case study attachment theory

CLINICAL CASE STUDY article

“a child’s nightmare. mum comes and comforts her child.” attachment evaluation as a guide in the assessment and treatment in a clinical case study.

• Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy

There is a gap between proposed theoretical attachment theory frameworks, measures of attachment in the assessment phase and their relationship with changes in outcome after a psychodynamic oriented psychotherapy. Based on a clinical case study of a young woman with Panic Attack Disorder, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the psychodynamic diagnostic manual. Treatment planning and post-treatment changes were described with the main aim to illustrate from a clinical point of view why a psycho-dynamic approach, with specific attention to an “attachment theory stance,” was considered the treatment of choice for this patient. The Symptom Check List 90 Revised (SCL-90-R) and the Shedler–Westen Assessment Procedure (SWAP–200) were administered to detect patient’s symptomatic perception and clinician’s diagnostic points of view, respectively; the Adult Attachment Interview and the Adult Attachment Projective Picture System (AAP) were also administered as to pay attention to patient’s unconscious internal organization and changes in defense processes. A qualitative description of how the treatment unfolded was included. Findings highlight the important contribution of attachment theory in a 22-month psychodynamic psychotherapy framework, promoting resolution of patient’s symptoms and adjustment.

Introduction

Attachment theory in Bowlby’s (1969/1982 , 1973 , 1980 , 1988 ) and Ainsworth’s (1963 , 1967 ) tradition postulates that an individual’s experience of early parental care contributes to the development of internal representations of self and others as safe and available. This theory offered the clinicians a scientific grounded model, which postulated and empirically demonstrated the origin of psychopathology in early separation experiences and in adverse emotional experiences ( Oppenheim and Goldsmith, 2007 ; Cassidy and Shaver, 2008 ). The most recent literature endorses that attachment theory is consonant with all assessment and treatment approaches which evaluate childhood experiences as an important contributor to adult functioning (e.g., Wallis and Steele, 2001 ; Blatt and Levy, 2003 ; Diamond, 2004 ; Bakermans-Kranenburg et al., 2005 ; Buchheim et al., 2007 ; Zegers et al., 2008 ; Buchheim and George, 2011 ). Throughout the case formulation and the planning of treatment, attachment theory has also the potential to provide-at least-a useful foundation for defining the target of change in psychotherapy (e.g., features of internal working models or attachment patterns), understanding the processes through which change occurs (e.g., through the development of a secure base and exploration of working models; e.g., Fonagy, 1999 , 2001 ; Cozzolino, 2002 ; Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Wallin, 2007 ; Fosha, 2009 ; Holmes, 2010 ; Siegel, 2010 ). As Bowlby originally stated, while reconsidering classical attachment theory, Davila and Levy 2006 , p. 990) stressed “five key tasks for psychotherapy: (a) establishing a secure base, which involves providing patients with a secure base from which they can explore the painful aspects of their life; (b) exploring past attachments, which involves helping patients explore past and present relationships, including their expectations, feelings, and behaviors; (c) exploring the therapeutic relationship, which involves helping the patient examine the relationship with the therapist and how it may relate to relationships or experiences outside of therapy; (d) linking past experiences to present ones, which involves encouraging awareness of how current relationship experiences may be related to past ones; and (e) revising internal working models, which involves helping patients to feel, think, and act in new ways that are unlike past relationship.” Despite the increasing interest in the relevance of attachment theory as a framework to understand the unfolding of psychodynamic treatment, there is a gap between the proposed theoretical frameworks and the empirical measures of attachment used in the assessment, and only few studies addressed the interplay between attachment pattern measures, and their implication for unfolding and outcome in a psychoanalytic oriented treatment ( Buchheim and Kachele, 2001 ; Dahlbender et al., 2004 ; Buchheim, 2005 ; Lis et al., 2008 , 2011 ; Isaacs et al., 2009 ).

Interpersonal problems, adult attachment, and emotion regulation have been increasingly studied across adult anxiety disorders. Literature linked attachment and separation in infants and preschool children to separation anxiety disorder, agoraphobia, and panic attacks later in life, underlining how insecure attachment can lead to an increased risk for attachment psychopathology and subsequent social and emotional maladjustment/attachment and separation anxiety/school or work phobia/attachment correlations ( Routh and Bernholtz, 1991 ). Of all the forms of anxiety, separation anxiety seems to be the one which is most likely to be associated with an anxious attachment style, because sufferers are by definition highly sensitive to real or perceived threats to relationships ( Main et al., 1985 ). Separation anxiety would appear to be a core form of anxiety associated with panic attack disorder and with attachment problems ( Hazan and Shaver, 1987 ; Bartholomew and Horowitz, 1991 ; Eng et al., 2001 ). Dysfunctional and not good-enough parenting and hereditary factors appear to play a role in generating early separation anxiety. However, the child’s anxiety itself may generate overprotective parenting ( Manicavasagar et al., 1999 , 2009 ) which, in turn, could make children approach their caregivers both in response to dangerous external stimuli and to caregiver’s permanent monitoring availability and attentiveness; moreover, overprotecting or over responsive parents could obstacle the expression of the explorative system, even when a “secure base” is provided ( Pacchierotti et al., 2002 ). Although attachment theory suggests that anxious attachment styles are mostly associated with risks of developing anxiety disorders, neither all anxious attached patients develop panic attack disorder, nor all secure attached patients do not develop it: the latter is a weird and rare condition because, theoretically, secure early relationships with adults are the basis for the development of a sense of control and predictability accounting for normal subjects’ tendency not to interpret ambiguous internal stimuli as threatening ( Shear, 1991 ).

Based on a clinical case study of a young woman with Panic Attack Disorder- Matilde-, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) 1 . The patient’s choice is motivated by this “rare combination”: a PAD patient with secure attachment. The first aim of this paper was to provide incremental usefulness to the picture of the patient’s idiographic and intra-subjective features, using a multi- method assessment based on (1) two performance-based attachment measures – the Adult Attachment Interview (AAI; George et al., 1984 / 1985 / 1996 ), and The Adult Attachment Projective Picture System (AAP; George and West, 2001 , 2012 ), (2) the Shedler–Westen Assessment Procedure (SWAP–200; Westen and Shedler, 1999a , b ), and (3) a self-report symptom scale, the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1983 ; Funder, 1997 ; Meyer et al., 1999 ; Ozer, 1999 ).The second aim was to describe how Matilde’s assessment findings – and more specifically attachment pattern analysis – could represent useful guidelines for the unfolding of a psychoanalytic therapy with a supportive approach, in an attachment theory framework ( Misch, 2000 ).

We hypothesized that the AAI, the AAP, the SCL-90-R, and the SWAP–200 would help in focusing on the most relevant dimensions of patient’s psychological functioning which make a meaningful diagnosis ( Barron, 1998 ; Shedler and Westen, 2007 ) at the beginning and at the end of treatment. Attention was directed to the interplay between modification of overt symptoms and behaviors, and changes in personality functioning and adaptation; more specifically, we focused on patterns and complexities in the patient’s internal organization and interpersonal functioning ( Shectman and Harty, 1986 ; Peebles-Kleiger, 2002 ; Bram, 2010 ). A reduction in psychopathological symptoms and an improvement in mental functioning according to the PDM M -axis and S -axis were expected at the end of the therapy.

Clinical Case Presentation: Matilde

Matilde was a pleasant 20-year-old young woman, who looked younger than her age. She was a self-referred patient, and was assessed for a high level of anxiety at a university-based psychology-training clinic 2 . Matilde had a diagnosis of Panic Attack Disorder in Axis I (DSM-IV; American Psychiatric Association [APA], 1994 ), and no diagnosis in Axis II. Although she was a 2-year student at the Medical School with outstanding results, she felt “ anxious, confused, and insecure, ” “ I do not know if this Faculty is good for me, maybe Biology would be better, or Pharmacy … I do not know really, I am so confused; I do not understand what is happening to me …. I am no more sure about anything. ” Insecurity caused her quite severe crying crises, pervasive anxiety, and some physical symptoms, such as psychomotor agitation and tachycardia. She had taken light tranquilizers in the last 3 months. She felt unable to control or understand her present distress. Since she started University, her life had been totally busy with studying, leaving no time or desire to engage in social relationships. She did not talk about any actual satisfying relationships. The only “ friends ” she kept in touch with were schoolmates from high school, with whom she shared school topics. She had never had a boyfriend, and felt very uncomfortable talking about romantic or sexual topics. Matilde moved away from her small native town to attend University, and she was sharing an apartment with other students next to the Medical School. She went back home to her family during University vacations. She came from an intact family, which she was very proud of. She had a 10-year-old sister, Sarah, to whom she was very attached. Sarah was described as very different from Matilde: very funny, an ironic with a lot of energy. They spent a lot of time playing together, and Matilde was unconcerned about her worries when she was with Sarah. Matilde describes her childhood with some enjoyment and unconcern while her present appears very worrying, uncertain and without any source of protection and soothing. Matilde supports a good relation with her mother, although the father is described as rigid and very involved in practical duties.

Approach to the Case: Procedure and Instruments

At the initial assessment phase Matilde underwent three interview sessions, two test sessions and one feedback session. In particular, Matilde’s evaluation involved the administration of the AAI and the AAP, the SCL-90-R, and the SWAP–200. All results were integrated with clinical interview contents to formulate a case conceptualization, according to specific dimensions of the PDM. In the feedback session, a once-a-week psychodynamic psychotherapy with a supportive approach was proposed to and accepted by Matilde. The therapy lasted 22 months. At treatment conclusion Matilde accepted to be re-administered the AAP and the SCL-90-R. Based on the last three sessions also the SWAP–200 was re-administered. All the tools administered were scored and interpreted by independent judges 3 . A brief description of used tools follows after timetable of administration (Table 1 ).

TABLE 1. Timetable of administered tools.

Symptom Checklist 90 Revised ( Derogatis, 1983 ) is a 90-item self-report questionnaire scored on a five-point Likert scale of distress from 0 (none) to 4 (extreme), indicating the rate of occurrence of symptoms during the time reference ( Derogatis et al., 1973 ). It is intended to measure symptom intensity on 10 different dimensions: somatization (SOM), obsessive–compulsive (O–C), interpersonal sensitivity (I-S), depression (DEP), anxiety (ANX, hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), and sleep difficulties (SLEEP). A Global Severity Index (GSI) of distress is calculated. According to the Italian Manual, an intensity raw score higher than one was qualified as penetrating in the clinical range. The internal consistency coefficient alphas for the nine symptom dimensions ranged from 0.77 for Psychoticism, to 0.90 for Depression. Test–retest reliability coefficients ranged between 0.80 and 0.90 after 1 week of therapy. The few validity studies of the SCL-90-R demonstrate levels of concurrent, convergent, discriminant, and construct validity comparable to other self-report inventories ( Derogatis, 1983 ).

The Shedler–Westen Assessment Procedure ( Westen and Shedler, 1999a , b ) is a set of 200 personality-descriptive statements developed for clinicians to assess adult personality traits and pathologies ( Shedler and Westen, 1998 ). Starting from clinical interviews, the assessor is asked to describe the patient by arranging the statements into eight categories, from those that are not descriptive (assigned a value of “0”) to those that are highly descriptive (assigned a value of “7”) for each of the 200 personality-descriptive variables. The instrument is based on the Q-sort method that requires clinicians to arrange items into a fixed distribution ( Block, 1978 ). The SWAP–200 could be interpreted at a nomothetic as well as at an idiographic level. Nomothetic interpretations are carried out following two profiles. The first is the PD-T score profile of the 10 Personality Disorders included in DSM–IV (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive); the Q-T profile covers 11 dimensions (psychological health, dysphoric, antisocial, schizoid, paranoid, obsessive, histrionic, narcissistic, avoidant, depressive high functioning, emotional dysregulation, dependent, hostile). Both PD-T and Q-T profiles include a score on a Healthy Functioning scale. Inter-rater reliability coefficients range from 0.70 to 0.80. Support for the validity of the SWAP–200 is derived from its ability to predict relevant variables in expected ways, including family psychiatric history, history of abuse, social, and school functioning, violence, suicidal behaviors and attempts, attachment status, and eating disorder diagnostic groups ( Westen and Muderrisoglu, 2003a , b ). Idiographic narrative case description is also included in the SWAP–200 (e.g., Lingiardi et al., 2006 ). Both levels were used to assess Matilde. Moreover, the SWAP–200 ( Westen and Shedler, 1999a , b ) is one of the instruments listed by PDM work-group members to be used to measure the dimensions of the M -axis.

The Adult Attachment Interview ( George et al., 1984 , 1985 , 1996 ; Hesse, 2008 ) is an about 1 h audio-recorded semi-structured interview that explores an adult’s mental representations of attachment, guiding the individual through a series of questions about past and present relationships with each parent and attachment-relevant events during childhood. The AAI focuses on the assessment of the attachment internal working model ( Bowlby, 1969/1982 ) and assumes developmental continuity of the attachment system along life. AAI final attachment classification is evaluated on two different set of scales (1) Experience Scales that evaluate for example Loving, Rejecting, Neglect, Role Reversal, Pressure to achieve and (2) State of Mind Scales that assess Coherence, Metacognitive Processes, Lack of Recall, Passivity of Discourse, Idealization, Anger, Derogation attitudes toward caregivers, Unresolved mourning or trauma, Feared loss of one’s own child. Starting from these scales, each interview is classified in one of the primary attachment patterns: secure/autonomous, dismissing/avoidant, and preoccupied/entangled or “cannot classify.” Where applicable, the “unresolved” pattern with respect to loss, trauma, or abuse could be scored. Multiple scoring is allowed (e.g., F/DS). AAI validation rests on more than 25 years of developmental and clinical research ( van IJzendoorn and Bakermans-Kranenburg, 2008 ). Rigorous psychometric testing and meta-analyses of the AAI demonstrate its stability, and discriminant and predictive validity in both clinical and non-clinical populations. In a recent meta-analysis of 61 clinical samples ( van IJzendoorn and Bakermans-Kranenburg, 2008 ), strong associations were found between psychiatric diagnoses (i.e., anxiety disorders, borderline personality disorder) and attachment insecurity.

The Adult Attachment Projective Picture System ( George and West, 2001 ) is based on a standardized set of seven drawn pictures divided in Alone and Dyadic stimuli 4 . The pictures describe major attachment events, potential threat of separation, illness, solitude, death, and abuse. The stimuli are: child at window (window); departure; bench; bed; ambulance; cemetery; and child at corner (corner). Individuals are asked to make up a story for each image in which they describe what is going on in the picture, what led up to the scene, what the characters are thinking or feeling and what might happen next. The responses are audiotaped for transcription and verbatim analysis. The AAP assesses attachment in the Bowlby-Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ). The AAP Coding System, leads to four adult attachment classification patterns, – secure/autonomous, dismissing, preoccupied, unresolved – as they were traditionally assessed in the AAI, even if no multiple scoring is allowed. The AAP also assesses attachment personal elements that individuals may exclude from conscious awareness. Attachment classification using the AAP is determined by evaluating patterns of responses using a set of seven scales grouped under three major categories: discourse, content, and defensive processing. These dimensions evaluate the attachment story content related to the hypothetical characters portrayed in the stimuli, to defenses, and to self-other boundaries in narrative discourse ( George and West, 2001 , 2012 ). Discourse codes evaluate personal experience. Content codes include agency of self and connectedness for alone pictures, and Synchrony for dyadic pictures. Finally, the AAP codes for defensive exclusion, segregated systems, deactivation, and cognitive disconnection ( Bowlby, 1980 ). They represent different degrees of “protection” from dangerous distressful events. Segregated systems describe a mental state in which painful attachment-related memories are isolated and blocked from conscious thought and rooted in experiences of trauma or loss through death ( Bowlby, 1980 ). Deactivating defensive processes are defined as attempts to dismiss, cool off, or shift attention away from attachment events, individuals, or feelings in response to the picture stimuli. Cognitive disconnection processes literally disconnect the elements of attachment from their source, thus undermining consistency and the capability of holding in one’s mind a unitary view of events, emotions, and the individuals associated with them. The most recent review of AAP reliability and validity was published in George and West (2012) . AAP–AAI convergence for secure versus insecure classifications was 0.95 (κ = 0.75, p = 0.000); convergence for the four major attachment groups was 0.89 (κ = 0.84, p = 0.000; George and West, 2001 , 2012 ; West and George, 2002 ). The AAP has also been shown to be useful in studying the neurobiological and emotional expression correlates of attachment in non-clinical and clinical samples ( Buchheim and Benecke, 2007 ; Buchheim et al., 2007 , 2008 , 2009 ; Fraedrich et al., 2010 ) as well as in single case studies ( Lis et al., 2011 ).

Both AAI and AAP show individual strengths in measuring attachment patterns, but their combined use increments their overall usefulness. The AAI, the golden standard measure of adult attachment ( Bakermans-Kranenburg and van Ijzendoorn, 1993 ), focuses on the assessment of the representational model and coherence of mind, and assumes developmental continuity of the attachment system, evaluating abuse and loss in one’s personal history. The AAP, based on the Bowlby–Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ), assesses current views of self, attachment figures, and expectations about the productiveness of attachment relationships, elucidating how current experience activates attachment accomplishment, disappointment, and trauma from the past ( West et al., 1995 ; George and West, 2012 ). The AAP is also more trauma sensitive and underscores defense patterns (e.g., Hesse, 2008 ; George and West, 2012 ). The combined use of the AAI and the AAP gives the chance to portray a complex image of the patient’s attachment pattern, providing a detailed narrative about life attachment activators such as separation, fear, solitude, and danger, shedding light on the unconscious defensive mechanisms and exploring the accessibility of attachment figures during the life-span (e.g., Hesse, 2008 ; George and West, 2012 ). The SCL-90-R contributed to get Matilde’s self-evaluation of symptoms.

Assessment Findings

Results from DSM-IV diagnosis, SCL-90-R and SWAP–200 during the assessment phases are described in Table 2 . Results from attachment tools are reported below and AAI subscales are shown in Tables 3 and 4 .

TABLE 2. Results from SCL-90-R and SWAP–200 in assessment phase.

TABLE 3. AAI experience scales.

TABLE 4. AAI state of mind scales.

Matilde’s AAI was scored F2/Ds3, secure with features of dismissing or some restriction in feelings of attachment (F2 = free somewhat dismissing or restricted in attachment; DS3 = dismissing restricted in feelings with some evidences of Lack of Memories; George and Solomon, 1996 ; see Tables 3 and 4 ). Matilde secure pattern was so defined because she was able to explore his or her thoughts and feelings about childhood experiences, with fresh speech, humor and forgiveness, without becoming angrily or passively overwhelmed while discussing them. Generally, Matilde appeared to be aware of the nature of experiences with her parents and of the effects of such experiences on her present state of mind and on her personality. Nevertheless, she remained a little bit restricted in her emotional expressions, preferring to rationalize. State of mind scales tapped a dismissing feature, showing a slight tendency to idealize parents and some lack of memories. Further information about Matilde derived from a qualitative analysis of the AAI. She did not report any severe illness, traumatic or abuse experience. However, separations caused her some distress, but she felt always supported and listened by her mother. She described herself as a very calm girl but, during early childhood, she was very shy and very worried about separation: “ I became very agitated when I did not see my parents, when they were not there, when they were away from home, ” “ Once we were at the lake. I was on the one side of the road and my parents were on the other side. Some people passed and so I could not see my parents anymore. I did not see them anymore and I began to scream .” However, she remembered that during her summer camp experience, when there were no well-known friends or schoolmates: “ I felt the distance from home, I felt lost and confused … I was very happy to go back home. The bus journey to go back home was very stressful,” “I do not like changes. I am worried about changes. ”

She described the relationship with her mother as: affectionate, playful, reciprocal, supportive, and protective. When she was asked to recall a specific example in respect with “supportive relationship” she reported that “ I gulped a small toy and it remained caught in my throat. I had to be taken to the hospital. I was very agitated, I screamed that I was frightened of dying. Mammy was very supporting … I mean comforting. ” She was able to identify a specific episode, but in a superficial and not qualitative consistent manner ( Grice’s qualitative maxim ): the adjective-descriptor (supportive) of relationship with her mother was supported with a second generalized positive descriptor (comforting). The adjectives she chose to describe the relationship with her father were: always affectionate, playful, formal ( “home rules had to be respected, for instance times for lunch and dinner” ), respectful ( “Nothing escaped from him; his words had always a weight” ), and important. Such aspects were more linked to father’s role as a parent and to school achievement: “I felt very bad about his criticism.” Matilde felt closer to her mother than to her father, from whom she felt more detached. Moreover, during school years she always felt a little bit anxious and agitated about school achievement and completion. Beside all these difficulties, she always felt supported and sustained by her mother, and at the end she demonstrated herself as very forgiving toward her father’s severity. When asked to imagine the possibility of being separated from her child, Matilde reported to feel “ a big void, a big feeling of lost, of mourning, a big pain, an absence of being complete ” and the three wishes about this child when he would be 20-years old were: “ to be able to choose, to have a clear reasoning, not being confused, and to be able to be autonomous. ”

Matilde was judged as secure on the AAP (F): she showed, at the representational level, a flexible and organized thinking about attachment situations and relationships ( Bowlby, 1969/1982 ). She was confident that she could rely on attachment figures to achieve care, safety and protection and, when alone, she could access internalized attachment relationships ( George and Solomon, 1996 , 1999 ). In response to two of the alone stimuli – Window and Cemetery- as a secure individual, she demonstrated the ability to think (i.e., Internalized Secure Base) and to take constructive action. She also used flexible defensive processes to integrate attachment feelings and events. Using these resources she was able to re-organize her attachment-related feelings, also in the few cases (Bed and Cemetery Stories) when she became disorganized by feelings of loss and danger. From the pattern of story responses it appears that Matilde, above all other response qualities, genuinely valued and represented the capacity for integration of self and relationships. The responses to the Alone pictures demonstrated Matilde’s internal resources, such as the potential availability and responsiveness of attachment figures. As a representative example of this attitude the Cemetery picture (a man stands by a gravesite headstone) story is reported.

