & Jacobvitz, 2008). The researchers found that fear was the primary emotion in attachment disorganization, and that disorganized attachment occurs when insecurity in the attachment system threatens the infant’s very survival, at a time when the infant is completely dependent on the parent. Main et al. (2002) observed that certain responses from the caregivers stimulated the child’s fearful response. These included a threatening posture, facial expression, and movements, or a frightened behavior, such as retreating and backing away from the child. The child also became fearful and disorganized when the caregiver expressed timidity, dissociation, deference, or sexualized touching of the child (Lyons-Ruth & Jacobvitz, 2008). Lyons-Ruth and Jacobvitz found that these behaviors were often unconscious, and stemmed from the parent’s own unresolved loss or trauma during their childhood. Attachment disorganization is related to later difficulties in cognitive functions, the capacity to regulate traumatic affect such as fear and anger, and the ability to form stable social relationships.

In their studies of infants, Lyons-Ruth et al. (2006) identified two groups of disorganized mother/infant dyads. She called them the helpless/fearful dyad, with mothers who projected fear and anxiety, and the hostile/intrusive dyad, with mothers who were overly intrusive and exhibited role-reversing behaviors, such as mocking and teasing. Longitudinal studies with disorganized children show that they express more anger and aggression than secure, avoidant, or ambivalent children (Lyons-Ruth & Jacobvitz, 2008). Two primary behavioral patterns were found in disorganized children: controlling/caregiving behaviors, or punitive/hostile behaviors toward the parent, as when the child ordered the parent around. These behaviors showed that the child attempted to control a parent who seemed helpless, unreliable, and unstable so that they would ensure their own survival (Hesse, 2008; Diamond, 2004). Main et al. (2002), and Hesse (2008), found that mothers with unresolved loss or trauma transmitted their disorganized state of mind to their child, as 84% of children in the Strange Situation had a parent with an unresolved/disoriented attachment.

Attachment trauma is clearly linked to relational disruptions during childhood. These disturbances include separation from the caregiver, which is especially traumatic for young children who do not understand the concept of time and of eventual reunion, and therefore experience the separation as abandonment. Threatened abandonment by parents, therefore, can cause deep anxiety in young children. When a caregiver dies, the loss is may be experienced as abandonment by infants and young children and may lead to pervasive anxiety and insecurity. Attachment trauma may have its origins in subtle communicative signals between parent and child. In her split screen observations of infant/caregiver interactions, Beebe (2005) showed how nonverbal signals from the caregiver such as facial expressions and movements can become over stimulating to the child and destabilize their sense of safety and security. Incremental disruption/repair cycles between parent and child contribute to the development of the child’s capacity to develop affect regulations skills and to manage frustrations and conflict with others as well as affect regulation skills. However, overwhelming attachment disruptions that are not resolved may lead to affect dysregulation and disorganization in the child. Anxious ambivalent adults, who have not experienced disorganization related to childhood developmental trauma, may still lack internal security and are vulnerable to experiences of rejection, loss, or separation in the context of intimate relational experiences. During these times of distress they may engage in hyper-activated attachment behaviors and seek proximity, or experience distress with the prospect of feared abandonment. In contrast, avoidant adults may manage their insecurity and relational distress through the deactivation of attachment behaviors such as distancing and external self- reliance (Mikulincer & Shaver, 2008).

In order to assess the role of temperament and genetics versus attachment and nurturing, Main and Solomon (1990) showed that 31 of 34 infants who were categorized as disorganized with one parent were not so classified with the other. In addition, van Ijzendoorn et al. (1999) showed that there was not a significant correlation between disorganized attachment in infancy and variables in temperament. Supporting this data are recent studies in epigenetics (Yehuda et al., 2014) suggesting that parental abuse and neglect early in life can significantly change the genetic expression of offspring within one generation, providing scientific support to the profound role that early attachment patterns play in shaping personality and subsequent relationships. In their studies of offspring of Holocaust survivors, Yehuda et al. showed both the physiological and psychological effects of intergenerational transmission of parental behavior experiences onto the child.

