Attachment theory

The inception of attachment theory proposed by John Bowlby in the 1970’s, has significantly informed health professionals understanding of child development and the nature of the parent-child relationship. Further research has shown evidence of how attachment theory can impact relationships and psychopathology in adulthood and the importance of considering attachment styles in therapeutic practice (Bettmann, 2006; Burke, Danquah, & Berry, 2016; Levy, Kivity, Johnson, & Gooch, 2018). This consideration of attachment styles is multi-faceted. Taking into account both the individual attachment style of the client and clinician and the impact on the therapeutic relationship. Furthermore, consideration of the development of the attachment relationship between the client and clinician is essential, as this can influence therapy outcomes (Horvath, Del Re, Flückiger, & Symonds, 2011).

Broadly, attachment theory proposes that our early relationships with caregivers form the basis of our relationships as adults. In his early influential texts, Bowlby (1969, 1973, 1980) and extended research by Mary Ainsworth (Ainsworth, Blehar, Waters, Everett, Wall, 2015) defined secure attachment as positive exchanges between child and caregivers that lay a foundational relationship, whereby the child saw the caregiver as a secure base from which they could explore the world. Interaction with the environment meant that the child could independently separate from the caregiver and return again securely, seeking positive reinforcement, protection and have their primary needs met. The caregiver responds in a sensitive, comforting and protective way, anticipating the child’s needs and meeting them in a timely manner. This behaviour develops an inner working model for the child that shapes impressions and expectations of self and entrenches a cognitive map to carry through life. A base from which to navigate and explore the world (Watkins & Riggs, 2012). Secure attachment can be explained through an evolutionary perspective, whereby the child is kept safe from external threats through close proximity to a primary attachment figure. Proximity is maintained through outward physical behaviour such as crying or clinging onto the caregiver that in turn causes the caregiver to respond in a soothing and reassuring manner (Hunter & Maunder, 2001).

Conversely, insecure attachment lacks a secure base from which the child can step away from and return to. The caregiver is unpredictable and inconsistent in their responsiveness to the child and may lack emotion, connection and protection. The child becomes to understand that the caregiver is not available in times of need and therefore adjusts their own emotional development to an insecure attachment style, namely anxious and avoidant attachment (Tasca et al., 2018).

Insecure-anxious attachment style is characterised by a minimal belief in caregivers and although the child may be initially soothed and calmed during the caregiver presence and desires close proximity, the child is unable to maintain a sense of calmness without the caregiver in the long term (Hunter & Maunder, 2001). Insecure-avoidant attachment describes an individual who does not believe that seeking proximity to a caregiver or expressing their emotions will result in protection or reassuring response from the caregiver. These individuals avoid attachment situations in order to cope with emotions on their own.

These attachment styles can be envisaged on a continuum with secure attachment in the middle and insecure-anxious and insecure-avoidant attachment at either ends of the spectrum (Tasca, Ritchie, & Balfour, 2011).

A fourth category of disorganised attachment has been identified whereby caregivers were absent or abusive, causing the affective experience of the child to be inconsistent and difficult to decipher (Hunter & Maunder, 2001; Tasca et al., 2011). Ongoing research has identified that an individual’s attachment style developed in childhood has a lifetime influence on adult functioning and mental health

The use of an attachment lens when working with adult clients in therapeutic practice is akin to embracing a holistic approach of viewing the client and a way of understanding the client with a completely new perspective (Rich, 2006). An advantage of using attachment theory in case formulation is that it can be applied to all clients, not only those with severe disorders (Hunter & Maunder, 2001). Everyone has a childhood and attachment theory is therefore deemed to be an inclusive and universal and more importantly, research has shown it to be an evidence-based approach. This approach promotes the belief that secure attachment relationships are central to mental wellbeing, and inform the clinician to consider the client in the context of their childhood attachment experiences that have formed the foundation for the trajectory of their adult life (Bucci, Roberts, Danquah, & Berry, 2015). In case formulation, the use of validated attachment based psychometric measures can be a useful addition to rule in or out any hypotheses and help to uncover more information to ultimately aid in treatment outcomes for the client.

Understanding a client’s attachment insecurity contributes to a better understanding of their symptoms and helps to inform treatment outcomes (Tasca et al., 2011). Attachment style can determine the willingness of a client to seek help for their problems within the therapeutic relationship. For example, a client who displays dismissive attachment style, may find it difficult to trust the clinician and believe that no one will be able to help improve their symptoms (Bucci et al., 2015). In comparison, a client who demonstrates a more secure attachment style is willing to rely on others and put their trust in the clinician (Bernecker, Levy, & Ellison, 2014).

The therapeutic relationship developed between client and clinician is likened to an extension of the child/caregiver attachment relationship. This relationship is an important part of treatment efficacy. Like the caregiver (Bowlby, 1969; 1973; 1980), a clinician can provide a safe space, both literally and figurately for a client to shelter in and exposure their true self (Holmes, 2010). The ongoing nature of the therapeutic relationship creates a safe haven for the client to explore their environment and return to the therapeutic space to process, de-brief, be reassured, understood, learn and grow (Mikulincer & Shaver, 2012). Some studies have shown that nature of the attachment relationship between client and clinician is incredibly important for success of treatment, reduction of symptomology and potential recovery of a client from their disorder (Illing et al., 2010; Tasca et al., 2011).