“A gentleman who had a bad day or felt sad or depressed or undervalued because of an episode that happened during the day and goes and visits his father … he feels reassured because he found a place where to think about his life by himself and then he will go back home and will be able to reconsider what happened from a different point of view.”

In Cemetery, Matilde reveals the intensity of feelings of pain associated with loss: she tries to deal with them through some form of uncertainty and desire to withdraw (cognitive disconnection). These forms of organized defensive mechanisms keep Matilde’s attachment system activated but they cannot prevent her from becoming dysregulated, as evidenced by painful attachment-related feelings of loss represented by the appearance of a them where no clear distinction is made between life and death (“he goes and visit his father”). A segregated system (spectral domain) was activated by the picture features, which portray a man visiting a grave. However, Matilde was able to depict the man as engaged in some kind of “thinking.” The man is able to “reconsider what happened from a different point of view.” This process belongs to Internalized Secure Base, and portrays Matilde’s ability to clearly differentiate between the living and the dead. The Dyadic picture stimuli portray attachment-caregiving dyads. The responses to Dyadic picture stimuli demonstrate Matilde’s representation of the self and other in attachment situations when attachment figures are present and accessible, but they also demonstrate the use of attachment figures to quell the attachment anxiety aroused in the scenes depicted in the cards. Bed picture (a child and woman sit opposite to each other on the child’s bed) could be a representative example.

“A boy had a nightmare during the night and his mother woke up eh … now he is scared and he would like to be close to his mum … the mum is trying to soothe him and she will be able to do it … the boy will come back to sleep quietly … (Anything else?) no.. maybe the bad dream was … was about the fact of staying alone without his mom … and now … he wants his mom first!”

In Matilde’s story, the child signals his attachment need after a “nightmare” (segregated system in AAP) and the mother is able to provide a contingent and soothing answer, containing the potential breakdown of the attachment system and resolving the segregated system. Both AAI and AAP classified Matilde as secure with somewhat dismissing or restricted feelings in attachment without elements of unresolved abuse or trauma. However, both tools detected some shortcomings about fears of separation and danger. The AAI was not able to draw attention in an exhaustive way to how Matilde experienced abandonment fears and felt scared without the presence of her parents. Instead the AAP clearly depicted this nuance, under a secure pattern, showing that her attachment was threatened by painful attachment-related feelings of loss, and by a nightmare (in Bed picture), a signal of danger. In both tools she demonstrated her ability to re-organize herself, but these disturbing feelings kept being alive underneath her reorganized secure pattern.

Case Formulation Based on PDM Axes

S -axis – Matilde had a diagnosis of DSM-IV ( American Psychiatric Association [APA], 1994 ), and showed a slightly High Functioning profile with Obsessive, Schizoid-Avoidant and Dysphoric characteristics, in both PD and Q factors in SWAP–200. Matilde’s SCL-90-R symptom profile revealed depression, anxiety, obsessive–compulsive, and somatization scores in the clinical range (Table 2 ).

M -axis – this Axis describes nine dimensions, which systematize the capacities that contribute to an individual’s personality and overall level of psychological health or pathology.

Capacity for regulation, attention, and learning

In the clinical interview, she said, “ I lost control of my body and thinking. ” She appeared in a profound state of crisis and she appeared to be unable to cope with it and with connected feelings of anxiety and distress. She (a) adhered rigidly to daily routines and became anxious or uncomfortable when they were altered, (b) had trouble making decisions and was indecisive or vacillated when faced with choices, (c) was overly concerned with rules, procedures, order, organization, and schedules: all obsessive strategies which would interfere with processes that support attention and learning from experience. However, according to Bowlby, being secure at both AAI and AAP means that Matilde had basic capacities for regulation. Matilde appeared to believe in the seeking of proximity and support as effective ways in regulating distress, in particular in AAP Dyadic pictures. However, at the moment of assessment, she was not able to recur to her internalized security patterns, showing how an emotional regressive crisis was rising up. Although Matilde subjectively felt unable to cope with it and was very frightened by it, according to the AAP and AAI, the dysregulation appeared momentary and not prolonged. It seems she was still functioning as she described herself in the early childhood memory, when she could not see her parents and she got anxious at the thought of being lost. However, her basic secure attachment suggests that, thanks to the therapy, she could re-establish her capacity of self-regulation, a secure person’s basic characteristic.

Capacity for interpersonal relationships

Although she was excessively devoted to work and productivity, compromising leisure and relationships, her secure attachment pattern at the AAI and AAP indicated that Matilde had a positive representation of available adults who can offer protection, support, care, and comfort in threatening and stressful situations. The AAP supported also her potential ability to be connected with other relational systems such as partners and peers, almost in a concrete manner, since she was able to tell stories in which she described specific connections with friends and other people in general. However, her agency, connectedness, and synchrony were at the moment “quite silent” in her everyday life. She needed help to regain these resources.

Quality of internal experiences

In AAI and AAP she felt reassured by (her) mother’s proximity, soothing, and comfort. However, episode and story plots clearly indicated some separation anxieties and worries in respect to changes, which she faced using dismissing defense mechanisms. AAP clearly depicted how under a secure pattern, her attachment was threatened by painful attachment-related feelings of loss and danger. Until that moment, such feelings were isolated and blocked from conscious thought. Even if she was able to deal with these experiences in childhood thanks to her mother’s comfort, her fear of loss connected to the fear of being alone and unprotected seem to re-emerge We hypothesized that she was having trouble in coping with new adolescence-through-young adulthood tasks, such as the adult separation-individuation process. According to the SWAP–200, she experienced a sense of personal dissatisfaction, poor self-regard, low self-esteem, lack of confidence, and chronic self-criticism. Her unrealistically high standards together with her expectation of being “perfect” above all in her achievements, made her feel guilty, depressed and despondent, with negative self-regard toward others, and the world at large.

Affective experience, expression, and communication

According to the SWAP–200, Matilde tended to defend herself via the inhibition of emotion expression, by means of abstract thinking and intellectualized terms, and appeared unable to recognize her wishes and impulses. Apparently, intellectualization and disavowal defenses (above all rationalization) led her to the avoidance of expressed conflict and emotions – both positive and painful. This emotional constriction resulted in a bottled up affect being channeled into panic attacks. The SWAP–200 stressed the risk of recurrent episodes of overt anxiety, tension, nervousness, and irritability and difficulty in acknowledging or expressing underlying feelings of anger and resentment. The AAP and AAI confirmed that underneath this block of affection there was a rich and positive affective state she had internalized during childhood life experiences. However, although not so rigid, her present affective state of constriction and inhibition was consistent with the rigid attempt to neutralize affect using deactivating defenses in the AAP. The emotions, which were bottled up in the segregated system, surely carried a negative and overwhelming emotional tone, which at the moment she was unable to deal with.

Defensive patterns and capacities

The SWAP–200 indicated the extent to which Matilde tended to defend her from expressing emotions, by abstract thinking and intellectualized terms. Although her defenses were at a mature-neurotic level, they were not solid enough to allow her to avoid the recourse to symptoms and anxiety. From an attachment viewpoint-AAP-Matilde shows a different picture underneath. Here defenses appeared organized and flexible, but in order to keep a regulated attachment she relied more on deactivation than on cognitive disconnection ( George and West, 2012 ).

Capacity to form internal representations

Matilde was able to form internal representations of self and others, and her experiences were symbolized mentally. However, in the current state of distress, some emotions and conflicts were expressed somatically through her somatic symptoms and panic attack episodes.

Capacity for differentiation and integration (ego strength, self-cohesion, stability of reality testing). Overall, her AAP stories and her narrative in the AAI revealed that she was able to look realistically at herself, people, and relationships. Also during the clinical interview, a solid, stable and good child image emerged, but was not integrated with an adolescent and adult image: Matilde’s ego was fragile and was shattered by a large number of symptoms, her self-image was damaged and not well integrated; moreover, she looked younger than her age and never talked about sexuality or intimate relationships.

Self-observing capacities

Matilde did not demonstrate good self-observation capacities. Her level of current distress, extension of intellectualization and rationalization defenses, avoidant and constricted emotional style did not allow for an adult and mature emotional insight.

Capacity to construct or use internal standards and ideals. SWAP–200 showed how she currently set unrealistically and childish high standards for herself and how she appeared intolerant of her own human defects.

Therapeutic Stance and Therapy Guiding Conception

Matilde looked younger than her age and did not talk about sexuality or intimate relationships and we supposed that she did not undergo a true adolescent process. Looking at her secure attachment pattern, the therapist hypothesized that the present state of dysregulation and symptomatic picture is transitory and derived from the new young adulthood tasks she has now to deal with during her transition toward adulthood, such as moving to University. From a psychoanalytic as well as an attachment-oriented viewpoint, we hypothesized she was not able to face adolescent and adult separation-individuation processes. According to attachment theory, attachment relationships foster integration of attachment with relationships in peer behavioral systems during adolescence and adulthood: these include friendships and romantic relationships ( West and George, 1999 ; Allen, 2008 ; George and Solomon, 2008 ; George and West, 2012 ). Psychoanalytic theories also agree that the individual needs to face adolescence as a separation-individuation process, where adolescents need to acquire an individual separate self-identity through identification with parents and separation from childhood ties. The AAP and AAI were taken into account, making the therapist sensible to specific topics concerning separation, loss, and loneliness, able to reactivate and unleash childhood attachment-related memories of fear of being lost and completely alone during treatment itself. Matilde needed to explore this topic with a therapist who would represent for her, in the transference, a secure parent similar to the one she had already experienced in her life via her mother’s supporting stance. In particular, the therapist expected that supportive psychotherapy would integrate the “segregated” themes locked in Matilde’s experience: she might then be able to consciously accept and deal with her blocked emotions and affects, as to regainenjoyment of life and satisfaction in the relationship with significant figures, re-finding the haven of safety of self and others that she had experienced in her childhood.

The clinical case formulation suggested for Matilde a therapeutic approach in the context of a “partial rapprochement” between attachment theory and psychoanalytic individual psychotherapies as the best solution ( Skean, 2005 ; Slade, 2008 ; Steele et al., 2009 ). This intervention would include: (a) The use of therapeutic relationship and alliance as vehicles for a “secure base” constitution, in order to observe and understand the client’s interpersonal behavior ( Spence, 1982 ; Binder et al., 1987 ; Dozier et al., 1994 ; Slade, 2008 ; Steele et al., 2009 ); (b) Relationships with the self and others (internal and external), in terms of personality functioning but also from client’s transference and therapist’s counter-transference points of view of ( McWilliams, 1999 ; Skean, 2005 ); moreover, patient’s real or transferential relationships and past-present pattern of emotional responses and behaviors were examined ( Gabbard, 2009 ). However, a particular emphasis was put on the supportive versus insight-oriented modes of therapy ( Skean, 2005 ), because Matilde needed: (a) to reduce physical and psychical symptoms ( S-Axis ; Gabbard, 2009 ), and reestablish a consistent level of functioning ( Dewald, 1971 ; Ursano and Silberman, 1996 ; Douglas, 2008 ); (b) to strengthen her fragile ego. Her defenses were at a mature-neurotic level, but were not solid enough to stop the recourse to symptoms and anxiety ( PDM: Defenses; Capacity for Differentiation and Integration ), (c) to change her self-definition, improving self-esteem, and getting a more integrated perception of the self, ( PDM: Qualiy of internal experiences; Capacity for Differentiation and Integration ); (d) To function better in everyday life investing lessin achievements and study matters ( Dewald, 1971 ; Ursano and Silberman, 1996 ; PDM: Rehabilitation ); (e) to improve her coping skills and to learn consistent strategies to manage her painful internalized feelings ( PDM: Capacity for regulation, attention, and learning ); (f) to increase her capacity to express affects both on the positive and negative aspects evidenced by AAI and that were consciously often inhibited and not acknowledged (PDM: Affective Experience, Expression, and Communication) ; (g) to encourage more consistent ways of relating to others ( PDM: Capacity for Intepersonal Relationships; Misch, 2000 ). In addition, her concrete and intellectualized thinking (SWAP–200) made also difficult for her to deal with interpretations, suggesting again the need of a more supportive approach.

Brief Outline of the Therapy Unfolding

As expected, during the first months of therapy Matilde showed a high symptomatic picture. She appeared very distressed and confused, with a sense of failure, of inability to reach her standards. Long boring and intellectualized descriptions of daily routines and of University achievement, anxiety, uncertainties and doubts about her achievements were her main topics. The therapist acted as a secure attachment figure ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ), as a caregiver who offered security and soothing to Matilde’s distress. She worked actively helping Matilde to contain anxiety, shame, and anger ( Winston et al., 2004 ). The therapist, very slowly and respecting her defenses, tried to reduce Matilde’s anxiety, to increase her self-esteem and hope, and to make her more aware about herself as a person, and not only as a student who had to achieve some standards. She begun anyway to talk about how she could count on her mother, the only person that always helped her when she felt anxious and distressed. This finally opened a window on her family and her separation difficulties during childhood, and she started to tellhow she felt alone and how much she needed her mother’s soothing, how much difficult it was to face her first experience of a 2-week summer camp, as well as to begin elementary school, middle school, and high school. She also admitted that anyway with her mother’s help she was able to face these separations. She began to recognize, following therapist’s verbalizations, that at that time she was beginning a new kind of “school-experience,” similarly to the situation at present. In parallel with this initial understanding of her fear of facing changes and separation, all symptoms increased, especially anxiety symptoms. “ It is a nightmare ” were her words. She told the therapist that she called mommy every morning and evening but it was not enough. She felt lost and alone. The episodes reported by Matilde at this phase of the therapy were very similar to the ones she reported in the AAI, and the ways she dealt with the present separation from her mother were similar to the ones she previously used during her childhood: going concretely to her mother to be soothed and supported. Moreover, she used the same words she previously used in the two AAP stories where segregated systems were unleashed but resolved. It could be hypothesized that in the transference with the therapist Matilde’s attachment system was activated and “seen in action” ( George and West, 2012 ). As she said during the AAI, it was always difficult for her to deal with changes. Now in the transference with the therapist she was reliving her fears, the same fears she experiencedin childhood, the ones that were unleashed at the beginning of the University andthat she was able to face only through anxiety and obsessive symptoms. It was difficult for her to connect this experience with the new separation experience from home and from herself as a child, now that she had to face University and all the complex processes connected with entering adulthood. In the transference with the therapist she was reviving an acute separation anxiety and she was also unconsciously angry at the therapist’s impossibility to help her. The therapist tried unsuccessfully to interpret and to connect this profound regression with Matilde’s previous separation anxieties. Words were not useful. Wallin (2007) supports that “ what patients are unable to explain with words, tends to be evocated, enacted or incorporated ” ( Zaccagnini and Zavattini, 2009 ). The working alliance showed for the first time some ruptures, and the risk of treatment disruption itself became a subject of discussion ( Appelbaum, 2005 ; Colli and Lingiardi, 2009 ). Matilde’s alliance rupture style was characterized by the presence of withdrawal maneuvers: emotional disengagement from the therapist, skipping from topic to topic, responding in an overly intellectualized fashion, and very short answers ( Safran and Muran, 2000 ). In such a moment of regression, she really needed a concrete comfort and physical contact with her mother. The therapeutic stance was not enough for her; she decided that the best way to deal with the situation was to go back home. Matilde went home, “ to be near to her family. ” Coming back to her parents represented for her the haven of safety she described in her AAP. Parents were still used as attachment figures during early, middle and late adolescence and also during young adulthood ( Fraley and Davis, 1997 ), especially under conditions of extreme stress ( Huntsinger and Luecken, 2004 ; Kamkar et al., 2012 ). She stayed home with her family for 3 weeks. When she came back, she appeared less anxious and more integrated: little by little, Matilde was more able to feel the setting as a place where exploration of her personal life and new experiences could be initiated, shared, and enjoyed. She was able to develop positive feelings toward the therapist ( Misch, 2000 ). She began to integrate positive and negative feelings in life events, becoming more and more flexible, increasing her ability to tolerate changes and learning to find new solutions to life schedule. She reached some goals toward adulthood and began to find real friends, also far from home, and to spend energy in different activities (e.g., organization, church, neighborhood, etc.). She loved challenges and she felt pleasure in realizing her goals and in pursuing long-term ambitions. A boyfriend appeared. The symptoms disappeared. She continued to use a great amount of razionalization in order to explain some affective aspect of her experiences. from the point of view of attachment, she mantained a tendency to change the topic when she approached emotional issues using displacement defenses in order not to deal with her core difficulties. The therapeutic goal of accomplishing a true adolescent process was also achieved. A solid and good child image was now more integrated with an adolescent and adult image. Some developmental tasks were reached on the way toward adultood (friendship and romantic relationship). The therapist discussed with Matilde the fact that some shortcomings were still present in her personality functioning, but both agreed that she wished now to try to go on with her life by herself. As Freud (1966) suggested, the aim of psychotherapy at a developmental age is to help the patient to proceed along his or her developmental lines. Now Matilde managed to integrate some issues concerning the developmental step of adolescence and young adulthood and she wished to try new experiences by herself.

Follow-Up Findings

Results from DSM-IV diagnosis, SCL-90-R, and SWAP–200 in the follow-up phase are described in Table 5 .

TABLE 5. Results from SCL-90-R and SWAP–200 in follow-up phase.

The AAP was scored secure, but without any segregated systems. As a representative example of some new attitudes, Matilde’s stories for Window and Departure pictures are reported.

Window (a child looks out a window): a girl who woke up eh … parents are not there, they are at work and she knows she is alone at home. She is quiet. She is looking out of the window thinking about her mom and the fact she will come back home in the afternoon. She is thinking about who she can invite in … who can … can keep … her company. She is quiet, excited by the day without parents (What might happen next?) she will find someone … a … a friend … a neighbor … finally she will have fun (Anything else?) No.

Matilde tells one of the most common AAP stories for the Window picture: a typical home-related scenario in which a little girl needs to manage her solitude. The girl is “ quiet ” although she is alone home. So, Matilde is not threatened by the girl’s loneliness, but she is somehow able to enjoy the possibility of being alone. The absence of segregated systems demonstrates the absence of dysregulating events, which could have led to her being alone (her parents are just working) and of girl’s traumatic reactions. More specifically, the girl is depicted “ thinking about her mom, ” activating her ability to internalize the secure base and being “ content in solitude. ” In fact, this connection with the thought of her mother’s coming back in the afternoon keeps the girl regulated and lets her also think about something specific to do alone: “ she looks out of the window thinking about who she can invite in … who can keep … her company. ” The little girl can recall the affiliative system (“ friend ”) to handle her loneliness. Her ability to think makes Matilde confident and envisages the possibility of changing things in the immediate future (“ she invited friends ”). From a developmental point of view, Matilde is now a late adolescent-young adult: she is prone to consider also peers and friends as a secure base to refer to in moderately distressful situations.

Departure (an adult man and woman stand facing each other with suitcases positioned nearby): a woman is going to leave for a business trip and she is saying goodbye to her husband … he took her to the station … she was already planning what she needed to do during the trip … yes during this period of work … he is quiet and he thinks about their relationship, about how they enjoy to be together, what he would do without … in these few days without his wife…however … she will leave and he will spend a few dull days … (Anything else?) No.

In Departure, Matilde is able to tell a typical AAP story, which portrays a couple at the train station. The husband thinks about their relationship and he feels that his days will be dull without his wife. Matilde’s story suggests togetherness and a goal-corrected partnership. She portrays the husband as involved in a contingent, reciprocal and mutually engaging relationship.

Qualitative Clinical Evaluation at the End of Therapy

Matilde did not have any DSM-IV diagnosis in Axis I and her personality functioning resulted carachterized by obsessive high functioning features (PDM S -axes, SWAP–200). She had no more panic attacks accompanied by strong physical arousal, and her experiences were now more mentally symbolized. Her SCL-90-R final symptom profile revealed a magnitude within the normal range. Only two symptomatic distress levels, obsessive–compulsive, and anxiety, still penetrated the clinical range, but their intensity had diminished compared to the assessment phase.