On the AAI, disorganization is directly associated with the loss of significant relationships or with the experience of attachment trauma. Specifically, Main (2000) linked the unresolved/disoriented response on the AAI to cognitive and behavioral indices (Main, 2000; Hesse, 2008). One indication is a highly detailed account of the loss, even one that occurred many years ago, as if the event has been frozen in memory. For example, a subject who lost her mother four years previously described the event as if it happened only yesterday:

“Well it happened Christmas Eve, and then over the next couple of weeks as it got worse. Well, she had an aneurism; it was probably three days after I got back. I was in school and we had winter break … for some reason I ended up staying back a couple of days, we did a lot of chores, we went around the city I, had just moved to (state) a year or 8 months before. We went out for those few days doing a lot of shopping … she was cooking a spaghetti dinner, I’m in the garage playing the drums, and then dad comes running and says hey call 911! … it took 45 minutes to get her to the hospital … she wasn’t convulsing … I slept on the floor of the waiting room, MD comes out and says operation was ok she was in intensive care for about three weeks, she got pneumonia again and was on a breathing machine … ” (Ringel, 2012).

Another speaker remembered her mother’s death 43 years ago: “I think it was a Thursday and then that Friday, which happened to be her birthday, Friday March 13, she had surgery … and had the brain tumor removed. And when my other sister had a little baby and another one of my older sisters became pregnant during that time” (Ringel, 2012).

These highly detailed memories are typical with people who suffer from PTSD, and still possess highly emotional and intense memories of the traumatic event. Another indication of disoriented response to loss or trauma includes the speaker’s feeling responsible for the loss or abuse, though clearly they were not responsible. For example, one speaker justified her mother’s failure to protect her from childhood abuse, because the abuse was her fault: “she wasn’t saving me, I wasn’t worth saving, there was something really wrong with me … this was all my fault, I was really bad, and kind of just gave up” (Ringel, 2012).

Some dismissive speakers, on the other hand, seem to distance themselves from painful experiences, fail to grieve, or talk about the deceased in a superficial manner (Hesse, 2008). The failure to grieve has been mentioned by Bowlby as one form of unresolved grief response (1980). In their studies of offspring of Holocaust survivors, Sagi-Schwartz et al. (2003) found respondents who showed a pattern of failure to grieve, most of them categorized with dismissive attachment. Sagi et al. relate this failure to several factors: The respondent’s early age at the time of loss; the multiple losses of family members at a time of massive trauma when the child lacked other social supports; lack of understanding of the contextual events leading to the loss; and the absence of subsequent loving caregivers. Bowlby (1980) included one’s early age, the nature of the attachment environment at the time of the loss, and the nature of the loss as significant factors in the process of disordered mourning. He observed that people with avoidant attachment styles, while seemingly independent and self-reliant, manifested failed mourning as a defensive tactic to protect from pain and vulnerability, but showed poor adaptation and high levels of anxiety later in their lives. For example, the following is a dismissive speaker discussing the loss of her parents: “I don’t obsess about this. Once people are gone they’re gone … It starts to get depressing when more people are in the grave that, that you are going to see too many people in the same graveyard” (Ringel, 2012). Or another speaker who described the death of an 18-year-old family friend: “after she died I saw a license plate that said God Bless America and I realized that her name is part of America. If you left off the AM it would say God Bless Erica” (Ringel, 2012).

Clinical Interventions with Children and Adults

Attachment findings have been applied in several prevention and intervention programs with children, families, and adults. One program is Child/Parent Psychotherapy (CPP), based on Fraiberg’s (1980) approach to treatment, which involves parent/child interactions during the first three years of life (Berlin et al., 2008). Fraiberg asserted that maternal difficulties were related to disruptions in the mother’s own developmental history, or in the mother’s relationship with her partner. Therefore, Fraiberg recommended that child/mother treatment should also include a focus on the couple’s developmental history and childhood experiences and conflicts that were directly related to interactive patterns with their own child. Several randomized research studies support the efficacy of CPP (Lieberman, Ippen, & van Horn, 2006; Cicchetti, Rogosch, & Toth, 2006).