Her self-image improved: she now experienced a sense of personal satisfaction, sufficient self-esteem and self-confidence (PDM M -axes). The “negative-stressful” components of her affective world were still present but the level of self-blame, and emotional constriction greatly diminished. She was now less inhibited and became more spontaneous in expressing emotions, and also anger. Matilde still showed a pattern of Mature-Neurotic defenses and an absence of primitive defenses. Rationalization, intellectualization, undoing, and displacement were the mostly used defenses, but were now more flexible, less pervasive and she was able to avoid recourring to symptoms and anxiety. The AAP confirmed a flexible use of defenses and reduction in thereliance on dectivation defenses; however, her kind of defense structure still did not allow neither an emotional insight about her motivations and behaviors, or psychological mindedness.

Matilde remained secure in her attachment pattern, changing her defensive approach through a more integrated and coherent one, in which no more segregated systems or disregulation were present: she was now able to use again her self-regulation capacities autonomously (PDM M -axes). Her attachment adolescent crisis was resolved; she was out of her “nightmare.” She still seemed naïve and used an excessive part of her mental energy to keep emotions and feelings at bay, showing a limited ability to appreciate metaphor, analogy, or nuance. In the context of a supportive stance, comprising a secure and holding environment and an atmosphere based on emotional safety, she was able to work on her fear of loss and changes allowing her internalized attachment status to reach an adult structure. She was now able to deal with adult tasks using her internalized parental figures, thinking about how they could protect her. Matilde now found pleasure, satisfaction, and enjoyment in everyday-life activities. Her underneath security pattern now re-emerged allowing her to maintain a loving relationship, and to engage and keep long-standing and intimate friendships and relationships (PDM M -axes). She now set less unrealistically high personal standards and she was now able to find meaning in belonging and contributing to a wider community (e.g., organization, church, neighborhood, etc.). Table 6 shows Matilde’s qualitative picture at baseline and at follow up.

TABLE 6. Qualitative Matilde’s picture of features at baseline and at the end of psychotherapy.

This clinical case study highlighted the importance of assessing patient’s idiographic and intra-subjective features ( Hilliard, 1993 ). The nature of the clinical case perspective requires a rich diagnostic process that includes both a nosographic approach (such as DSM-IV) and a more multifaceted point of view to assess the specific patient’s psychological functioning ( Barron, 1998 ; Shedler and Westen, 2007 ). There have been few studies investigating the psychotherapy process in supportive therapies ( Orlinsky et al., 2004 ), and very few studies were devoted to inserting also the contribution of validated measures of attachment. Slade (2008) endorsed that, although attachment theory terms have been incorporated in the present psychoanalytic theory, only few therapists have really integrated core elements of the attachment perspective in their clinical thought. Above all, few of them inserted measures of attachment and their strategies to understand the therapy unfolding ( Rockland, 1989 ; Porcerelli et al., 2011 ). Assessing attachment means more than just determining a patient’s attachment classification status. The benefit from the inclusion of attachment assessment to a multi-method approach is the chance of using results to elucidate the patient’s representational and defensive patterns related to attachment activation ( Bowlby, 1980 ).

This paper tried to illustrate a clinical case where results from attachment tools together with PDM assessment could help to give a more integrate picture and to form and inform the unfolding of the therapy. The incremented validity about symptoms and attachment internal working models evaluation added a specific qualitative contribution to each tool (e.g., SCL-90-R gave the self perception of symptomatology and SWAP–200 the clinical perception of it; AAI and AAP increased biographical information and defense mechanism, respectively). The paper presented a case formulation in which a psychodynamic approach was integrated with an attachment theory framework both in the assessment and post-assessment phases and with a “ supportive psychotherapy approach. ” The secure attachment status, as derived from the AAI and the AAP, helped to structure Matilde’s therapy, adding information to the therapeutic intervention: Matilde’s secure attachment resulted helpful to establish a therapeutic plan, to facilitate the therapeutic alliance and the answer to the therapy, and to help her to face her symptoms and internal difficulties ( Douglas, 2008 ; Steele and Steele, 2008 ). The AAP and AAI were taken into account, making the therapist sensible to the specific topics concerning separation and loss, which were reactivated throughout treatment. Matilde needed to explore them in the context of a “ safe haven, ” the same context she had previously experienced in her life with her mother’s supporting stance. On her side, the therapist recreated and maintained a well knownholding environment, affective mirroring and personal warmth ( Markowitz, 2008 ) and an atmosphere based on emotional safety ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). She provided Matilde with the secure base she temporary lost, a starting point from where the exploration of painful experiences in her present life could finally begin. This gave her the possibility to recall some hidden memories, leading to self-exploration ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Holmes, 2010 ). The “supportive approach” and the role of attachment framework turned out to be a key factor in the assessment and in the development of an effective therapeutic relationship with Matilde. Within a psychoanalytic framework, through the unfolding relationship with the therapist, Matilde brought her interpersonal world into the treatment room and allowed the therapist to experience aspects of her structuring of reality ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). The conclusion of the therapy showed a more integrated picture, where symptoms were no more outstanding and Matilde seemed to be out of her big “nightmare” and ready to face her life tasks in a more integrated and young-adult way. The post-treatment AAP confirmed that Matilde was able to integrate these issues of separation and loss. She was a very defensive neurotic patient blocked at latency, and showed some shortcomings related to the separation-individuation process ( Mahler et al., 1975 ) both from a psychoanalytic and from an attachment point of view.

The treatment helped Matilde to make a developmental step toward maturity: “from childish features to adolescent ones, reaching the capacity of (emotionally) exploring the possibility of living independently from parents (…) because they know that they can turn to parents in case of real need” ( Allen and Land, 1999 , p. 322). The therapist was both an “attachment figure” that helped Matilde to face new experiences, as well as a transference object ( Dozier et al., 1994 ). Matilde’s development resulted in increased abilities in managing the goal-corrected partnership with each parent, in which behavior is not determined only by adolescent’s current needs and wishes, but also by recognition of the need to manage certain set goals for the partnership ( Bowlby, 1973 ).

As all clinical case studies, this study suffered from some limitations ( Hodkinson and Hodkinson, 2001 ): results are not generalizable in the conventional sense; it looks expensive, if attempted on a large scale and the complexity examined is difficult to represent simply and briefly. Furthermore, clinical case studies results stronger when researchers’ expertise and intuition are maximized, but this raises doubts about their “objectivity”: this type of research is easily subjected to criticisms by those who do not like the messages that they contain; and finally it cannot answer a large number of relevant and appropriate research questions that future studies could address (e.g., in this sense, it could be highly valuable for future research to compare PAD patients with different attachment styles). However, this particular case study could be considered an original and extremely valuable one, because it is grounded in “lived reality.” This helps us to understand complex inter-relationships between diagnosis, measures and their clinical application, facilitating the development of conceptual/theoretical issues and the exploration of unexpected and unusual situations, such as PAD in a secure attached patient. As regards the choice of this patient, the present paper can provide “provisional truths, in a Popperian sense” ( Hodkinson and Hodkinson, 2001 ): it represents the best account of such assessment and treatment in the current literature, and it should stand, until contradictory findings or better theories are developed.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

• ^ The PDM was developed to describe “the depth as well as the surface of emotional, cognitive, and social patterns” (p. 1) of an individual’s functioning, as to improve the diagnosis and treatment of psychological disorders. PDM comprises three areas: personality patterns (Axis P ), mental functioning ( M -axis), and symptoms ( S -axis). Our attention focused mainly on mental functioning or M -axis, “a microscopic look at mental life” (p. 8), although some attention was paid to symptoms and concerns or S -axis.
• ^ The patient self-referred to a psychodynamic service, where therapists are trained to use an Operationalized Psychodynamic Diagnosis approach during consultation sessions, preferring free or “per area” clinical sessions to interviews (e.g., SCID).
• ^ The self report SCL-90-R was digitally computed. Inter-reliability reached Cohen’s k = 1 for AAI and AAPs final classifications; 0.93 for AAI subscales; 0.85 for AAP codings; 0.72 for SWAP–200 final scales.
• ^ (1) Neutral (children playing ball); (2) child at window (alone); (3) departure (dyad); (4) bench (alone); (5) bed (dyad); (6) ambulance (dyad); (7) cemetery (alone); (8) child in corner (alone).

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Keywords : assessment, attachment, psychodynamic supportive therapy, outcome research, clinical case study

Citation: Salcuni S, Di Riso D and Lis A (2014) “A child’s nightmare. Mum comes and comforts her child.” Attachment evaluation as a guide in the assessment and treatment in a clinical case study. Front. Psychol. 5 :912. doi: 10.3389/fpsyg.2014.00912

Received: 21 May 2014; Accepted: 30 July 2014; Published online: 20 August 2014.

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*Correspondence: Silvia Salcuni, Department of Developmental and Socialization Psychology, University of Padua, via Venezia 12, 35100 Padova, Italy e-mail: [email protected]

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• Case report
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• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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What Is Attachment Theory?

The Importance of Early Emotional Bonds

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

• Attachment Theory
• Stages of Attachment

Attachment Styles

Attachment theory focuses on relationships and bonds (particularly long-term) between people, including those between a parent and child and between romantic partners. It is a psychological explanation for the emotional bonds and relationships between people.

This theory suggests that people are born with a need to forge bonds with caregivers as children. These early bonds may continue to have an influence on attachments throughout life.

History of the Attachment Theory

British psychologist John Bowlby was the first attachment theorist. He described attachment as a "lasting psychological connectedness between human beings." Bowlby was interested in understanding the anxiety and distress that children experience when separated from their primary caregivers.

Thinkers like Freud suggested that infants become attached to the source of pleasure. Infants, who are in the oral stage of development, become attached to their mothers because she fulfills their oral needs.

Some of the earliest behavioral theories suggested that attachment was simply a learned behavior. These theories proposed that attachment was merely the result of the feeding relationship between the child and the caregiver. Because the caregiver feeds the child and provides nourishment, the child becomes attached.

Bowlby observed that feedings did not diminish separation anxiety. Instead, he found that attachment was characterized by clear behavioral and motivation patterns. When children are frightened, they seek proximity from their primary caregiver in order to receive both comfort and care.

Understanding Attachment

Attachment is an emotional bond with another person. Bowlby believed that the earliest bonds formed by children with their caregivers have a tremendous impact that continues throughout life. He suggested that attachment also serves to keep the infant close to the mother, thus improving the child's chances of survival.

Bowlby viewed attachment as a product of evolutionary processes. While the behavioral theories of attachment suggested that attachment was a learned process, Bowlby and others proposed that children are born with an innate drive to form attachments with caregivers.

Throughout history, children who maintained proximity to an attachment figure were more likely to receive comfort and protection, and therefore more likely to survive to adulthood. Through the process of natural selection, a motivational system designed to regulate attachment emerged.

The central theme of attachment theory is that primary caregivers who are available and responsive to an infant's needs allow the child to develop a sense of security. The infant learns that the caregiver is dependable, which creates a secure base for the child to then explore the world.

So what determines successful attachment? Behaviorists suggest that it was food that led to forming this attachment behavior, but Bowlby and others demonstrated that nurturance and responsiveness were the primary determinants of attachment.

Ainsworth's "Strange Situation"

In her research in the 1970s, psychologist Mary Ainsworth expanded greatly upon Bowlby's original work. Her groundbreaking "strange situation" study  revealed the profound effects of attachment on behavior. In the study, researchers observed children between the ages of 12 and 18 months as they responded to a situation in which they were briefly left alone and then reunited with their mothers.

Based on the responses the researchers observed, Ainsworth described three major styles of attachment: secure attachment, ambivalent-insecure attachment, and avoidant-insecure attachment. Later, researchers Main and Solomon (1986) added a fourth attachment style called disorganized-insecure attachment based on their own research.

A number of studies since that time have supported Ainsworth's attachment styles and have indicated that attachment styles also have an impact on behaviors later in life.

Maternal Deprivation Studies

Harry Harlow's infamous studies on maternal deprivation and social isolation during the 1950s and 1960s also explored early bonds. In a series of experiments, Harlow demonstrated how such bonds emerge and the powerful impact they have on behavior and functioning.  

In one version of his experiment, newborn rhesus monkeys were separated from their birth mothers and reared by surrogate mothers. The infant monkeys were placed in cages with two wire-monkey mothers. One of the wire monkeys held a bottle from which the infant monkey could obtain nourishment, while the other wire monkey was covered with a soft terry cloth.

While the infant monkeys would go to the wire mother to obtain food, they spent most of their days with the soft cloth mother. When frightened, the baby monkeys would turn to their cloth-covered mother for comfort and security.

Harlow's work also demonstrated that early attachments were the result of receiving comfort and care from a caregiver rather than simply the result of being fed.

The Stages of Attachment

Researchers Rudolph Schaffer and Peggy Emerson analyzed the number of attachment relationships that infants form in a longitudinal study with 60 infants. The infants were observed every four weeks during the first year of life, and then once again at 18 months.

Based on their observations, Schaffer and Emerson outlined four distinct phases of attachment, including:

Pre-Attachment Stage

From birth to 3 months, infants do not show any particular attachment to a specific caregiver. The infant's signals, such as crying and fussing, naturally attract the attention of the caregiver and the baby's positive responses encourage the caregiver to remain close.

Indiscriminate Attachment

Between 6 weeks of age to 7 months, infants begin to show preferences for primary and secondary caregivers. Infants develop trust that the caregiver will respond to their needs. While they still accept care from others, infants start distinguishing between familiar and unfamiliar people, responding more positively to the primary caregiver.

Discriminate Attachment

At this point, from about 7 to 11 months of age, infants show a strong attachment and preference for one specific individual. They will protest when separated from the primary attachment figure (separation anxiety), and begin to display anxiety around strangers (stranger anxiety).

Multiple Attachments

After approximately 9 months of age, children begin to form strong emotional bonds with other caregivers beyond the primary attachment figure. This often includes a second parent, older siblings, and grandparents.

Factors That Influence Attachment

While this process may seem straightforward, there are some factors that can influence how and when attachments develop, including:

• Opportunity for attachment : Children who do not have a primary care figure, such as those raised in orphanages, may fail to develop the sense of trust needed to form an attachment.
• Quality caregiving : When caregivers respond quickly and consistently, children learn that they can depend on the people who are responsible for their care, which is the essential foundation for attachment. This is a vital factor.

There are four patterns of attachment, including:

• Ambivalent attachment : These children become very distressed when a parent leaves. Ambivalent attachment style is considered uncommon, affecting an estimated 7% to 15% of U.S. children. As a result of poor parental availability, these children cannot depend on their primary caregiver to be there when they need them.
• Avoidant attachment :   Children with an avoidant attachment tend to avoid parents or caregivers, showing no preference between a caregiver and a complete stranger. This attachment style might be a result of abusive or neglectful caregivers. Children who are punished for relying on a caregiver will learn to avoid seeking help in the future.
• Disorganized attachment : These children display a confusing mix of behavior, seeming disoriented, dazed, or confused. They may avoid or resist the parent. Lack of a clear attachment pattern is likely linked to inconsistent caregiver behavior. In such cases, parents may serve as both a source of comfort and fear, leading to disorganized behavior.
• Secure attachment : Children who can depend on their caregivers show distress when separated and joy when reunited. Although the child may be upset, they feel assured that the caregiver will return. When frightened, securely attached children are comfortable seeking reassurance from caregivers. This is the most common attachment style.

The Lasting Impact of Early Attachment

Children who are securely attached as infants tend to develop stronger self-esteem and better self-reliance as they grow older. These children also tend to be more independent, perform better in school, have successful social relationships, and experience less depression and anxiety.

Research suggests that failure to form secure attachments early in life can have a negative impact on behavior in later childhood and throughout life.

Children diagnosed with oppositional defiant disorder (ODD), conduct disorder (CD), or post-traumatic stress disorder (PTSD) frequently display attachment problems, possibly due to early abuse, neglect, or trauma. Children adopted after the age of 6 months may have a higher risk of attachment problems.

Attachment Disorders

In some cases, children may also develop attachment disorders. There are two attachment disorders that may occur: reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED).

• Reactive attachment disorder occurs when children do not form healthy bonds with caregivers. This is often the result of early childhood neglect or abuse and results in problems with emotional management and patterns of withdrawal from caregivers.
• Disinhibited social engagement disorder affects a child's ability to form bonds with others and often results from trauma, abandonment, abuse, or neglect. It is characterized by a lack of inhibition around strangers, often leading to excessively familiar behaviors around people they don't know and a lack of social boundaries.

Adult Attachments

Although attachment styles displayed in adulthood are not necessarily the same as those seen in infancy, early attachments can have a serious impact on later relationships. Adults who were securely attached in childhood tend to have good self-esteem, strong romantic relationships, and the ability to self-disclose to others.

A Word From Verywell

Our understanding of attachment theory is heavily influenced by the early work of researchers such as John Bowlby and Mary Ainsworth. Today, researchers recognize that the early relationships children have with their caregivers play a critical role in healthy development. 

Such bonds can also have an influence on romantic relationships in adulthood. Understanding your attachment style may help you look for ways to become more secure in your relationships.

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By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

What is Attachment Theory? Bowlby’s 4 Stages Explained

No matter what the “it” refers to, Sigmund Freud would have probably said yes to that question.

However, we now know a lot more about psychology, parenting, and human relationships than Freud did.

It’s clear now that not every issue can be traced back to one’s mother. After all, there is another person involved in the raising (or at least the creation) of a child.

In addition, there are many other important people in a child’s life who influence him or her. There are siblings, grandparents, aunts and uncles, godparents, close family friends, nannies, daycare workers, teachers, peers, and others who interact with a child on a regular basis.

The question posed above is tongue-in-cheek, but it touches upon an important discussion in psychology—what influences children to turn out the way they do? What affects their ability to form meaningful, satisfying relationships with those around them?

What factors contribute to their experiences of anxiety, avoidance, and fulfillment when it comes to relationships?

Although psychologists can pretty conclusively say that it’s not entirely the mother’s fault or even the fault of both parents, we know that a child’s early experiences with their parents have a profound impact on their relationship skills as adults.

Much of the knowledge we have on this subject today comes from a concept developed in the 1950s called attachment theory . This theory will be the focus of this article: We’ll explore what it is, how it describes and explains behavior, and what its applications are in the real world.

Before you continue, we thought you might like to download our three Positive Relationships Exercises for free . These detailed, science-based exercises will help you or your clients build healthy, life-enriching relationships.

This Article Contains:

What is attachment theory a definition, research and studies, erik erikson, attachment theory in babies, infants, and early childhood development, attachment theory in adults: close relationships, parenting, love, and divorce, attachment theory in grief and trauma, the attachment theory test, using attachment theory in the classroom (worksheet and pdf), attachment theory in social work, criticisms of attachment theory, recommended books, articles, and essays, a take-home message.

The psychological theory of attachment was first described by John Bowlby, a psychoanalyst who researched the effects of separation between infants and their parents (Fraley, 2010).

Bowlby hypothesized that the extreme behaviors infants engage in to avoid separation from a parent or when reconnecting with a physically separated parent—like crying, screaming, and clinging—were evolutionary mechanisms. Bowlby thought these behaviors had possibly been reinforced through natural selection and enhanced the child’s chances of survival.

These attachment behaviors are instinctive responses to the perceived threat of losing the survival advantages that accompany being cared for and attended to by the primary caregiver(s). Since the infants who engaged in these behaviors were more likely to survive, the instincts were naturally selected and reinforced over generations.

These behaviors make up what Bowlby termed an “attachment behavioral system,” the system that guides us in our patterns and habits of forming and maintaining relationships (Fraley, 2010).

Research on Bowlby’s theory of attachment showed that infants placed in an unfamiliar situation and separated from their parents will generally react in one of these ways upon reunion with the parents:

• Secure attachment: These infants showed distress upon separation but sought comfort and were easily comforted when the parents returned;
• Anxious-resistant attachment: A smaller portion of infants experienced greater levels of distress and, upon reuniting with the parents, seemed both to seek comfort and to attempt to “punish” the parents for leaving.
• Avoidant attachment: Infants in the third category showed no stress or minimal stress upon separation from the parents and either ignored the parents upon reuniting or actively avoided the parents (Fraley, 2010).
• In later years, researchers added a fourth attachment style to this list: the disorganized-disoriented attachment style, which refers to children who have no predictable pattern of attachment behaviors (Kennedy & Kennedy, 2004).

It makes intuitive sense that a child’s attachment style is largely a function of the caregiving the child receives in his or her early years. Those who received support and love from their caregivers are likely to be secure, while those who experienced inconsistency or negligence from their caregivers are likely to feel more anxiety surrounding their relationship with their parents.

However, attachment theory takes it one step further, applying what we know about attachment in children to relationships we engage in as adults. These relationships (particularly intimate and/or romantic relationships) are also directly related to our attachment styles as children and the care we received from our primary caregivers (Firestone, 2013).

The development of this theory gives us an interesting look into the study of child development.

Bowlby and Ainsworth: The History and Psychology of Attachment Theory

Bowlby’s interest in child development traces back to his first experiences out of college, in which he volunteered at a school for maladjusted children. According to Bowlby, two children sparked his curiosity and drive that laid the foundations of attachment theory.

There was an isolated and distant teenager who had no stable mother figure in his life and had recently been expelled from his school for stealing, and an anxious 7- or 8-year-old boy who followed Bowlby wherever he went, earning himself a reputation as Bowlby’s “shadow” (Bretherton, 1992).

Through his work with children, Bowlby developed a strong belief in the impact of family experiences on children’s emotional and behavioral wellbeing .

Early on in his career, Bowlby proposed that psychoanalysts working with children should take a holistic perspective, considering children’s living environments, families, and other experiences in addition to any behaviors exhibited by the children themselves.

This idea grew into a strategy of helping children by helping their parents, a generally effective strategy given the importance of the child’s relationships with their parents (or other caregivers).

At roughly the same time Bowlby was creating the foundations for his theory on attachment, Mary Ainsworth was finishing her graduate degree and studying security theory, which proposed that children need to develop a secure dependence on their parents before venturing out into unfamiliar situations.

In 1950, the two crossed paths when Ainsworth took a position in Bowlby’s research unit at the Tavistock Clinic in London. Her initial responsibilities included analyzing records of children’s behavior, which inspired her to conduct her own studies on children in their natural settings.

Through several papers, numerous research studies, and theories that were discarded, altered, or combined, Bowlby and Ainsworth developed and provided evidence for attachment theory.

Theirs was a more rigorous explanation and description of attachment behavior than any others on the topic at the time, including those that had grown out of Freud’s work and those that were developed in direct opposition to Freud’s ideas (Bretherton, 1992).

There were several groundbreaking studies that contributed to the development of attachment theory or provided evidence for its validity, including the study described earlier in which infants were separated from their primary caregivers and their behavior was observed to fall into a “style” of attachment.

Further findings on emotional attachment came from a surprising place: rhesus monkeys.

The Harlow Experiments

His work showed that motherly love was emotional rather than physiological, that the capacity for attachment is heavily dependent upon experiences in early childhood, and that this capacity was unlikely to change much after it was “set” (Herman, 2012).

Harlow discovered these interesting findings by conducting two groundbreaking experiments.

In the first experiment, Harlow separated infant monkeys from their mothers a few hours after birth. Each monkey was instead raised by two inanimate surrogate “mothers.” Both provided the infant monkeys with the milk they needed to survive, but one was made out of wire mesh while the other was wire mesh covered with soft terry cloth.

The monkeys who were given the freedom to choose which mother to associate with almost always chose to take milk from the terry cloth “mother.” This finding showed that infant attachment is not simply a matter of where they get their milk—other factors are at play.

For his second experiment, Harlow modified his original setup. The monkeys were given either the bare wire mesh surrogate mother or the terry cloth mother, both of which provided the milk the monkeys needed to grow.

Both groups of monkeys survived and thrived physically, but they displayed extremely different behavioral tendencies. Those with a terry cloth mother returned to the surrogate when presented with strange, loud objects, while those with a wire mesh mother would throw themselves to the floor, clutch themselves, rock back and forth, or even “scream in terror.”

This provided a clear indication that emotional attachment in infancy, gained through cuddling, affected the monkey’s later responses to stress and emotion regulation (Herman, 2012).

These two experiments laid the foundations for further work on attachment in children and the impacts of attachment experiences in later life.

Erikson’s work was based on Freud’s original personality theories and drew from his idea of the ego. However, Erikson placed more importance on context from culture and society than on Freud’s focus on the conflict between the id and the superego.

In addition, his stages of development are based on how children socialize and how it affects their sense of self rather than on sexual development.

The eight stages of psychosocial development according to Erikson are:

• Infancy—Trust vs. Mistrust : In this stage, infants require a great deal of attention and comfort from their parents, leading them to develop their first sense of trust (or, in some cases, mistrust);
• Early Childhood—Autonomy vs. Shame and Doubt : Toddlers and very young children are beginning to assert their independence and develop their unique personality, making tantrums and defiance common;
• Preschool Years—Initiative vs. Guilt : Children at this stage begin learning about social roles and norms. Their imagination will take off at this point, and the defiance and tantrums of the previous stage will likely continue. The way trusted adults interact with the child will encourage him or her to act independently or to develop a sense of guilt about any inappropriate actions;
• School Age—Industry (Competence) vs. Inferiority : At this stage, the child is building important relationships with peers and is likely beginning to feel the pressure of academic performance. Mental health issues may begin at this stage, including depression, anxiety, ADHD, and other problems.
• Adolescence—Identity vs. Role Confusion : The adolescent is reaching new heights of independence and is beginning to experiment and put together his or her identity. Problems with communication and sudden emotional and physical changes are common at this stage (Wells, Sueskind, & Alcamo, 2017).
• Young Adulthood—Intimacy vs. Isolation : At this stage (ages 18-40, approximately), the individual will begin sharing with others more, including people outside o the family. If the individual is successful in this stage of development, he or she will build satisfying relationships that have a sense of commitment, safety, and care; if not, they may fear commitment and experience isolation, loneliness, and depression (McLeod, 2017).
• Middle Adulthood—Generativity vs. Stagnation : In the penultimate stage (ages 40-65, approximately), the individual is likely established in his or her career, relationship, and family. If the individual is not established and contributing to society, he or she may feel stagnant and unproductive.
• Late Adulthood—Ego Integrity vs. Despair : Finally, late adulthood (ages 65 and above) usually brings reduced productivity, which can either be embraced as a reward for one’s contributions or be met with guilt or dissatisfaction. Successfully navigating this stage will protect the individual from feeling depressed or hopeless, and help the individual cultivate wisdom (McLeod, 2017).

Although it does not map completely onto attachment theory, Erikson’s findings are clearly related to the attachment styles and behaviors Bowlby, Ainsworth, and Harlow identified.

John Bowlby – Attachment Theory – Diana Simon Psihoterapeut

According to Bowlby and Ainsworth, attachments with the primary caregiver develop during the first 18 months or so of the child’s life, starting with instinctual behaviors like crying and clinging (Kennedy & Kennedy, 2004). These behaviors are quickly directed at one or a few caregivers in particular, and by 7 or 8 months old, children usually start protesting against the caregiver(s) leaving and grieve for their absence.

Once children reach the toddler stage, they begin forming an internal working model of their attachment relationships. This internal working model provides the framework for the child’s beliefs about their own self-worth and how much they can depend on others to meet their needs.

In Bowlby and Ainsworth’s view, the attachment styles that children form based on their early interactions with caregivers form a continuum of emotion regulation, with anxious-avoidant attachment at one end and anxious-resistant at the other.

Secure attachment falls at the midpoint of this spectrum, between overly organized strategies for controlling and minimizing emotions and the uncontrolled, disorganized, and ineffectively managed emotions.

The most recently added classification, disorganized-disoriented, may display strategies and behaviors from all across the spectrum, but generally, they are not effective in controlling their emotions and may have outbursts of anger or aggression (Kennedy & Kennedy, 2004).

Research has shown that there are many behaviors in addition to emotion regulation that relates to a child’s attachment style. Among other findings, there is evidence of the following connections:

• Secure Attachment: These children are generally more likely to see others as supportive and helpful and themselves as competent and worthy of respect. They relate positively to others and display resilience, engage in complex play and are more successful in the classroom and in interactions with other children. They are better at taking the perspectives of others and have more trust in others;
• Anxious-Avoidant Attachment : Children with an anxious-avoidant attachment style are generally less effective in managing stressful situations. They are likely to withdraw and resist seeking help, which inhibits them from forming satisfying relationships with others . They show more aggression and antisocial behavior, like lying and bullying, and they tend to distance themselves from others to reduce emotional stress;
• Anxious-Resistant Attachment : These children are on the opposite end of the spectrum from anxious-avoidant children. They likely lack self-confidence and stick close to their primary caregivers. They may display exaggerated emotional reactions and keep their distance from their peers, leading to social isolation.
• Disorganized Attachment : Children with a disorganized attachment style usually fail to develop an organized strategy for coping with separation distress, and tend to display aggression, disruptive behaviors, and social isolation. They are more likely to see others as threats than sources of support, and thus may switch between social withdrawal and defensively aggressive behavior (Kennedy & Kennedy, 2004).

It is easy to see from these descriptions of behaviors and emotion regulation how attachment style in childhood can lead to relationship problems in adulthood.

Attachment styles are primarily discussed in the context of our childhood and upbringing.

In the early stages of development, children develop different attachment patterns to their parents or caregiver. These attachment styles can be predictive of how children grow up. For example, anxious or avoidant attachment styles are often powerful predictors for psychopathology or maladjustment development in the later stages of life (Benoit, 2004).

On the contrary, children with secure attachment styles to their parents are also more likely to have secure attachments to their romantic partners. This being said, attachment styles from childhood play a significant role in all the relationships you will encounter.

From this image, you may notice that the secure attachment style is the only one with a “positive” connotation, whereas the other attachment styles seem to have more unfavorable consequences.

If you recognize yourself as displaying one of the more maladaptive attachment styles, don’t fret because this is 1. very common and 2. not set in stone. For example, if you identify with the fearful-avoidant attachment style, you may see that trust seems to be the biggest issue.

The purpose of this image is not to make you feel ashamed about having a particular attachment style, but the opposite. By accepting and embracing your weaknesses, you allow yourself to grow.

Indeed, it is clear how these attachment styles in childhood lead to attachment types in adulthood. Below is an explanation of the four attachment types in adult relationships.

Examples: The Types, Styles, and Stages (Secure, Avoidant, Ambivalent, and Disorganized)

The adult attachment styles follow the same general pattern described above (Firestone, 2013):

Secure Attachment

These adults are more likely to be satisfied with their relationships, feeling secure and connected to their partners without feeling the need to be together all the time. Their relationships are likely to feature honesty , support, independence, and deep emotional connections.

Dismissive-Avoidant (or Anxious-Avoidant) Attachment

One of the two types of adult avoidant attachments, people with this attachment style generally keep their distance from others. They may feel that they don’t need human connection to survive or thrive, and insist on maintaining their independence and isolation from others.

These individuals are often able to “shut down” emotionally when a potentially hurtful scenario arises, such as a serious argument with their partner or a threat to the continuance of their relationship.

Anxious-Preoccupied (or Anxious-Resistant) Attachment

Those who form less secure bonds with their partners may feel desperate for love or affection and feel that their partner must “complete” them or fix their problems.

While they long for safety and security in their romantic relationships, they may also be acting in ways that push their partner away rather than invite them in. The behavioral manifestations of their fears can include being clingy, demanding, jealous, or easily upset by small issues.

Fearful-Avoidant (or Disorganized) Attachment:

The second type of adult avoidant attachment manifests as ambivalence rather than isolation. People with this attachment style generally try to avoid their feelings because it is easy to get overwhelmed by them. They may suffer from unpredictable or abrupt mood swings and fear getting hurt by a romantic partner.

These individuals are simultaneously drawn to a partner or potential partner and fearful of getting to close. Unsurprisingly, this style makes it difficult to form and maintain meaningful, healthy relationships with others.

Each of these styles should be thought of as a continuum of attachment behaviors, rather than a specific “type” of person. Someone with a generally secure attachment style may on occasion display behaviors more suited to the other types, or someone with a dismissive-avoidant style may form a secure bond with a particular person.

Therefore, these “types” should be considered a way to describe and understand an individual’s behavior rather than an exact description of someone’s personality.

Based on a person’s attachment style, the way he or she approaches intimate relationships, marriage, and parenting can vary widely.

The number of ways in which this theory can be applied or used to explain behavior is compounded and expanded by the fact that relationships require two (or more) people; any attachment behaviors that an individual displays will impact and be influenced by the attachment behaviors of other people.

Given the huge variety of individuals, behaviors, and relationships, it is not surprising that there is so much conflict and confusion.

It is also not surprising, although no less unfortunate, that many relationships end up in divorce or dissolution, an event that may continue an unhealthy cycle of attachment in the children of these unions.

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Speaking of unfortunate situations, attachment theory also has applications in the understanding of the  grief and trauma associated with loss.

Although you may be most familiar with Kübler-Ross’s Five Stages of Grief, they were preceded by Bowlby’s Four Stages. During Bowlby’s work on attachment, he and his colleague Colin Murray Parkes noticed four stages of grief:

• Shock and Numbness: In this initial phase, the bereaved may feel that the loss is not real, or that it is simply impossible to accept. He or she may experience physical distress and will be unable to understand and communicate his or her emotions.
• Yearning and Searching: In this phase, the bereaved is very aware of the void in his or her life and may try to fill that void with something or someone else. He or she still identifies strongly and may be preoccupied with the deceased.
• Despair and Disorganization: The bereaved now accepts that things have changed and cannot go back to the way they were before. He or she may also experience despair, hopelessness, and anger, as well as questioning and an intense focus on making sense of the situation. He or she might withdraw from others in this phase.
• Reorganization and Recovery: In the final phase, the bereaved person’s faith in life may start to come back. He or she will start to rebuild and establish new goals, new patterns, and new habits in life. The bereaved will begin to trust again, and grief will recede to the back of his or her mind instead of staying front and center (Williams & Haley, 2017).

Of course, one’s attachment style will influence how grief is experienced as well. For example, someone who is secure may move through the stages fairly quickly or skip some altogether, while someone who is anxious or avoidant may get stuck on one of the stages.

We all experience grief differently, but viewing these experiences through the lens of attachment theory can bring new perspective and insight into our unique grieving processes and why some of us get “stuck” after a loss.

If you’re interested in learning about your attachment style, there are many tests, scales, and questionnaires out available for you to take.

Feeny, Noller, and Hanrahan developed the Original Attachment Three-Category Measure in 1987 to test respondents’ adult attachment style. It contains only three items and is very simple, but it can still give you a good idea of which category you fall into: avoidant, anxious/ambivalent, or secure. You can complete the measure yourself or read more about it on page 3 of  this PDF .

Bartholomew and Horowitz’s Relationships Questionnaire added to The Three-Category Measure by expanding it to include the dismissive-avoidant category. You can find it on the same PDF as the Three-Category Measure, starting on page 3.

Fraley, Waller, and Brennan’s Experiences in Close Relationships Questionnaire-Revised (ECR-R) is a 32-item questionnaire that gives results measured by two subscales related to attachment: avoidance and anxiety (Fraley, Waller, & Brennan, 2000). Items are rated on a scale from 1 (strongly disagree) to 7 (strongly agree). You can find this questionnaire on the final three pages of the PDF mentioned above.

In addition to these scales, there are several less rigorous attachment style tests that can help you learn about your own style of connecting with others. These aren’t instruments often used in empirical research, but they can be helpful tools for learning more about yourself and your attachment style.

Diane Poole Heller developed an Attachment Styles Test, which contains 45 items rated on a three-point scale from “Rarely/Never” to “Usually/Often.” You can find it here , although after completing it you must enter an email to receive your results.

The Relationship Attachment Style Test is a 50-item test hosted on Psychology Today’s website. It covers the four attachment types noted earlier (Secure, Anxious-Ambivalent, Dismissive-Avoidant, Fearful-Avoidant) as well as Dependent and Codependent attachment styles .

If you are interested in taking this test, you can find it at this link . However, be aware that while you receive a free “snapshot report” at the end, you will need to pay to see your full results.

One of the ways in which the principles and concepts of attachment theory have been effectively applied to teaching is the practice of emotion coaching.

Emotion coaching is about helping children to become aware of their emotions and to manage their own feelings particularly during instances of ‘misbehavior.’ It enables practitioners to create an ethos of positive learning behavior and to have the confidence to de-escalate situations when behavior is challenging” (National College for Teaching and Leadership, 2014).

Emotion coaching is more about supporting children in learning about and regulating their own emotions and behavior than it is about “coaching” in the traditional sense. In emotion coaching, teachers are not required—or even encouraged—to promote proper behavior through rewards or punishments.

Instead, emotion coaching involves:

• Teaching students about the world of “in the moment” emotion;
• Showing students strategies for dealing with emotional ups and downs;
• Empathizing with and accepting negative or unpleasant emotions as normal, but not accepting negative behavior;
• Using moments of challenging behavior as opportunities for teaching;
• Building trusting and respectful relationships with the students (National College for Teaching and Leadership, 2014).

According to attachment theory expert Dr. John Gottman, there are five steps to emotion coaching, and they can be practiced by parents, teachers, or any significant adult in a child’s life:

• Tune in: Notice or become aware of your own and the child’s emotions. Make sure you are calm enough to practice emotion coaching, otherwise, you might want to give both of you a quick breather;
• Connect: Use this situation as an opportunity for you to practice and for the child to learn. State objectively (This is important!) what emotions you think the child is experiencing to help them connect their emotions to their behavior;
• Accept and Listen: Practice empathy. Put yourself in the child’s shoes, think about a situation when you felt a similar emotion, and try to remember what it felt like;
• Reflect: Once everyone is calm, go back over what the child said or did, mentioning only what you saw, heard, or understand of the situation. Reflect on what happened and why it happened;
• End with Problem Solving/Choices/Setting Limits: Whenever possible, try to end the situation by guiding or involving the child in problem-solving (Somerset Children & Young People, n.d.).

To learn more about emotion coaching and improve your skills as a parent or teacher, try the following activity.

What Would an Emotion Coach Do?

This short, two-page activity from the Somerset Emotion Coaching Project can help you enhance your understanding of what emotion coaching is—and what it is not.

There are five scenarios presented along with six potential responses. Your task is to read the scenario and decide which response(s) is/are the appropriate emotion coaching response(s).

The first scenario is: “Angry pupil over not wanting to attend a compulsory revision session.”

Your options include:

• Get cross with the pupil for the bad behavior;
• Tell the pupil they will have to complete an extra session due to the bad behavior;
• Help the pupil to think about what they can do about the problem;
• Tell the pupil not to make a big deal about staying after school;
• Validate the pupil’s expression of anger and frustration;
• Soothe the pupil.

This is an excellent activity to do in groups, as you can discuss each option with others and hear different perspectives from your own. In addition to identifying the emotion coaching response(s), you can also discuss which options are dismissive, avoidant, etc.

You can see the rest of the scenarios and try your hand at this activity by clicking here (an automatic download will start when you click on the link).

Emotion Coaching Scripts

Another great resource from the Somerset Emotion Coaching Project, this activity gives you a chance to practice brainstorming emotion coaching-appropriate responses.

As an added bonus, you can use the scripts you develop to guide you the next time you encounter a situation like those described.

There are six scenarios which you are instructed to create a script for:

• A pupil arrives late to class. She refuses to communicate with you and says “Don’t even start, just leave me alone”;
• A young person refuses to sit by her usual friends at a youth center and says that they have been saying unkind comments about her size;
• A boy regularly fails to complete work independently and will often sit passively and contribute little. He rarely presents with disruptive behavior but simply completes very little work. He appears isolated from his peers;
• A nursery child is crying at drop-off time and is clinging to her parent who has to go to work;
• An aggressive, confrontational parent is annoyed because she’s been asked to come in and talk about her son’s behavior. She approaches you and starts the conversation by saying, “You’re always having a go at us”;
• During recess, a group of young boys was fighting and one of them was hurt (not seriously). You approach them and they all look at you with worried expressions.

For each scenario, the instructions encourage you to:

• Recognize the emotion the child is displaying;
• Validate that emotion;
• Label the emotion the child is feeling;
• Empathize with the child;
• Set limits, if appropriate, and problem-solve.

Completing this worksheet provides you with an excellent opportunity to think, plan, and prepare for effective emotion coaching. You can download this activity for your own use here (an automatic download will start when you click on the link).

If you’re interested in learning more about applying attachment theory to teaching, check out Louis Cozolino’s book Attachment-Based Teaching: Creating a Tribal Classroom . He puts forth a simple but potentially game-changing idea: Relationships are the key to better performance rather than rigidly structured curricula.

In addition, our article Attachment Styles in Therapy: Worksheets & Handouts provides useful worksheets pertaining attachment styles.

Emotion coaching can also be used by social workers, to some extent. However, the application of attachment theory to social work is more significant in the three key messages that it espouses:

• It is vital for social workers to offer children and families a safe haven and secure base. This does not mean families should be forever comfortable and come to depend on the social worker, but families should know a social worker can provide a safe place when they are struggling as well as support for moving forward and outward;
• Social workers must be aware of children’s (and their families’) inner experiences and practice mentalization , or “bringing the inside out.” One of the most important factors in finding healing and improving family relations is to ensure that parents have an idea of what is going on in their children’s heads, including how they feel and think about their parents;
• Among the most effective tools in a social worker’s toolbox is the practice of recording parents as they interact with their child and using the videos to coach the parent. Valuable insights can be found in watching oneself parenting, and the social worker can provide in the moment coaching, offering praise for the parents’ strengths alongside suggestions for improvement (Shemmings, 2015).

Of course, there are many ways to apply attachment theory to working with children, especially those who are in the midst of family crises. However, if these three points are attended to, you’ll have the most important bases covered.