Another attachment-based treatment program is the UCLA Family Development Project, which includes weekly home visits during the mother’s pregnancy and through the infant’s first year, followed by biweekly home visits during the second year (Berlin et al., 2008). Findings support the efficacy of this program (Heinicke et al., 2006). A third intervention program is called Minding the Baby (MTB), which is also a home visiting program intended to serve high-risk mothers with a history of abuse (Slade et al., 2005). Weekly home visits by social workers and nurse practitioners serve as a secure base for the parent, and interventions are designed to help develop the mother’s reflective functioning. A fourth treatment strategy is the Attachment and Biobehavioral Catch-Up (ABC), developed by Dozier and colleagues, which is a home visiting program for foster parents and their foster infants and toddlers (Dozier, Lindheim, & Ackerman, 2005). Finally, Marvin et al. (2002) developed an intervention protocol they called the Circle of Security (COS). COS is a 20-week group-based program for parents or primary caregivers of infants, toddlers, or preschoolers (Berlin et al., 2008). This intervention includes an attachment assessment and classification, which is used to design the counseling approach with parents. An initial study with a sample of low-income parents who reported childhood maltreatment and their children show that the program decreased disorganized and insecure attachment in the children (Hoffman et al., 2006). All of these programs are based on findings from attachment research, the Strange Situation and the AAI, which identify disturbances in the attachment system between children and parents and are designed to address them.

The following are attachment-based approaches with adult individuals and couples. Based on their research regarding the development of reflective functioning, or mentalization through interactions between children and their caregivers, Fonagy and Bateman (2008) developed a treatment approach for clients diagnosed with borderline personality disorder (BPD). Fonagy and Bateman (2008) suggest that BPD develops as a result of deficits in the mirroring and validating responses of significant others during the client’s developmental years. In addition, many clients with BPD also experienced childhood abuse. Consequently, they develop distortions in their perceptions of their own mental states and the mental states of others, particularly during time of distress. Individuals with BPD have compromised mentalization functions, leading to disturbances in identity, relationships, and sense of self, along with difficulty in affect regulation and a sense of emptiness and inauthenticity (Fonagy & Bateman, 2008). In the mentalization continuum, they present with psychic equivalence, or a concrete thought process, and the inability to consider perspectives other than their own. Fonagy and Bateman have developed a mentalization-based treatment model based on psychodynamic principles, which emphasizes the clinician’s attunement and mirroring, the building of a secure base, and gradual introduction of alternative points of view. The model aims to develop in clients a more flexible mode of perception of self and others, acceptance of limitations and failures, and more adaptive response to stressful events.

An attachment based approach with couples was developed by Susan Johnson (Johnson, 2002; Johnson, 2008). Emotion Focused Therapy (EFT) is based on the principle that attachment needs constitute the primary motivation for couples and that attachment bonds provide a natural regulatory system essential for human emotional survival. Johnson postulated that dependency needs should not be viewed as pathological, but rather, that dependency needs constitute universal and normative human needs. This model is based on the following premises. First, secure attachment allows the child, and later the adult, to look to the primary attachment figure for help in regulating overwhelming affects and for the provision of love and support during times of distress. Second, having a secure attachment helps people to achieve greater success in intimate relationships. Finally, individuals with secure attachment histories are also more flexible, open, and likely to seek closeness at times of crisis and distress. During the EFT process, the therapist encourages each partner to identify and articulate their attachment needs, and to be open and accepting of the attachment needs of the other. Johnson found that anger and avoidance typically hide feelings of vulnerability, fear, and sadness that may be too risky to express.


Attachment studies suggest that early developmental experiences based on the early relationship between parents and children have long-lasting effects on adult personality and social behaviors, and findings also indicate that attachment patterns, both adaptive and pathological, are likely to be transmitted from parent to child. Research has shown that attachment behaviors remain relatively consistent across cultures though sociocultural considerations have a significant impact on attachment-based classification and should be taken into consideration as contextual factors beyond the child/caregiver system. This review further suggests that it is important to provide early clinical interventions to address attachment insecurity in children, and to train parents and families and enhance their parenting skills in order to ensure an optimal emotional environment for their children.


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