For social workers who work with adults, there are some different strategies and key points to keep in mind, specifically:

• Remember that attachment theory applies throughout the entire range of life, and many behaviors and processes are shaped by early attachment, including staying safe, seeking comfort, regulating proximity to the attachment figure, and seeking predictability;
• Keep in mind that attachment patterns are not based on a few key moments, but on thousands of moments throughout early life, and how an attachment figure responds (or does not respond) sets a template for the child’s attachment style in the future. This template affects how the child recognizes and responds to their own emotions and how they interact with attachment figures;
• This early template becomes deeply embedded in the brain and therefore has a significant impact on our ability to regulate our emotions and connect and relate to others in adulthood. This can lead an adult who was abused in childhood to fail to recognize that they are being abused in their intimate relationship, or even cause them to find comfort and stability in the predictability of their situation;
• Remember that attachment behaviors are adaptive to the context in which they were formed. Habits and behaviors that are adaptive in childhood, in an evolutionary sense at least, may become maladaptive and harmful in adulthood;
• Finally, social workers should never think that they are “treating” a set of behaviors and must recognize that the individual’s strategies were formed for a reason and likely helped him or her survive a difficult situation in childhood. The role of a social worker is to help clients avoid overapplying those strategies and to guide them in adding effective, new strategies to their toolboxes (Hardy, 2016).

As with any popular theory in psychology, there are several criticisms that have been raised against it.

Chief among them are the following criticisms:

• Overemphasis on Nurture: This criticism stems from psychologist J. R. Harris, who believes that parents do not have as much of an influence over their child’s personality or character as most people believe. She notes that much of one’s personality is determined by genetics rather than environment (Harris, 1998; Lee, 2003).
• The stressful situation criticism of attachment theory’s limitations notes that the model was based on a child’s reactions in momentary, stressful situations (being separated from one’s parent), and does not provide any insight into how children and parents interact in non-stressful situations;
• Further, the early model did not take into consideration the fact that children can have different kinds of attachments to different people; the attachment with the mother may not represent the attachments formed with others;
• Finally, the mother was viewed as the automatic primary attachment figure in the early model, when the father, stepparent, sibling, grandparent, aunt, or uncle may be the person that the child connects most strongly with (Field, 1996; Lee, 2003).

Although some of these criticisms have faded over time as the theory is injected with new evidence and updated concepts, it is useful to look at any theory with a critical eye.

17 Exercises for Positive, Fulfilling Relationships

Empower others with the skills to cultivate fulfilling, rewarding relationships and enhance their social wellbeing with these 17 Positive Relationships Exercises [PDF].

Created by experts. 100% Science-based.

A few of the most popular books on attachment theory can be found below:

• Attached: The New Science of Adult Attachment and How It Can Help You Find—and Keep—Love by Amir Levine and Rachel Heller ( Amazon );
• Attachment in Psychotherapy by David J. Wallin ( Amazon );
• Handbook of Attachment: Theory, Research, and Clinical Applications (3rd Edition) by Jude Cassidy and Phillip R. Shaver ( Amazon );
• Theories of Attachment: An Introduction to Bowlby, Ainsworth, Gerber, Brazelton, Kennell, & Klaus by Carol Garhart Mooney ( Amazon );
• Insecure in Love: How Anxious Attachment Can Make You Feel Jealous, Needy, and Worried and What You Can Do About It by Leslie Becker-Phelps ( Amazon );
• Wired for Love: How Understanding Your Partner’s Brain and Attachment Style Can Help You Defuse Conflict and Build a Secure Relationship by Dr. Stan Tatkin ( Amazon ).

There are also several great websites that host insightful essays and informative articles about attachment theory and its applications, including:

• www.communitycare.co.uk : The Community Care website calls itself “The heart of your social care career” and offers many interesting pieces on social work, attachment theory, and working with children and families who are struggling.
• “Attachment Theory” by Saul McLeod:  This article provides an excellent, brief introduction to attachment theory, as well as information on the Harlow experiments, the stages of attachment, and Lorenz’s imprinting theory.
• “A Brief Overview of Adult Attachment Theory and Research” by R. Chris Fraley:  This piece from attachment theory expert R. Chris Fraley also gives readers a thorough and academic introduction to familiarize them with the theory.
• “Attachment Styles at Work: Measurement, Collegial Relationships, and Burnout” by Michael P. Leiter, Arla Day, and Lisa Price:  This article , published in the journal Burnout Research in 2015, dives into the applications of attachment theory in the workplace, a subject we didn’t explore in this piece. The authors share some interesting insights about how one’s attachment style affects their relationships and performance in the workplace.

This piece tackled attachment theory, a theory developed by John Bowlby in the 1950s and expanded upon by Mary Ainsworth and countless other researchers in later years. The theory helps explain how our childhood relationships with our caregivers can have a profound impact on our relationships with others as adults.

Although attachment theory may not be able to explain every peculiarity of personality, it lays the foundations for a solid understanding of yourself and those around you when it comes to connecting and interacting with others.

What do you think about attachment theory? Do you think there are attachment styles not covered by the four categories? Are there any other criticisms of attachment theory you think are valid and worthy of discussion? We’d love to hear your thoughts in the comment section.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Relationships Exercises for free .

• Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics & Child Health, 9(8) , 541-545.
• Bretherton, I. (1992). The origins of Attachment Theory: John Bowlby and Mary Ainsworth. Developmental Psychology, 28, 759-775.
• Cherry, K. (2018). The story of Bowlby, Ainsworth, and Attachment Theory: The importance of early emotional bonds. Retrieved from https://www.verywellmind.com/what-is-attachment-theory-2795337
• Field, T. (1996). Attachment and separation in young children. Annual Review of Psychology, 47 , 541-561.
• Firestone, L. (2013). How your attachment style impacts your relationship.  Retrieved from https://www.psychologytoday.com/blog/compassion-matters/201307/how-your-attachment-style-impacts-your-relationship
• Fraley, R. C. (2010). A brief overview of adult attachment theory and research. Retrieved from https://internal.psychology.illinois.edu/~rcfraley/attachment.htm
• Hardy, R. (2016). Tips on applying attachment theory in social work with adults. Retrieved from http://www.communitycare.co.uk/2016/12/06/attachment-theory-social-work-adults/
• Harris, J. R. (1998). The nurture assumption: Why our children turn out the way they do. Free Press.
• Herman, E. (2012). Harry F. Harlow, monkey love experiments. Retrieved from http://pages.uoregon.edu/adoption/studies/HarlowMLE.htm
• Kennedy, J. H., & Kennedy, C. E. (2004). Attachment theory: Implications for school psychology. Psychology in the Schools, 41 , 247-259.
• Lee, E. J. (2003). The attachment system throughout the life course: Review and criticisms of attachment theory . Retrieved from http://www.personalityresearch.org/papers/lee.html
• McLeod, S. (2017). Erik Erikson. Retrieved from https://www.simplypsychology.org/Erik-Erikson.html
• National College for Teaching and Leadership (2014). An introduction to attachment and the implications for learning and behaviour [PDF Slide Presentation] . Retrieved from https://www.bathspa.ac.uk/media/bathspaacuk/education-/research/digital-literacy/education-resource-introduction-to-attatchment.pdf
• Shemmings, D. (2015). How social workers can use attachment theory in direct work. Retrieved from http://www.communitycare.co.uk/2015/09/02/using-attachment-theory-research-help-families-just-assess/
• Somerset Children & Young People Health & Wellbeing. (n.d.). Emotion coaching and self-regulation. Retrieved from http://www.cypsomersethealth.org/?ks=1&page=mhtk_secp_5
• Wells, J., Sueskind, B., & Alcamo, K. (2017). Child and adolescent issues. Retrieved from https://www.goodtherapy.org/learn-about-therapy/issues/child-and-adolescent-issues
• Williams, L., & Haley, E. (2017). Before the five stages were the FOUR stages of grief. Retrieved from https://whatsyourgrief.com/bowlby-four-stages-of-grief/

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What our readers think.

muchas gracias por la información

The linked surveys are problematic, when they refer to intimate or close relationships, particularly for persons who’ve only had one close adult relationship. Or none.

Article is defective (‘to’ instead of ‘too’ aside). Cannot – for the life of me – find the four stages of attachment declared at the outset; only four styles. For what’s it’s worth I experienced paternal absence and maternal rejection – prostitute mother and pimp father – which is to say, no parenting or attachment at all – leading to a hotch-potch of all three non-secure ‘styles’.

how does attachment influences personality development in adulthood.

Good question! We answer this question by linking the different attachment styles to adult behaviors traits in this article: https://positivepsychology.com/attachment-style-worksheets/ (see the subsection ‘Attachment Theory in Psychology: 4 Types & Characteristics’)

Hope this helps!

– Nicole | Community Manager

How do I reference this article

You can reference this article in APA 7th as follows: Ackerman, C. A. (2018, April 27). What is Attachment Theory? Bowlby’s 4 stages explained. PositivePsychology.com. https://positivepsychology.com/attachment-theory/

I think that a big limitation when discussing Attachment Theory, that I haven’t seen addressed, is the effect of trauma on a older child past the early defining stage, or an adult. Bullying, accidents and injury, severe illness, family upheaval, or other significant life events can significantly affect a person’s psychological state, and thus alter a Securely Attached style to one of the other types.

Thank you for an informative article! Do you happen to know of any non-profit organizations that focus on stopping the cycle of maladaptive attachment in families? I’m a student with some ideas for a program that I’d like to pitch to some organizations that serve at risk individuals.

Glad you found the article helpful — that sounds like an interesting idea! Your question’s a little tricky. It’s hard to know how explicitly existing services draw on Bowlby’s principles. However, I suspect that the messages of the framework are likely embedded in various parent support groups and educational opportunities. If you’re interested in the U.S. specifically, maybe check out some of the services listed here and inquire about any curriculums.

Thank you, Nicole!

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3 Positive Relationships Exercises Pack

John Bowlby’s Attachment Theory

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

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John Bowlby (1907 – 1990) was a psychoanalyst (like Freud) and believed that mental health and behavioral problems could be attributed to early childhood.

Key Takeaways

• Bowlby’s evolutionary theory of attachment suggests that children come into the world biologically pre-programmed to form attachments with others, because this will help them to survive.
• Bowlby argued that a child forms many attachments, but one of these is qualitatively different. This is what he called primary attachment, monotropy.
• Bowlby suggests that there is a critical period for developing attachment (2.5 years). If an attachment has not developed during this time period, then it may well not happen at all. Bowlby later proposed a sensitive period of up to 5 years.
• Bowlby’s maternal deprivation hypothesis suggests that continual attachment disruption between the infant and primary caregiver could result in long-term cognitive, social, and emotional difficulties for that infant.
• According to Bowlby, an internal working model is a cognitive framework comprising mental representations for understanding the world, self, and others, and is based on the relationship with a primary caregiver.
• It becomes a prototype for all future social relationships and allows individuals to predict, control, and manipulate interactions with others.

Evolutionary Theory of Attachment

Bowlby (1969, 1988) was greatly influenced by ethological theory, but especially by Lorenz’s (1935) study of imprinting .  Lorenz showed that attachment was innate (in young ducklings) and therefore had a survival value.

During the evolution of the human species, it would have been the babies who stayed close to their mothers that would have survived to have children of their own.  Bowlby hypothesized that both infants and mothers had evolved a biological need to stay in contact with each other.

Bowlby (1969) believed that attachment behaviors (such as proximity seeking) are instinctive and will be activated by any conditions that seem to threaten the achievement of proximity, such as separation, insecurity, and fear.

Bowlby also postulated that the fear of strangers represents an important survival mechanism, built-in by nature.

Babies are born with the tendency to display certain innate behaviors (called social releases), which help ensure proximity and contact with the mother or attachment figure (e.g., crying, smiling, crawling, etc.) – these are species-specific behaviors.

These attachment behaviors initially function like fixed action patterns and share the same function. The infant produces innate ‘social releaser’ behaviors such as crying and smiling that stimulate caregiving from adults.

The determinant of attachment is not food but care and responsiveness.

Bowlby’s monotropic theory

A child has an innate (i.e., inborn) need to attach to one main attachment figure (i.e., monotropy).

Bowlby’s monotropic theory of attachment suggests attachment is important for a child’s survival.

Attachment behaviors in both babies and their caregivers have evolved through natural selection. This means infants are biologically programmed with innate behaviors that ensure that attachment occurs.

Although Bowlby did not rule out the possibility of other attachment figures for a child, he did believe that there should be a primary bond which was much more important than any other (usually the mother).

Other attachments may develop in a hierarchy below this. An infant may therefore have a primary monotropy attachment to its mother, and below her, the hierarchy of attachments may include its father, siblings, grandparents, etc.

Bowlby believes that this attachment is qualitatively different from any subsequent attachments.  Bowlby argues that the relationship with the mother is somehow different altogether from other relationships.

The child behaves in ways that elicit contact or proximity to the caregiver.  When a child experiences heightened arousal, he/she signals to their caregiver.

Crying, smiling, and locomotion are examples of these signaling behaviors.  Instinctively, caregivers respond to their children’s behavior, creating a reciprocal pattern of interaction.

Critical Period

A child should receive the continuous care of this single most important attachment figure for approximately the first two years of life.

Bowlby (1951) claimed that mothering is almost useless if delayed until after two and a half to three years and, for most children, if delayed till after 12 months, i.e., there is a critical period.

If the attachment figure is broken or disrupted during the critical two-year period, the child will suffer irreversible long-term consequences of this maternal deprivation.  This risk continues until the age of five.

Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as the failure to develop an attachment.

The underlying assumption of Bowlby’s Maternal Deprivation Hypothesis is that continual disruption of the attachment between infant and primary caregiver (i.e., mother) could result in long-term cognitive, social, and emotional difficulties for that infant.

The implications of this are vast – if this is true, should the primary caregiver leave their child in daycare, while they continue to work?

Maternal Deprivation

Bowlby’s maternal deprivation hypothesis suggests that continual attachment disruption between the infant and primary caregiver (i.e., mother) could result in long-term cognitive, social, and emotional difficulties for that infant.

Bowlby (1988) suggested that the nature of monotropy (attachment conceptualized as being a vital and close bond with just one attachment figure) meant that a failure to initiate or a breakdown of the maternal attachment would lead to serious negative consequences, possibly including affectionless psychopathy.

Bowlby’s theory of monotropy led to the formulation of his maternal deprivation hypothesis.

John Bowlby (1944) believed that the infant’s and mother’s relationship during the first five years of life was crucial to socialization.

According to Bowlby, if separation from the primary caregiver occurs during the critical period and there is no adequate substitute emotional care, the child will suffer from deprivation.

This will lead to irreversible long-term consequences in the child’s intellectual, social, and emotional development.

Bowlby initially believed the effects to be permanent and irreversible:

• delinquency,
• reduced intelligence,
• increased aggression,
• depression,
• affectionless psychopathy

Bowlby also argued that the lack of emotional care could lead to affectionless psychopathy,

Affectionless psychopathy is characterized by a lack of concern for others, a lack of guilt, and the inability to form meaningful relationships.

Such individuals act on impulse with little regard for the consequences of their actions.  For example, showing no guilt for antisocial behavior.

The prolonged deprivation of the young child of maternal care may have grave and far-reaching effects on his character and so on the whole of his future life (Bowlby, 1952, p. 46).

Bowlby believed that disrupting this primary relationship could lead to a higher incidence of juvenile delinquency, emotional difficulties, and antisocial behavior. To test his hypothesis, he studied 44 adolescent juvenile delinquents in a child guidance clinic.

Bowlby 44 Thieves

To investigate the long-term effects of maternal deprivation on people to see whether delinquents have suffered deprivation.

According to the Maternal Deprivation Hypothesis, breaking the maternal bond with the child during their early life stages is likely to affect intellectual, social, and emotional development seriously.

Between 1936 and 1939, an opportunity sample of 88 children was selected from the clinic where Bowlby worked. Of these, 44 were juvenile thieves (31 boys and 13 girls) who had been referred to him because of their stealing.

Bowlby selected another group of 44 children (34 boys and 10 girls) to act as ‘controls (individuals referred to the clinic because of emotional problems but not yet committed any crimes).

On arrival at the clinic, each child had their IQ tested by a psychologist who assessed their emotional attitudes toward the tests. The two groups were matched for age and IQ.

The children and their parents were interviewed to record details of the child’s early life (e.g., periods of separation, diagnosing affectionless psychopathy) by a psychiatrist (Bowlby), a psychologist, and a social worker.  The psychiatrist, psychologist, and social worker made separate reports.

Bowlby found that 14 children from the thief group were identified as affectionless psychopaths (they were unable to care about or feel affection for others); 12 had experienced prolonged separation of more than six months from their mothers in their first two years of life.

In contrast, only 5 of the 30 children not classified as affectionless psychopaths had experienced separations.

Out of the 44 children in the control group, only two experienced prolonged separations, and none were affectionless psychopaths.

The results support the maternal deprivation hypothesis as they show that most of the children diagnosed as affectionless psychopaths (12 out of 14) had experienced prolonged separation from their primary caregivers during the critical period, as the hypothesis predicts

Bowlby concluded that maternal deprivation in the child’s early life caused permanent emotional damage.

He diagnosed this as a condition and called it Affectionless Psychopathy. According to Bowlby, this condition involves a lack of emotional development, characterized by a lack of concern for others, a lack of guilt, and an inability to form meaningful and lasting relationships.

Bowlby directly observed parental separation’s harm in evacuating children from bombing during WWII, strengthening his hospital research indicating it profoundly impacts children’s emotional and behavioral development.

Limitations

The supporting evidence that Bowlby (1944) provided was in the form of clinical interviews of, and retrospective data on, those who had and had not been separated from their primary caregiver.

This meant that Bowlby asked the participants to look back and recall separations.  These memories may not be accurate.

A criticism of the 44 thieves study was that it concluded affectionless psychopathy was caused by maternal deprivation.  This is correlational data and only shows a relationship between these two variables. It cannot show a cause-and-effect relationship between separation from the mother and the development of affectionless psychopathy.

Other factors could have been involved, such as the reason for the separation, the role of the father, and the child’s temperament. Thus, as Rutter (1972) pointed out, Bowlby’s conclusions were flawed, mixing up cause and effect with correlation.

Many of the 44 thieves in Bowlby’s study had been moved around a lot during childhood, and had probably never formed an attachment.  This suggested that they were suffering from privation, rather than deprivation, which Rutter (1972) suggested was far more deleterious to the children. This led to a very important study on the long-term effects of privation, carried out by Hodges and Tizard (1989).

The study was vulnerable to researcher bias. Bowlby conducted the psychiatric assessments himself and made the diagnosis of Affectionless Psychopathy. He knew whether the children were in the ‘theft group’ or the control group. Consequently, his findings may have been unconsciously influenced by his own expectations. This potentially undermines their validity.

Bowlby struggled to apply his new maladaptation model to retrospective research on adolescents with conduct problems, as such studies prejudice outcomes by selecting for problems and then looking backward.

Cautious of this, in 1950, Bowlby, Robertson, and new researcher Mary Ainsworth (1956) began a forward-looking “follow-up study” on whether preschoolers who were hospitalized long-term subsequently developed conduct issues.

Assessing 60 such children aged 6-13 and controls, contrary to maternal deprivation hypotheses, they found more emotional apathy, withdrawal, and poor control than criminality.

So, while early prolonged separation impacted some children’s later adjustment, outcomes proved far more varied than Bowlby’s theory initially predicted. The improved prospective methodology highlighted limitations in Bowlby’s previous retrospective approaches.

In the conclusions of the paper Bowlby admitted that his theory regarding the development of conduct problems may be wrong:

It is clear that some of the workers, including the present senior author, in their desire to call attention to dangers which can often be avoided have on occasion overstated their case. In particular, statements implying that children who are brought up in institutions or who suffer other forms of serious privation and deprivation in early life commonly develop psychopathic or affectionless characters (e.g., Bowlby, 1944) are seen to be mistaken. (Bowlby et al., 1956, p. 240)

Short-Term Separation

When WWII ended in 1945, Bowlby had to choose between completing child psychoanalysis training or researching parental separation’s impact on children. He chose the latter, joining colleagues at London’s Tavistock Clinic.

Robertson and Bowlby (1952) believe that short-term separation from an attachment figure leads to distress.

John Bowlby spent two years working alongside a social worker, James Robertson (1952), who observed that children experienced intense distress when separated from their mothers. Even when other caregivers fed such children, this did not diminish the child’s anxiety.

They found three progressive stages of distress:

• Protest : The child cries, screams, and protests angrily when the parent leaves. They will try to cling to their parents to stop them from leaving. Protest could last from a few hours to several days.
• Despair : The child’s protesting gradually stops, and they appear calmer, although still upset. The child refuses others’ attempts for comfort and often seems withdrawn and uninterested in anything. In the despair stage, children become increasingly withdrawn and hopeless.
• Detachment : If separation continues, the child will engage with other people again. All emotions are suppressed, and children live moment-to-moment by repressing feelings for their mother. On the surface, children were seen to be happy and content, but when the mother visited, they frequently ignored her and hardly cried when she left. If this state continues, children become so withdrawn as to seek no mothering at all – a sign of major psychological trauma.

Controversy arose between Bowlby and Robertson regarding the stages of separation, particularly the third stage, which Robertson termed denial, but Bowlby called detachment.

However, both powerfully influenced attitudes and practices around keeping mothers and children together. This led to advocacy for allowing parental presence and major reforms in hospital policies.

A Two-Year-Old Goes to Hospital

Though doctors saw the despair phase as adjustment, Bowlby felt it showed distress’s harm.

To demonstrate this, Robertson filmed two-year-old Laura’s distress when hospitalized for eight days for minor surgery in “ A Two-Year-Old Goes to Hospital ” (1952).

Time series photography showed the stages through which a small child, Laura, passed during her 8-day admission for umbilical hernia repair. The film graphically depicted Laura’s behavior while separated from her mother for a period of time in strange circumstances” (Alsop-Shields & Mohay, 2001).

Laura cries out for her mother from admission onward, pleading in anguish to go home when visited the second day. As the week progresses, her initial constant distress gives way to listlessness and detachment during the parents’ increasingly ambivalent visits.

However, when approached by hospital staff, Laura startles out of her trance to suddenly burst into tears and fruitlessly call for her mother once more.

The raw behaviors captured on film revealed the three-phase separation response of protest, despair, and detachment observed in Bowlby and Robertson’s prior research.

Laura’s suffering starkly contradicts expectations of childrens’ ready hospital adjustment, instead demonstrating their deep distress from both physical separation and the hospital environment itself.

These findings contradicted the dominant behavioral theory of attachment (Dollard and Miller, 1950), which was shown to underestimate the child’s bond with their mother.  The behavioral theory of attachment states that the child becomes attached to the mother because she feeds the infant.

Implications for nursing include the development of family-centered care models keeping parents integral to a child’s hospital care in order to minimize trauma, principles now widely implemented as a result of this pioneering work on attachment.

Internal Working Model

The child’s attachment relationship with their primary caregiver leads to the development of an internal working model (Bowlby, 1969).

This internal working model is a cognitive framework comprising mental representations for understanding the world, self, and others.

The social and emotional responses of the primary caregiver provide the infant with information about the world and other people, and also how they view themselves as individuals.

For example, the extent to which an individual perceives himself/herself as worthy of love and care, and information regarding the availability and reliability of others (Bowlby, 1969).

Bowlby referred to this knowledge as an internal working model (IWM), which begins as a mental and emotional representation of the infant’s first attachment relationship and forms the basis of an individual’s attachment style.

A person’s interaction with others is guided by memories and expectations from their internal model which influence and help evaluate their contact with others (Bretherton & Munholland, 1999).

Working models also comprise cognitions of how to behave and regulate affect when a person’s attachment behavioral system is activated, and notions regarding the availability of attachment figures when called upon.

Bowlby (1969) suggested that the first five years of life were crucial to developing the IWM, although he viewed this as more of a sensitive period rather than a critical one.

Around the age of three, these seem to become part of a child’s personality and thus affect their understanding of the world and future interactions with others (Schore, 2000).

According to Bowlby (1969), the primary caregiver acts as a prototype for future relationships via the internal working model.

There are three main features of the internal working model: (1) a model of others as being trustworthy, (2) a model of the self as valuable, and (3) a model of the self as effective when interacting with others.

It is this mental representation that guides future social and emotional behavior as the child’s internal working model guides their responsiveness to others in general.

The concept of an internal model can be used to show how prior experience is retained over time and to guide perceptions of the social world and future interactions with others.

Early models are typically reinforced via interactions with others over time, and become strengthened and resistant to change, operating mostly at an unconscious level of awareness.

Although working models are generally stable over time they are not impervious to change and as such remain open to modification and revision.  This change could occur due to new experiences with attachment figures or through a reconceptualization of past experiences.

Although Bowlby (1969, 1988) believed attachment to be monotropic, he did acknowledge that rather than being a bond with one person, multiple attachments can occur arranged in the form of a hierarchy.

A person can have many internal models, each tied to different relationships and different memory systems, such as semantic and episodic (Bowlby, 1980).

Collins and Read (1994) suggest a hierarchical model of attachment representations whereby general attachment styles and working models appear on the highest level, while relationship-specific models appear on the lowest level.

General models of attachment are thought to originate from early relationships during childhood, and are carried forward to adulthood where they shape perception and behavior in close relationships.

Attachment & Loss Trilogy

The attachment books trilogy developed key concepts regarding attachment, separation distress, loss responses, and clinical implications over the course of the three volumes.

Attachment (1969/1982)

• Provided evidence for the importance of early parent-child relationships.
• Analyzed the systemic and “goal-corrected” nature of behavior.
• Introduced the concept of an “environment of adaptedness” that organisms inherit a potential to develop systems suited for.
• Discussed how attachment behaviors in infants are components of an attachment system designed to achieve security.
• Explained how attachment behaviors change via feedback from caregivers, becoming oriented toward discriminated figures.
• Posited attachment as a foundational system for survival that interacts with other systems like exploration.

Separation (1973)

• Focused on the negative impacts of separation from attachment figures.
• Outlined phases of separation responses in infants and children.
• Analyzed short- and long-term pathological effects of loss or deprivation.
• Studied how mourning progresses in relation to attachment bonds.
• Linked separation distress and avoidance to later issues of delinquency.

Loss (1980)

• Explored the concept of “loss” in relation to attachment theory.
• Proposed stages of the mourning process.
• Studied outcomes following the loss of an attachment figure.
• Examined detachment and defense processes resulting from loss.
• Applied attachment theory understanding to treatment approaches.

Critical Evaluation

Implications for children’s nursing.

• During Robertson and Bowlby’s research, the British government established a parliamentary committee investigating children’s hospital conditions. This resulted in the 1959 Platt Report, containing 55 recommendations, including allowing parental presence and provisions for their accommodation and children’s education/recreation (Alsop-Shields & Mohay, 2001).
• Robertson also specifically critiqued task-oriented nursing and childcare institutions (Robertson, 1955, 1968, 1970) as emotionally neglectful. He and Bowlby suggested dysfunctional families be kept together but supported (Robertson & Bowlby, 1952) – principles now accepted but decades ahead of their time.
• Robertson and Bowlby’s work has greatly influenced the development of family-centered pediatric nursing models like partnership-in-care and family-centered care in the 1990s. By planning care around the whole family unit rather than just the hospitalized child, and involving parents closely in care, these models aim to reduce emotional trauma for children.

Bifulco et al. (1992) support the maternal deprivation hypothesis. They studied 250 women who had lost mothers, through separation or death, before they were 17.

They found that the loss of their mother through separation or death doubles the risk of depressive and anxiety disorders in adult women. The rate of depression was the highest in women whose mothers had died before the child reached 6 years.

Mary Ainsworth’s (1971, 1978) Strange Situation study provides evidence for the existence of the internal working model. A secure child will develop a positive internal working model because it has received sensitive, emotional care from its primary attachment figure.

An insecure-avoidant child will develop an internal working model in which it sees itself as unworthy because its primary attachment figure has reacted negatively to it during the sensitive period for attachment formation.

Bowlby’s Maternal Deprivation is supported by Harlow’s (1958) research with monkeys .  Harlow showed that monkeys reared in isolation from their mother suffered emotional and social problems in older age.  The monkey’s never formed an attachment (privation) and, as such grew up to be aggressive and had problems interacting with other monkeys.

Konrad Lorenz (1935) supports Bowlby’s maternal deprivation hypothesis as the attachment process of imprinting is an innate process.

Bowlby’s (1944, 1956) ideas had a significant influence on the way researchers thought about attachment, and much of the discussion of his theory has focused on his belief in monotropy.

Although Bowlby may not dispute that young children form multiple attachments, he still contends that the attachment to the mother is unique in that it is the first to appear and remains the strongest.  However, the evidence seems to suggest otherwise on both of these counts.

• Schaffer & Emerson (1964) noted that specific attachments started at about eight months, and very shortly thereafter, the infants became attached to other people. By 18 months, very few (13%) were attached to only one person; some had five or more attachments.
• Rutter (1972) points out that several indicators of attachment (such as protest or distress when an attached person leaves) have been shown for various attachment figures – fathers, siblings, peers, and even inanimate objects.

Critics such as Rutter have also accused Bowlby of not distinguishing between deprivation and privation – the complete lack of an attachment bond, rather than its loss.  Rutter stresses that the quality of the attachment bond is the most important factor, rather than just deprivation in the critical period.

Bowlby used the term maternal deprivation to refer to the separation or loss of the mother as well as the failure to develop an attachment.  Are the effects of maternal deprivation as dire as Bowlby suggested?

Michael Rutter (1972) wrote a book called Maternal Deprivation Re-assessed .  In the book, he suggested that Bowlby may have oversimplified the concept of maternal deprivation.

Bowlby used the term “maternal deprivation” to refer to separation from an attached figure, loss of an attached figure and failure to develop an attachment to any figure.  These each have different effects, argued Rutter.  In particular, Rutter distinguished between privation and deprivation.

Michael Rutter (1981) argued that if a child fails to develop an emotional bond , this is privation, whereas deprivation refers to the loss of or damage to an attachment.

Deprivation might be defined as losing something that a person once had, whereas privation might be defined as never having something in the first place.

From his survey of research on privation, Rutter proposed that it is likely to lead initially to clinging, dependent behavior, attention-seeking, and indiscriminate friendliness, then as the child matures, an inability to keep rules, form lasting relationships, or feel guilt.

He also found evidence of anti-social behavior, affectionless psychopathy, and disorders of language, intellectual development and physical growth.

Rutter argues that these problems are not due solely to the lack of attachment to a mother figure, as Bowlby claimed, but to factors such as the lack of intellectual stimulation and social experiences that attachments normally provide.  In addition, such problems can be overcome later in the child’s development, with the right kind of care.

Bowlby assumed that physical separation on its own could lead to deprivation, but Rutter (1972) argues that it is the disruption of the attachment rather than the physical separation.

This is supported by Radke-Yarrow (1985), who found that 52% of children whose mothers suffered from depression were insecurely attached. This figure raised to 80% when this occurred in a context of poverty (Lyons-Ruth,1988). This shows the influence of social factors. Bowlby did not take into account the quality of the substitute care. Deprivation can be avoided if there is good emotional care after separation.

Is attachment theory sexist?

Feminist critics argue Bowlby’s attachment theory is sexist for overly emphasizing mothers as ideal caregivers while neglecting other influences like fathers (e.g., Vicedo, 2017).

His popular 1950s parenting articles reinforced gender roles by proclaiming mothers uniquely important and always available. Critics also attacked his concept “monotropy” – instincts focused on one caregiver, presumably the mother.

However, Bowlby’s academic writings use phrases like “mothers or foster-mothers,” adoptive mothers, and “mother substitutes,” acknowledging many can serve as primary caregiver.

He never scientifically stated only biological mothers suffice. While “monotropy” poorly implies a singular caregiver, Bowlby meant children form one main attachment, not only to mothers. So academically, Bowlby did not limit caregivers to mothers, though his public emphasis on maternal deprivation and parenting did reinforce gender biases.

There are implications arising from Bowlby’s work.  He reinforced the idea that a mother should be the most central caregiver and that this care should be given continuously. An obvious implication is that mothers should not go out to work.  There have been many attacks on this claim:

• Mothers are the exclusive carers in only a very small percentage of human societies; often there are a number of people involved in the care of children, such as relations and friends (Weisner, & Gallimore, 1977).
• Van Ijzendoorn, & Tavecchio (1987) argue that a stable network of adults can provide adequate care and that this care may even have advantages over a system where a mother has to meet all a child’s needs.
• There is evidence that children develop better with a mother who is happy in her work, than a mother who is frustrated by staying at home (Schaffer, 1990).

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Further Reading

• The Internal Working Models Concept: What Do We Really Know About the Self in Relation to Others?
• The Effects of Maternal Deprivation
• Davies, R. (2010). Marking the 50th anniversary of the Platt Report: from exclusion, to toleration and parental participation in the care of the hospitalized child .  Journal of Child Health Care ,  14 (1), 6-23.
• Bowlby, J. (1963). Pathological mourning and childhood mourning .  Journal of the American Psychoanalytic Association ,  11 (3), 500-541.

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Attachment Theory In Psychology

A Case Study of a Maltreated Thirteen-Year-Old Boy: Using Attachment Theory to Inform Treatment in a Residential Program

• Published: October 2001
• Volume 18 , pages 335–352, ( 2001 )

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• Timothy F. Page  

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This paper presents therapeutic interventions from an attachment perspective with a thirteen-year-old boy with a history of maltreatment, living in a residential treatment facility. Attachment theory holds that accumulated memories of experiences with caregivers become organized into representational structures called “internal working models.” The guiding principles of the therapy begin with the critical role played by the individual therapist as an attachment figure. The central purposes of the therapy are conceived as promoting the restructuring of the internal working models of others to reflect expectations of trustworthiness and reliability, and models of the self as worthy to receive care. The approach described is contrasted with common approaches to residential treatment that rely on environmental behavioral contingencies, modeled on social learning theory.

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Cunningham, P., Page, T.F. A Case Study of a Maltreated Thirteen-Year-Old Boy: Using Attachment Theory to Inform Treatment in a Residential Program. Child and Adolescent Social Work Journal 18 , 335–352 (2001). https://doi.org/10.1023/A:1012503306793

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“A child’s nightmare. Mum comes and comforts her child.” Attachment evaluation as a guide in the assessment and treatment in a clinical case study

There is a gap between proposed theoretical attachment theory frameworks, measures of attachment in the assessment phase and their relationship with changes in outcome after a psychodynamic oriented psychotherapy. Based on a clinical case study of a young woman with Panic Attack Disorder, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the psychodynamic diagnostic manual. Treatment planning and post-treatment changes were described with the main aim to illustrate from a clinical point of view why a psycho-dynamic approach, with specific attention to an “attachment theory stance,” was considered the treatment of choice for this patient. The Symptom Check List 90 Revised (SCL-90-R) and the Shedler–Westen Assessment Procedure (SWAP–200) were administered to detect patient’s symptomatic perception and clinician’s diagnostic points of view, respectively; the Adult Attachment Interview and the Adult Attachment Projective Picture System (AAP) were also administered as to pay attention to patient’s unconscious internal organization and changes in defense processes. A qualitative description of how the treatment unfolded was included. Findings highlight the important contribution of attachment theory in a 22-month psychodynamic psychotherapy framework, promoting resolution of patient’s symptoms and adjustment.

INTRODUCTION

Attachment theory in Bowlby’s (1969/1982 , 1973 , 1980 , 1988 ) and Ainsworth’s (1963 , 1967 ) tradition postulates that an individual’s experience of early parental care contributes to the development of internal representations of self and others as safe and available. This theory offered the clinicians a scientific grounded model, which postulated and empirically demonstrated the origin of psychopathology in early separation experiences and in adverse emotional experiences ( Oppenheim and Goldsmith, 2007 ; Cassidy and Shaver, 2008 ). The most recent literature endorses that attachment theory is consonant with all assessment and treatment approaches which evaluate childhood experiences as an important contributor to adult functioning (e.g., Wallis and Steele, 2001 ; Blatt and Levy, 2003 ; Diamond, 2004 ; Bakermans-Kranenburg et al., 2005 ; Buchheim et al., 2007 ; Zegers et al., 2008 ; Buchheim and George, 2011 ). Throughout the case formulation and the planning of treatment, attachment theory has also the potential to provide-at least-a useful foundation for defining the target of change in psychotherapy (e.g., features of internal working models or attachment patterns), understanding the processes through which change occurs (e.g., through the development of a secure base and exploration of working models; e.g., Fonagy, 1999 , 2001 ; Cozzolino, 2002 ; Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Wallin, 2007 ; Fosha, 2009 ; Holmes, 2010 ; Siegel, 2010 ). As Bowlby originally stated, while reconsidering classical attachment theory, Davila and Levy 2006 , p. 990) stressed “five key tasks for psychotherapy: (a) establishing a secure base, which involves providing patients with a secure base from which they can explore the painful aspects of their life; (b) exploring past attachments, which involves helping patients explore past and present relationships, including their expectations, feelings, and behaviors; (c) exploring the therapeutic relationship, which involves helping the patient examine the relationship with the therapist and how it may relate to relationships or experiences outside of therapy; (d) linking past experiences to present ones, which involves encouraging awareness of how current relationship experiences may be related to past ones; and (e) revising internal working models, which involves helping patients to feel, think, and act in new ways that are unlike past relationship.” Despite the increasing interest in the relevance of attachment theory as a framework to understand the unfolding of psychodynamic treatment, there is a gap between the proposed theoretical frameworks and the empirical measures of attachment used in the assessment, and only few studies addressed the interplay between attachment pattern measures, and their implication for unfolding and outcome in a psychoanalytic oriented treatment ( Buchheim and Kachele, 2001 ; Dahlbender et al., 2004 ; Buchheim, 2005 ; Lis et al., 2008 , 2011 ; Isaacs et al., 2009 ).

Interpersonal problems, adult attachment, and emotion regulation have been increasingly studied across adult anxiety disorders. Literature linked attachment and separation in infants and preschool children to separation anxiety disorder, agoraphobia, and panic attacks later in life, underlining how insecure attachment can lead to an increased risk for attachment psychopathology and subsequent social and emotional maladjustment/attachment and separation anxiety/school or work phobia/attachment correlations ( Routh and Bernholtz, 1991 ). Of all the forms of anxiety, separation anxiety seems to be the one which is most likely to be associated with an anxious attachment style, because sufferers are by definition highly sensitive to real or perceived threats to relationships ( Main et al., 1985 ). Separation anxiety would appear to be a core form of anxiety associated with panic attack disorder and with attachment problems ( Hazan and Shaver, 1987 ; Bartholomew and Horowitz, 1991 ; Eng et al., 2001 ). Dysfunctional and not good-enough parenting and hereditary factors appear to play a role in generating early separation anxiety. However, the child’s anxiety itself may generate overprotective parenting ( Manicavasagar et al., 1999 , 2009 ) which, in turn, could make children approach their caregivers both in response to dangerous external stimuli and to caregiver’s permanent monitoring availability and attentiveness; moreover, overprotecting or over responsive parents could obstacle the expression of the explorative system, even when a “secure base” is provided ( Pacchierotti et al., 2002 ). Although attachment theory suggests that anxious attachment styles are mostly associated with risks of developing anxiety disorders, neither all anxious attached patients develop panic attack disorder, nor all secure attached patients do not develop it: the latter is a weird and rare condition because, theoretically, secure early relationships with adults are the basis for the development of a sense of control and predictability accounting for normal subjects’ tendency not to interpret ambiguous internal stimuli as threatening ( Shear, 1991 ).

Based on a clinical case study of a young woman with Panic Attack Disorder- Matilde-, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) 1 . The patient’s choice is motivated by this “rare combination”: a PAD patient with secure attachment. The first aim of this paper was to provide incremental usefulness to the picture of the patient’s idiographic and intra-subjective features, using a multi- method assessment based on (1) two performance-based attachment measures – the Adult Attachment Interview (AAI; George et al., 1984 / 1985 / 1996 ), and The Adult Attachment Projective Picture System (AAP; George and West, 2001 , 2012 ), (2) the Shedler–Westen Assessment Procedure (SWAP–200; Westen and Shedler, 1999a , b ), and (3) a self-report symptom scale, the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1983 ; Funder, 1997 ; Meyer et al., 1999 ; Ozer, 1999 ).The second aim was to describe how Matilde’s assessment findings – and more specifically attachment pattern analysis – could represent useful guidelines for the unfolding of a psychoanalytic therapy with a supportive approach, in an attachment theory framework ( Misch, 2000 ).

We hypothesized that the AAI, the AAP, the SCL-90-R, and the SWAP–200 would help in focusing on the most relevant dimensions of patient’s psychological functioning which make a meaningful diagnosis ( Barron, 1998 ; Shedler and Westen, 2007 ) at the beginning and at the end of treatment. Attention was directed to the interplay between modification of overt symptoms and behaviors, and changes in personality functioning and adaptation; more specifically, we focused on patterns and complexities in the patient’s internal organization and interpersonal functioning ( Shectman and Harty, 1986 ; Peebles-Kleiger, 2002 ; Bram, 2010 ). A reduction in psychopathological symptoms and an improvement in mental functioning according to the PDM M -axis and S -axis were expected at the end of the therapy.

CLINICAL CASE PRESENTATION: MATILDE

Matilde was a pleasant 20-year-old young woman, who looked younger than her age. She was a self-referred patient, and was assessed for a high level of anxiety at a university-based psychology-training clinic 2 . Matilde had a diagnosis of Panic Attack Disorder in Axis I (DSM-IV; American Psychiatric Association [APA], 1994 ), and no diagnosis in Axis II. Although she was a 2-year student at the Medical School with outstanding results, she felt “ anxious, confused, and insecure, ” “ I do not know if this Faculty is good for me, maybe Biology would be better, or Pharmacy … I do not know really, I am so confused; I do not understand what is happening to me …. I am no more sure about anything. ” Insecurity caused her quite severe crying crises, pervasive anxiety, and some physical symptoms, such as psychomotor agitation and tachycardia. She had taken light tranquilizers in the last 3 months. She felt unable to control or understand her present distress. Since she started University, her life had been totally busy with studying, leaving no time or desire to engage in social relationships. She did not talk about any actual satisfying relationships. The only “ friends ” she kept in touch with were schoolmates from high school, with whom she shared school topics. She had never had a boyfriend, and felt very uncomfortable talking about romantic or sexual topics. Matilde moved away from her small native town to attend University, and she was sharing an apartment with other students next to the Medical School. She went back home to her family during University vacations. She came from an intact family, which she was very proud of. She had a 10-year-old sister, Sarah, to whom she was very attached. Sarah was described as very different from Matilde: very funny, an ironic with a lot of energy. They spent a lot of time playing together, and Matilde was unconcerned about her worries when she was with Sarah. Matilde describes her childhood with some enjoyment and unconcern while her present appears very worrying, uncertain and without any source of protection and soothing. Matilde supports a good relation with her mother, although the father is described as rigid and very involved in practical duties.

APPROACH TO THE CASE: PROCEDURE AND INSTRUMENTS

At the initial assessment phase Matilde underwent three interview sessions, two test sessions and one feedback session. In particular, Matilde’s evaluation involved the administration of the AAI and the AAP, the SCL-90-R, and the SWAP–200. All results were integrated with clinical interview contents to formulate a case conceptualization, according to specific dimensions of the PDM. In the feedback session, a once-a-week psychodynamic psychotherapy with a supportive approach was proposed to and accepted by Matilde. The therapy lasted 22 months. At treatment conclusion Matilde accepted to be re-administered the AAP and the SCL-90-R. Based on the last three sessions also the SWAP–200 was re-administered. All the tools administered were scored and interpreted by independent judges 3 . A brief description of used tools follows after timetable of administration ( Table ​ Table1 1 ).

Timetable of administered tools.

Symptom Checklist 90 Revised ( Derogatis, 1983 ) is a 90-item self-report questionnaire scored on a five-point Likert scale of distress from 0 (none) to 4 (extreme), indicating the rate of occurrence of symptoms during the time reference ( Derogatis et al., 1973 ). It is intended to measure symptom intensity on 10 different dimensions: somatization (SOM), obsessive–compulsive (O–C), interpersonal sensitivity (I-S), depression (DEP), anxiety (ANX, hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), and sleep difficulties (SLEEP). A Global Severity Index (GSI) of distress is calculated. According to the Italian Manual, an intensity raw score higher than one was qualified as penetrating in the clinical range. The internal consistency coefficient alphas for the nine symptom dimensions ranged from 0.77 for Psychoticism, to 0.90 for Depression. Test–retest reliability coefficients ranged between 0.80 and 0.90 after 1 week of therapy. The few validity studies of the SCL-90-R demonstrate levels of concurrent, convergent, discriminant, and construct validity comparable to other self-report inventories ( Derogatis, 1983 ).

The Shedler–Westen Assessment Procedure ( Westen and Shedler, 1999a , b ) is a set of 200 personality-descriptive statements developed for clinicians to assess adult personality traits and pathologies ( Shedler and Westen, 1998 ). Starting from clinical interviews, the assessor is asked to describe the patient by arranging the statements into eight categories, from those that are not descriptive (assigned a value of “0”) to those that are highly descriptive (assigned a value of “7”) for each of the 200 personality-descriptive variables. The instrument is based on the Q-sort method that requires clinicians to arrange items into a fixed distribution ( Block, 1978 ). The SWAP–200 could be interpreted at a nomothetic as well as at an idiographic level. Nomothetic interpretations are carried out following two profiles. The first is the PD-T score profile of the 10 Personality Disorders included in DSM–IV (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive); the Q-T profile covers 11 dimensions (psychological health, dysphoric, antisocial, schizoid, paranoid, obsessive, histrionic, narcissistic, avoidant, depressive high functioning, emotional dysregulation, dependent, hostile). Both PD-T and Q-T profiles include a score on a Healthy Functioning scale. Inter-rater reliability coefficients range from 0.70 to 0.80. Support for the validity of the SWAP–200 is derived from its ability to predict relevant variables in expected ways, including family psychiatric history, history of abuse, social, and school functioning, violence, suicidal behaviors and attempts, attachment status, and eating disorder diagnostic groups ( Westen and Muderrisoglu, 2003a , b ). Idiographic narrative case description is also included in the SWAP–200 (e.g., Lingiardi et al., 2006 ). Both levels were used to assess Matilde. Moreover, the SWAP–200 ( Westen and Shedler, 1999a , b ) is one of the instruments listed by PDM work-group members to be used to measure the dimensions of the M -axis.

The Adult Attachment Interview ( George et al., 1984 , 1985 , 1996 ; Hesse, 2008 ) is an about 1 h audio-recorded semi-structured interview that explores an adult’s mental representations of attachment, guiding the individual through a series of questions about past and present relationships with each parent and attachment-relevant events during childhood. The AAI focuses on the assessment of the attachment internal working model ( Bowlby, 1969/1982 ) and assumes developmental continuity of the attachment system along life. AAI final attachment classification is evaluated on two different set of scales (1) Experience Scales that evaluate for example Loving, Rejecting, Neglect, Role Reversal, Pressure to achieve and (2) State of Mind Scales that assess Coherence, Metacognitive Processes, Lack of Recall, Passivity of Discourse, Idealization, Anger, Derogation attitudes toward caregivers, Unresolved mourning or trauma, Feared loss of one’s own child. Starting from these scales, each interview is classified in one of the primary attachment patterns: secure/autonomous, dismissing/avoidant, and preoccupied/entangled or “cannot classify.” Where applicable, the “unresolved” pattern with respect to loss, trauma, or abuse could be scored. Multiple scoring is allowed (e.g., F/DS). AAI validation rests on more than 25 years of developmental and clinical research ( van IJzendoorn and Bakermans-Kranenburg, 2008 ). Rigorous psychometric testing and meta-analyses of the AAI demonstrate its stability, and discriminant and predictive validity in both clinical and non-clinical populations. In a recent meta-analysis of 61 clinical samples ( van IJzendoorn and Bakermans-Kranenburg, 2008 ), strong associations were found between psychiatric diagnoses (i.e., anxiety disorders, borderline personality disorder) and attachment insecurity.

The Adult Attachment Projective Picture System ( George and West, 2001 ) is based on a standardized set of seven drawn pictures divided in Alone and Dyadic stimuli 4 . The pictures describe major attachment events, potential threat of separation, illness, solitude, death, and abuse. The stimuli are: child at window (window); departure; bench; bed; ambulance; cemetery; and child at corner (corner). Individuals are asked to make up a story for each image in which they describe what is going on in the picture, what led up to the scene, what the characters are thinking or feeling and what might happen next. The responses are audiotaped for transcription and verbatim analysis. The AAP assesses attachment in the Bowlby-Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ). The AAP Coding System, leads to four adult attachment classification patterns, – secure/autonomous, dismissing, preoccupied, unresolved – as they were traditionally assessed in the AAI, even if no multiple scoring is allowed. The AAP also assesses attachment personal elements that individuals may exclude from conscious awareness. Attachment classification using the AAP is determined by evaluating patterns of responses using a set of seven scales grouped under three major categories: discourse, content, and defensive processing. These dimensions evaluate the attachment story content related to the hypothetical characters portrayed in the stimuli, to defenses, and to self-other boundaries in narrative discourse ( George and West, 2001 , 2012 ). Discourse codes evaluate personal experience. Content codes include agency of self and connectedness for alone pictures, and Synchrony for dyadic pictures. Finally, the AAP codes for defensive exclusion, segregated systems, deactivation, and cognitive disconnection ( Bowlby, 1980 ). They represent different degrees of “protection” from dangerous distressful events. Segregated systems describe a mental state in which painful attachment-related memories are isolated and blocked from conscious thought and rooted in experiences of trauma or loss through death ( Bowlby, 1980 ). Deactivating defensive processes are defined as attempts to dismiss, cool off, or shift attention away from attachment events, individuals, or feelings in response to the picture stimuli. Cognitive disconnection processes literally disconnect the elements of attachment from their source, thus undermining consistency and the capability of holding in one’s mind a unitary view of events, emotions, and the individuals associated with them. The most recent review of AAP reliability and validity was published in George and West (2012) . AAP–AAI convergence for secure versus insecure classifications was 0.95 (κ = 0.75, p = 0.000); convergence for the four major attachment groups was 0.89 (κ = 0.84, p = 0.000; George and West, 2001 , 2012 ; West and George, 2002 ). The AAP has also been shown to be useful in studying the neurobiological and emotional expression correlates of attachment in non-clinical and clinical samples ( Buchheim and Benecke, 2007 ; Buchheim et al., 2007 , 2008 , 2009 ; Fraedrich et al., 2010 ) as well as in single case studies ( Lis et al., 2011 ).

Both AAI and AAP show individual strengths in measuring attachment patterns, but their combined use increments their overall usefulness. The AAI, the golden standard measure of adult attachment ( Bakermans-Kranenburg and van Ijzendoorn, 1993 ), focuses on the assessment of the representational model and coherence of mind, and assumes developmental continuity of the attachment system, evaluating abuse and loss in one’s personal history. The AAP, based on the Bowlby–Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ), assesses current views of self, attachment figures, and expectations about the productiveness of attachment relationships, elucidating how current experience activates attachment accomplishment, disappointment, and trauma from the past ( West et al., 1995 ; George and West, 2012 ). The AAP is also more trauma sensitive and underscores defense patterns (e.g., Hesse, 2008 ; George and West, 2012 ). The combined use of the AAI and the AAP gives the chance to portray a complex image of the patient’s attachment pattern, providing a detailed narrative about life attachment activators such as separation, fear, solitude, and danger, shedding light on the unconscious defensive mechanisms and exploring the accessibility of attachment figures during the life-span (e.g., Hesse, 2008 ; George and West, 2012 ). The SCL-90-R contributed to get Matilde’s self-evaluation of symptoms.

ASSESSMENT FINDINGS

Results from DSM-IV diagnosis, SCL-90-R and SWAP–200 during the assessment phases are described in Table ​ Table2 2 . Results from attachment tools are reported below and AAI subscales are shown in Tables ​ Tables3 3 and ​ 4 4 .

Results from SCL-90-R and SWAP–200 in assessment phase.

AAI experience scales.

AAI state of mind scales.

Matilde’s AAI was scored F2/Ds3, secure with features of dismissing or some restriction in feelings of attachment (F2 = free somewhat dismissing or restricted in attachment; DS3 = dismissing restricted in feelings with some evidences of Lack of Memories; George and Solomon, 1996 ; see Tables ​ Tables3 3 and ​ 4 4 ). Matilde secure pattern was so defined because she was able to explore his or her thoughts and feelings about childhood experiences, with fresh speech, humor and forgiveness, without becoming angrily or passively overwhelmed while discussing them. Generally, Matilde appeared to be aware of the nature of experiences with her parents and of the effects of such experiences on her present state of mind and on her personality. Nevertheless, she remained a little bit restricted in her emotional expressions, preferring to rationalize. State of mind scales tapped a dismissing feature, showing a slight tendency to idealize parents and some lack of memories. Further information about Matilde derived from a qualitative analysis of the AAI. She did not report any severe illness, traumatic or abuse experience. However, separations caused her some distress, but she felt always supported and listened by her mother. She described herself as a very calm girl but, during early childhood, she was very shy and very worried about separation: “ I became very agitated when I did not see my parents, when they were not there, when they were away from home, ” “ Once we were at the lake. I was on the one side of the road and my parents were on the other side. Some people passed and so I could not see my parents anymore. I did not see them anymore and I began to scream .” However, she remembered that during her summer camp experience, when there were no well-known friends or schoolmates: “ I felt the distance from home, I felt lost and confused … I was very happy to go back home. The bus journey to go back home was very stressful,” “I do not like changes. I am worried about changes. ”

She described the relationship with her mother as: affectionate, playful, reciprocal, supportive, and protective. When she was asked to recall a specific example in respect with “supportive relationship” she reported that “ I gulped a small toy and it remained caught in my throat. I had to be taken to the hospital. I was very agitated, I screamed that I was frightened of dying. Mammy was very supporting … I mean comforting. ” She was able to identify a specific episode, but in a superficial and not qualitative consistent manner ( Grice’s qualitative maxim ): the adjective-descriptor (supportive) of relationship with her mother was supported with a second generalized positive descriptor (comforting). The adjectives she chose to describe the relationship with her father were: always affectionate, playful, formal ( “home rules had to be respected, for instance times for lunch and dinner” ), respectful ( “Nothing escaped from him; his words had always a weight” ), and important. Such aspects were more linked to father’s role as a parent and to school achievement: “I felt very bad about his criticism.” Matilde felt closer to her mother than to her father, from whom she felt more detached. Moreover, during school years she always felt a little bit anxious and agitated about school achievement and completion. Beside all these difficulties, she always felt supported and sustained by her mother, and at the end she demonstrated herself as very forgiving toward her father’s severity. When asked to imagine the possibility of being separated from her child, Matilde reported to feel “ a big void, a big feeling of lost, of mourning, a big pain, an absence of being complete ” and the three wishes about this child when he would be 20-years old were: “ to be able to choose, to have a clear reasoning, not being confused, and to be able to be autonomous. ”

Matilde was judged as secure on the AAP (F): she showed, at the representational level, a flexible and organized thinking about attachment situations and relationships ( Bowlby, 1969/1982 ). She was confident that she could rely on attachment figures to achieve care, safety and protection and, when alone, she could access internalized attachment relationships ( George and Solomon, 1996 , 1999 ). In response to two of the alone stimuli – Window and Cemetery- as a secure individual, she demonstrated the ability to think (i.e., Internalized Secure Base) and to take constructive action. She also used flexible defensive processes to integrate attachment feelings and events. Using these resources she was able to re-organize her attachment-related feelings, also in the few cases (Bed and Cemetery Stories) when she became disorganized by feelings of loss and danger. From the pattern of story responses it appears that Matilde, above all other response qualities, genuinely valued and represented the capacity for integration of self and relationships. The responses to the Alone pictures demonstrated Matilde’s internal resources, such as the potential availability and responsiveness of attachment figures. As a representative example of this attitude the Cemetery picture (a man stands by a gravesite headstone) story is reported.

“A gentleman who had a bad day or felt sad or depressed or undervalued because of an episode that happened during the day and goes and visits his father … he feels reassured because he found a place where to think about his life by himself and then he will go back home and will be able to reconsider what happened from a different point of view.”

In Cemetery, Matilde reveals the intensity of feelings of pain associated with loss: she tries to deal with them through some form of uncertainty and desire to withdraw (cognitive disconnection). These forms of organized defensive mechanisms keep Matilde’s attachment system activated but they cannot prevent her from becoming dysregulated, as evidenced by painful attachment-related feelings of loss represented by the appearance of a them where no clear distinction is made between life and death (“he goes and visit his father”). A segregated system (spectral domain) was activated by the picture features, which portray a man visiting a grave. However, Matilde was able to depict the man as engaged in some kind of “thinking.” The man is able to “reconsider what happened from a different point of view.” This process belongs to Internalized Secure Base, and portrays Matilde’s ability to clearly differentiate between the living and the dead. The Dyadic picture stimuli portray attachment-caregiving dyads. The responses to Dyadic picture stimuli demonstrate Matilde’s representation of the self and other in attachment situations when attachment figures are present and accessible, but they also demonstrate the use of attachment figures to quell the attachment anxiety aroused in the scenes depicted in the cards. Bed picture (a child and woman sit opposite to each other on the child’s bed) could be a representative example.

“A boy had a nightmare during the night and his mother woke up eh … now he is scared and he would like to be close to his mum … the mum is trying to soothe him and she will be able to do it … the boy will come back to sleep quietly … (Anything else?) no.. maybe the bad dream was … was about the fact of staying alone without his mom … and now … he wants his mom first!”

In Matilde’s story, the child signals his attachment need after a “nightmare” (segregated system in AAP) and the mother is able to provide a contingent and soothing answer, containing the potential breakdown of the attachment system and resolving the segregated system. Both AAI and AAP classified Matilde as secure with somewhat dismissing or restricted feelings in attachment without elements of unresolved abuse or trauma. However, both tools detected some shortcomings about fears of separation and danger. The AAI was not able to draw attention in an exhaustive way to how Matilde experienced abandonment fears and felt scared without the presence of her parents. Instead the AAP clearly depicted this nuance, under a secure pattern, showing that her attachment was threatened by painful attachment-related feelings of loss, and by a nightmare (in Bed picture), a signal of danger. In both tools she demonstrated her ability to re-organize herself, but these disturbing feelings kept being alive underneath her reorganized secure pattern.

CASE FORMULATION BASED ON PDM AXES

S -axis – Matilde had a diagnosis of DSM-IV ( American Psychiatric Association [APA], 1994 ), and showed a slightly High Functioning profile with Obsessive, Schizoid-Avoidant and Dysphoric characteristics, in both PD and Q factors in SWAP–200. Matilde’s SCL-90-R symptom profile revealed depression, anxiety, obsessive–compulsive, and somatization scores in the clinical range ( Table ​ Table2 2 ).

M -axis – this Axis describes nine dimensions, which systematize the capacities that contribute to an individual’s personality and overall level of psychological health or pathology.

Capacity for regulation, attention, and learning

In the clinical interview, she said, “ I lost control of my body and thinking. ” She appeared in a profound state of crisis and she appeared to be unable to cope with it and with connected feelings of anxiety and distress. She (a) adhered rigidly to daily routines and became anxious or uncomfortable when they were altered, (b) had trouble making decisions and was indecisive or vacillated when faced with choices, (c) was overly concerned with rules, procedures, order, organization, and schedules: all obsessive strategies which would interfere with processes that support attention and learning from experience. However, according to Bowlby, being secure at both AAI and AAP means that Matilde had basic capacities for regulation. Matilde appeared to believe in the seeking of proximity and support as effective ways in regulating distress, in particular in AAP Dyadic pictures. However, at the moment of assessment, she was not able to recur to her internalized security patterns, showing how an emotional regressive crisis was rising up. Although Matilde subjectively felt unable to cope with it and was very frightened by it, according to the AAP and AAI, the dysregulation appeared momentary and not prolonged. It seems she was still functioning as she described herself in the early childhood memory, when she could not see her parents and she got anxious at the thought of being lost. However, her basic secure attachment suggests that, thanks to the therapy, she could re-establish her capacity of self-regulation, a secure person’s basic characteristic.

Capacity for interpersonal relationships

Although she was excessively devoted to work and productivity, compromising leisure and relationships, her secure attachment pattern at the AAI and AAP indicated that Matilde had a positive representation of available adults who can offer protection, support, care, and comfort in threatening and stressful situations. The AAP supported also her potential ability to be connected with other relational systems such as partners and peers, almost in a concrete manner, since she was able to tell stories in which she described specific connections with friends and other people in general. However, her agency, connectedness, and synchrony were at the moment “quite silent” in her everyday life. She needed help to regain these resources.

Quality of internal experiences

In AAI and AAP she felt reassured by (her) mother’s proximity, soothing, and comfort. However, episode and story plots clearly indicated some separation anxieties and worries in respect to changes, which she faced using dismissing defense mechanisms. AAP clearly depicted how under a secure pattern, her attachment was threatened by painful attachment-related feelings of loss and danger. Until that moment, such feelings were isolated and blocked from conscious thought. Even if she was able to deal with these experiences in childhood thanks to her mother’s comfort, her fear of loss connected to the fear of being alone and unprotected seem to re-emerge We hypothesized that she was having trouble in coping with new adolescence-through-young adulthood tasks, such as the adult separation-individuation process. According to the SWAP–200, she experienced a sense of personal dissatisfaction, poor self-regard, low self-esteem, lack of confidence, and chronic self-criticism. Her unrealistically high standards together with her expectation of being “perfect” above all in her achievements, made her feel guilty, depressed and despondent, with negative self-regard toward others, and the world at large.

Affective experience, expression, and communication

According to the SWAP–200, Matilde tended to defend herself via the inhibition of emotion expression, by means of abstract thinking and intellectualized terms, and appeared unable to recognize her wishes and impulses. Apparently, intellectualization and disavowal defenses (above all rationalization) led her to the avoidance of expressed conflict and emotions – both positive and painful. This emotional constriction resulted in a bottled up affect being channeled into panic attacks. The SWAP–200 stressed the risk of recurrent episodes of overt anxiety, tension, nervousness, and irritability and difficulty in acknowledging or expressing underlying feelings of anger and resentment. The AAP and AAI confirmed that underneath this block of affection there was a rich and positive affective state she had internalized during childhood life experiences. However, although not so rigid, her present affective state of constriction and inhibition was consistent with the rigid attempt to neutralize affect using deactivating defenses in the AAP. The emotions, which were bottled up in the segregated system, surely carried a negative and overwhelming emotional tone, which at the moment she was unable to deal with.

Defensive patterns and capacities

The SWAP–200 indicated the extent to which Matilde tended to defend her from expressing emotions, by abstract thinking and intellectualized terms. Although her defenses were at a mature-neurotic level, they were not solid enough to allow her to avoid the recourse to symptoms and anxiety. From an attachment viewpoint-AAP-Matilde shows a different picture underneath. Here defenses appeared organized and flexible, but in order to keep a regulated attachment she relied more on deactivation than on cognitive disconnection ( George and West, 2012 ).

Capacity to form internal representations

Matilde was able to form internal representations of self and others, and her experiences were symbolized mentally. However, in the current state of distress, some emotions and conflicts were expressed somatically through her somatic symptoms and panic attack episodes.

Capacity for differentiation and integration (ego strength, self-cohesion, stability of reality testing). Overall, her AAP stories and her narrative in the AAI revealed that she was able to look realistically at herself, people, and relationships. Also during the clinical interview, a solid, stable and good child image emerged, but was not integrated with an adolescent and adult image: Matilde’s ego was fragile and was shattered by a large number of symptoms, her self-image was damaged and not well integrated; moreover, she looked younger than her age and never talked about sexuality or intimate relationships.

Self-observing capacities

Matilde did not demonstrate good self-observation capacities. Her level of current distress, extension of intellectualization and rationalization defenses, avoidant and constricted emotional style did not allow for an adult and mature emotional insight.

Capacity to construct or use internal standards and ideals. SWAP–200 showed how she currently set unrealistically and childish high standards for herself and how she appeared intolerant of her own human defects.

THERAPEUTIC STANCE AND THERAPY GUIDING CONCEPTION

Matilde looked younger than her age and did not talk about sexuality or intimate relationships and we supposed that she did not undergo a true adolescent process. Looking at her secure attachment pattern, the therapist hypothesized that the present state of dysregulation and symptomatic picture is transitory and derived from the new young adulthood tasks she has now to deal with during her transition toward adulthood, such as moving to University. From a psychoanalytic as well as an attachment-oriented viewpoint, we hypothesized she was not able to face adolescent and adult separation-individuation processes. According to attachment theory, attachment relationships foster integration of attachment with relationships in peer behavioral systems during adolescence and adulthood: these include friendships and romantic relationships ( West and George, 1999 ; Allen, 2008 ; George and Solomon, 2008 ; George and West, 2012 ). Psychoanalytic theories also agree that the individual needs to face adolescence as a separation-individuation process, where adolescents need to acquire an individual separate self-identity through identification with parents and separation from childhood ties. The AAP and AAI were taken into account, making the therapist sensible to specific topics concerning separation, loss, and loneliness, able to reactivate and unleash childhood attachment-related memories of fear of being lost and completely alone during treatment itself. Matilde needed to explore this topic with a therapist who would represent for her, in the transference, a secure parent similar to the one she had already experienced in her life via her mother’s supporting stance. In particular, the therapist expected that supportive psychotherapy would integrate the “segregated” themes locked in Matilde’s experience: she might then be able to consciously accept and deal with her blocked emotions and affects, as to regainenjoyment of life and satisfaction in the relationship with significant figures, re-finding the haven of safety of self and others that she had experienced in her childhood.

The clinical case formulation suggested for Matilde a therapeutic approach in the context of a “partial rapprochement” between attachment theory and psychoanalytic individual psychotherapies as the best solution ( Skean, 2005 ; Slade, 2008 ; Steele et al., 2009 ). This intervention would include: (a) The use of therapeutic relationship and alliance as vehicles for a “secure base” constitution, in order to observe and understand the client’s interpersonal behavior ( Spence, 1982 ; Binder et al., 1987 ; Dozier et al., 1994 ; Slade, 2008 ; Steele et al., 2009 ); (b) Relationships with the self and others (internal and external), in terms of personality functioning but also from client’s transference and therapist’s counter-transference points of view of ( McWilliams, 1999 ; Skean, 2005 ); moreover, patient’s real or transferential relationships and past-present pattern of emotional responses and behaviors were examined ( Gabbard, 2009 ). However, a particular emphasis was put on the supportive versus insight-oriented modes of therapy ( Skean, 2005 ), because Matilde needed: (a) to reduce physical and psychical symptoms ( S-Axis ; Gabbard, 2009 ), and reestablish a consistent level of functioning ( Dewald, 1971 ; Ursano and Silberman, 1996 ; Douglas, 2008 ); (b) to strengthen her fragile ego. Her defenses were at a mature-neurotic level, but were not solid enough to stop the recourse to symptoms and anxiety ( PDM: Defenses; Capacity for Differentiation and Integration ), (c) to change her self-definition, improving self-esteem, and getting a more integrated perception of the self, ( PDM: Qualiy of internal experiences; Capacity for Differentiation and Integration ); (d) To function better in everyday life investing lessin achievements and study matters ( Dewald, 1971 ; Ursano and Silberman, 1996 ; PDM: Rehabilitation ); (e) to improve her coping skills and to learn consistent strategies to manage her painful internalized feelings ( PDM: Capacity for regulation, attention, and learning ); (f) to increase her capacity to express affects both on the positive and negative aspects evidenced by AAI and that were consciously often inhibited and not acknowledged (PDM: Affective Experience, Expression, and Communication) ; (g) to encourage more consistent ways of relating to others ( PDM: Capacity for Intepersonal Relationships; Misch, 2000 ). In addition, her concrete and intellectualized thinking (SWAP–200) made also difficult for her to deal with interpretations, suggesting again the need of a more supportive approach.

BRIEF OUTLINE OF THE THERAPY UNFOLDING

As expected, during the first months of therapy Matilde showed a high symptomatic picture. She appeared very distressed and confused, with a sense of failure, of inability to reach her standards. Long boring and intellectualized descriptions of daily routines and of University achievement, anxiety, uncertainties and doubts about her achievements were her main topics. The therapist acted as a secure attachment figure ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ), as a caregiver who offered security and soothing to Matilde’s distress. She worked actively helping Matilde to contain anxiety, shame, and anger ( Winston et al., 2004 ). The therapist, very slowly and respecting her defenses, tried to reduce Matilde’s anxiety, to increase her self-esteem and hope, and to make her more aware about herself as a person, and not only as a student who had to achieve some standards. She begun anyway to talk about how she could count on her mother, the only person that always helped her when she felt anxious and distressed. This finally opened a window on her family and her separation difficulties during childhood, and she started to tellhow she felt alone and how much she needed her mother’s soothing, how much difficult it was to face her first experience of a 2-week summer camp, as well as to begin elementary school, middle school, and high school. She also admitted that anyway with her mother’s help she was able to face these separations. She began to recognize, following therapist’s verbalizations, that at that time she was beginning a new kind of “school-experience,” similarly to the situation at present. In parallel with this initial understanding of her fear of facing changes and separation, all symptoms increased, especially anxiety symptoms. “ It is a nightmare ” were her words. She told the therapist that she called mommy every morning and evening but it was not enough. She felt lost and alone. The episodes reported by Matilde at this phase of the therapy were very similar to the ones she reported in the AAI, and the ways she dealt with the present separation from her mother were similar to the ones she previously used during her childhood: going concretely to her mother to be soothed and supported. Moreover, she used the same words she previously used in the two AAP stories where segregated systems were unleashed but resolved. It could be hypothesized that in the transference with the therapist Matilde’s attachment system was activated and “seen in action” ( George and West, 2012 ). As she said during the AAI, it was always difficult for her to deal with changes. Now in the transference with the therapist she was reliving her fears, the same fears she experiencedin childhood, the ones that were unleashed at the beginning of the University andthat she was able to face only through anxiety and obsessive symptoms. It was difficult for her to connect this experience with the new separation experience from home and from herself as a child, now that she had to face University and all the complex processes connected with entering adulthood. In the transference with the therapist she was reviving an acute separation anxiety and she was also unconsciously angry at the therapist’s impossibility to help her. The therapist tried unsuccessfully to interpret and to connect this profound regression with Matilde’s previous separation anxieties. Words were not useful. Wallin (2007) supports that “ what patients are unable to explain with words, tends to be evocated, enacted or incorporated ” ( Zaccagnini and Zavattini, 2009 ). The working alliance showed for the first time some ruptures, and the risk of treatment disruption itself became a subject of discussion ( Appelbaum, 2005 ; Colli and Lingiardi, 2009 ). Matilde’s alliance rupture style was characterized by the presence of withdrawal maneuvers: emotional disengagement from the therapist, skipping from topic to topic, responding in an overly intellectualized fashion, and very short answers ( Safran and Muran, 2000 ). In such a moment of regression, she really needed a concrete comfort and physical contact with her mother. The therapeutic stance was not enough for her; she decided that the best way to deal with the situation was to go back home. Matilde went home, “ to be near to her family. ” Coming back to her parents represented for her the haven of safety she described in her AAP. Parents were still used as attachment figures during early, middle and late adolescence and also during young adulthood ( Fraley and Davis, 1997 ), especially under conditions of extreme stress ( Huntsinger and Luecken, 2004 ; Kamkar et al., 2012 ). She stayed home with her family for 3 weeks. When she came back, she appeared less anxious and more integrated: little by little, Matilde was more able to feel the setting as a place where exploration of her personal life and new experiences could be initiated, shared, and enjoyed. She was able to develop positive feelings toward the therapist ( Misch, 2000 ). She began to integrate positive and negative feelings in life events, becoming more and more flexible, increasing her ability to tolerate changes and learning to find new solutions to life schedule. She reached some goals toward adulthood and began to find real friends, also far from home, and to spend energy in different activities (e.g., organization, church, neighborhood, etc.). She loved challenges and she felt pleasure in realizing her goals and in pursuing long-term ambitions. A boyfriend appeared. The symptoms disappeared. She continued to use a great amount of razionalization in order to explain some affective aspect of her experiences. from the point of view of attachment, she mantained a tendency to change the topic when she approached emotional issues using displacement defenses in order not to deal with her core difficulties. The therapeutic goal of accomplishing a true adolescent process was also achieved. A solid and good child image was now more integrated with an adolescent and adult image. Some developmental tasks were reached on the way toward adultood (friendship and romantic relationship). The therapist discussed with Matilde the fact that some shortcomings were still present in her personality functioning, but both agreed that she wished now to try to go on with her life by herself. As Freud (1966) suggested, the aim of psychotherapy at a developmental age is to help the patient to proceed along his or her developmental lines. Now Matilde managed to integrate some issues concerning the developmental step of adolescence and young adulthood and she wished to try new experiences by herself.

FOLLOW-UP FINDINGS

Results from DSM-IV diagnosis, SCL-90-R, and SWAP–200 in the follow-up phase are described in Table ​ Table5 5 .

Results from SCL-90-R and SWAP–200 in follow-up phase.

The AAP was scored secure, but without any segregated systems. As a representative example of some new attitudes, Matilde’s stories for Window and Departure pictures are reported.

Window (a child looks out a window): a girl who woke up eh … parents are not there, they are at work and she knows she is alone at home. She is quiet. She is looking out of the window thinking about her mom and the fact she will come back home in the afternoon. She is thinking about who she can invite in … who can … can keep … her company. She is quiet, excited by the day without parents (What might happen next?) she will find someone … a … a friend … a neighbor … finally she will have fun (Anything else?) No.

Matilde tells one of the most common AAP stories for the Window picture: a typical home-related scenario in which a little girl needs to manage her solitude. The girl is “ quiet ” although she is alone home. So, Matilde is not threatened by the girl’s loneliness, but she is somehow able to enjoy the possibility of being alone. The absence of segregated systems demonstrates the absence of dysregulating events, which could have led to her being alone (her parents are just working) and of girl’s traumatic reactions. More specifically, the girl is depicted “ thinking about her mom, ” activating her ability to internalize the secure base and being “ content in solitude. ” In fact, this connection with the thought of her mother’s coming back in the afternoon keeps the girl regulated and lets her also think about something specific to do alone: “ she looks out of the window thinking about who she can invite in … who can keep … her company. ” The little girl can recall the affiliative system (“ friend ”) to handle her loneliness. Her ability to think makes Matilde confident and envisages the possibility of changing things in the immediate future (“ she invited friends ”). From a developmental point of view, Matilde is now a late adolescent-young adult: she is prone to consider also peers and friends as a secure base to refer to in moderately distressful situations.

Departure (an adult man and woman stand facing each other with suitcases positioned nearby): a woman is going to leave for a business trip and she is saying goodbye to her husband … he took her to the station … she was already planning what she needed to do during the trip … yes during this period of work … he is quiet and he thinks about their relationship, about how they enjoy to be together, what he would do without … in these few days without his wife…however … she will leave and he will spend a few dull days … (Anything else?) No.

In Departure, Matilde is able to tell a typical AAP story, which portrays a couple at the train station. The husband thinks about their relationship and he feels that his days will be dull without his wife. Matilde’s story suggests togetherness and a goal-corrected partnership. She portrays the husband as involved in a contingent, reciprocal and mutually engaging relationship.

QUALITATIVE CLINICAL EVALUATION AT THE END OF THERAPY

Matilde did not have any DSM-IV diagnosis in Axis I and her personality functioning resulted carachterized by obsessive high functioning features (PDM S -axes, SWAP–200). She had no more panic attacks accompanied by strong physical arousal, and her experiences were now more mentally symbolized. Her SCL-90-R final symptom profile revealed a magnitude within the normal range. Only two symptomatic distress levels, obsessive–compulsive, and anxiety, still penetrated the clinical range, but their intensity had diminished compared to the assessment phase.

Her self-image improved: she now experienced a sense of personal satisfaction, sufficient self-esteem and self-confidence (PDM M -axes). The “negative-stressful” components of her affective world were still present but the level of self-blame, and emotional constriction greatly diminished. She was now less inhibited and became more spontaneous in expressing emotions, and also anger. Matilde still showed a pattern of Mature-Neurotic defenses and an absence of primitive defenses. Rationalization, intellectualization, undoing, and displacement were the mostly used defenses, but were now more flexible, less pervasive and she was able to avoid recourring to symptoms and anxiety. The AAP confirmed a flexible use of defenses and reduction in thereliance on dectivation defenses; however, her kind of defense structure still did not allow neither an emotional insight about her motivations and behaviors, or psychological mindedness.

Matilde remained secure in her attachment pattern, changing her defensive approach through a more integrated and coherent one, in which no more segregated systems or disregulation were present: she was now able to use again her self-regulation capacities autonomously (PDM M -axes). Her attachment adolescent crisis was resolved; she was out of her “nightmare.” She still seemed naïve and used an excessive part of her mental energy to keep emotions and feelings at bay, showing a limited ability to appreciate metaphor, analogy, or nuance. In the context of a supportive stance, comprising a secure and holding environment and an atmosphere based on emotional safety, she was able to work on her fear of loss and changes allowing her internalized attachment status to reach an adult structure. She was now able to deal with adult tasks using her internalized parental figures, thinking about how they could protect her. Matilde now found pleasure, satisfaction, and enjoyment in everyday-life activities. Her underneath security pattern now re-emerged allowing her to maintain a loving relationship, and to engage and keep long-standing and intimate friendships and relationships (PDM M -axes). She now set less unrealistically high personal standards and she was now able to find meaning in belonging and contributing to a wider community (e.g., organization, church, neighborhood, etc.). Table ​ Table6 6 shows Matilde’s qualitative picture at baseline and at follow up.

Qualitative Matilde’s picture of features at baseline and at the end of psychotherapy.

This clinical case study highlighted the importance of assessing patient’s idiographic and intra-subjective features ( Hilliard, 1993 ). The nature of the clinical case perspective requires a rich diagnostic process that includes both a nosographic approach (such as DSM-IV) and a more multifaceted point of view to assess the specific patient’s psychological functioning ( Barron, 1998 ; Shedler and Westen, 2007 ). There have been few studies investigating the psychotherapy process in supportive therapies ( Orlinsky et al., 2004 ), and very few studies were devoted to inserting also the contribution of validated measures of attachment. Slade (2008) endorsed that, although attachment theory terms have been incorporated in the present psychoanalytic theory, only few therapists have really integrated core elements of the attachment perspective in their clinical thought. Above all, few of them inserted measures of attachment and their strategies to understand the therapy unfolding ( Rockland, 1989 ; Porcerelli et al., 2011 ). Assessing attachment means more than just determining a patient’s attachment classification status. The benefit from the inclusion of attachment assessment to a multi-method approach is the chance of using results to elucidate the patient’s representational and defensive patterns related to attachment activation ( Bowlby, 1980 ).

This paper tried to illustrate a clinical case where results from attachment tools together with PDM assessment could help to give a more integrate picture and to form and inform the unfolding of the therapy. The incremented validity about symptoms and attachment internal working models evaluation added a specific qualitative contribution to each tool (e.g., SCL-90-R gave the self perception of symptomatology and SWAP–200 the clinical perception of it; AAI and AAP increased biographical information and defense mechanism, respectively). The paper presented a case formulation in which a psychodynamic approach was integrated with an attachment theory framework both in the assessment and post-assessment phases and with a “ supportive psychotherapy approach. ” The secure attachment status, as derived from the AAI and the AAP, helped to structure Matilde’s therapy, adding information to the therapeutic intervention: Matilde’s secure attachment resulted helpful to establish a therapeutic plan, to facilitate the therapeutic alliance and the answer to the therapy, and to help her to face her symptoms and internal difficulties ( Douglas, 2008 ; Steele and Steele, 2008 ). The AAP and AAI were taken into account, making the therapist sensible to the specific topics concerning separation and loss, which were reactivated throughout treatment. Matilde needed to explore them in the context of a “ safe haven, ” the same context she had previously experienced in her life with her mother’s supporting stance. On her side, the therapist recreated and maintained a well knownholding environment, affective mirroring and personal warmth ( Markowitz, 2008 ) and an atmosphere based on emotional safety ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). She provided Matilde with the secure base she temporary lost, a starting point from where the exploration of painful experiences in her present life could finally begin. This gave her the possibility to recall some hidden memories, leading to self-exploration ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Holmes, 2010 ). The “supportive approach” and the role of attachment framework turned out to be a key factor in the assessment and in the development of an effective therapeutic relationship with Matilde. Within a psychoanalytic framework, through the unfolding relationship with the therapist, Matilde brought her interpersonal world into the treatment room and allowed the therapist to experience aspects of her structuring of reality ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). The conclusion of the therapy showed a more integrated picture, where symptoms were no more outstanding and Matilde seemed to be out of her big “nightmare” and ready to face her life tasks in a more integrated and young-adult way. The post-treatment AAP confirmed that Matilde was able to integrate these issues of separation and loss. She was a very defensive neurotic patient blocked at latency, and showed some shortcomings related to the separation-individuation process ( Mahler et al., 1975 ) both from a psychoanalytic and from an attachment point of view.

The treatment helped Matilde to make a developmental step toward maturity: “from childish features to adolescent ones, reaching the capacity of (emotionally) exploring the possibility of living independently from parents (…) because they know that they can turn to parents in case of real need” ( Allen and Land, 1999 , p. 322). The therapist was both an “attachment figure” that helped Matilde to face new experiences, as well as a transference object ( Dozier et al., 1994 ). Matilde’s development resulted in increased abilities in managing the goal-corrected partnership with each parent, in which behavior is not determined only by adolescent’s current needs and wishes, but also by recognition of the need to manage certain set goals for the partnership ( Bowlby, 1973 ).

As all clinical case studies, this study suffered from some limitations ( Hodkinson and Hodkinson, 2001 ): results are not generalizable in the conventional sense; it looks expensive, if attempted on a large scale and the complexity examined is difficult to represent simply and briefly. Furthermore, clinical case studies results stronger when researchers’ expertise and intuition are maximized, but this raises doubts about their “objectivity”: this type of research is easily subjected to criticisms by those who do not like the messages that they contain; and finally it cannot answer a large number of relevant and appropriate research questions that future studies could address (e.g., in this sense, it could be highly valuable for future research to compare PAD patients with different attachment styles). However, this particular case study could be considered an original and extremely valuable one, because it is grounded in “lived reality.” This helps us to understand complex inter-relationships between diagnosis, measures and their clinical application, facilitating the development of conceptual/theoretical issues and the exploration of unexpected and unusual situations, such as PAD in a secure attached patient. As regards the choice of this patient, the present paper can provide “provisional truths, in a Popperian sense” ( Hodkinson and Hodkinson, 2001 ): it represents the best account of such assessment and treatment in the current literature, and it should stand, until contradictory findings or better theories are developed.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

1 The PDM was developed to describe “the depth as well as the surface of emotional, cognitive, and social patterns” (p. 1) of an individual’s functioning, as to improve the diagnosis and treatment of psychological disorders. PDM comprises three areas: personality patterns (Axis P ), mental functioning ( M -axis), and symptoms ( S -axis). Our attention focused mainly on mental functioning or M -axis, “a microscopic look at mental life” (p. 8), although some attention was paid to symptoms and concerns or S -axis.

2 The patient self-referred to a psychodynamic service, where therapists are trained to use an Operationalized Psychodynamic Diagnosis approach during consultation sessions, preferring free or “per area” clinical sessions to interviews (e.g., SCID).

3 The self report SCL-90-R was digitally computed. Inter-reliability reached Cohen’s k = 1 for AAI and AAPs final classifications; 0.93 for AAI subscales; 0.85 for AAP codings; 0.72 for SWAP–200 final scales.

4 (1) Neutral (children playing ball); (2) child at window (alone); (3) departure (dyad); (4) bench (alone); (5) bed (dyad); (6) ambulance (dyad); (7) cemetery (alone); (8) child in corner (alone).

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