Introduction
In modern highly multitasking and stressful life, many people tend to encounter psychological problems. They are manifested in personal relationships, career, and self-understanding issues that inhibit a balanced and harmonious life. It is widely recognized that childhood problems can cause difficulties in adulthood. Attachment-based psychotherapy is one that explores how one’s childhood experiences affect his or her current social and psychological challenges (Diamond et al., 2021). This paper aims to scrutinize attachment-based psychotherapy, including its theory, practical implications, and clinical effectiveness, thus contributing to psychotherapy research.
Overviewing Attachment-Based Psychotherapy
Many people visiting psychotherapists have disorganized and insecure attachments. Accordingly, they are also likely to mistrust specialists and fail to communicate constructively. Slade and Holmes (2019) state that attachment-based therapists act as change agents by serving as a reliable base (Slade & Holmes, 2019). The core of this therapy modality refers to discovering a client’s childhood experiences and rebuilding them by working on attachment regulation. The main goal of the therapist is to help the client connect with his or her inner child without judgment. These assumptions are based on an attachment theory developed by clinicians John Bowlby and Mary Ainsworth. Even though the theory was elaborated in the 1950s, it was seriously researched and accepted by practitioners only after decades (Slade & Holmes, 2019). The practice techniques of the mentioned psychotherapy show that attachment is likely to moderate treatment effectiveness. Among the potential improvements resulting from a series of attachment-based therapy sessions there are emotional expressivity, relationship satisfaction, adequate self-esteem, decreased depressive and anxiety symptoms, and a more stable mental state.
Discussing Theoretical Perspectives
The attachment-based psychotherapy uses an attachment theory that explains how children tend to be attached to their caregivers from birth and across early development. In building their theory, Bowlby and Ainsworth focused on Freud’s psychoanalysis, paying special attention to the first years of a person’s life, when a mother and a baby are in a close interaction that largely determines the further development of the child (Levy & Johnson, 2019). However, the authors considered that from an early age, a child has all the prerequisites for inclusion in social life, while from Freud’s point of view, the infant is aimed at the mother as a source of satisfaction for his or her needs. According to Bowlby, children are highly dependent on their adults, which means that they must have special behavioral mechanisms that would guarantee security.
The attachment theory explores the interpersonal connections between two people, which determine both the mental and psychological structure of a person, such as an attitude toward herself or himself, the world, various experiences, cognitive and creative abilities, et cetera. Since the first connections with another person arise in infancy age, the experience of relationships gained in early childhood is natural (Diamond et al., 2021). Without proper relationships, grown-up children may feel confusion, insecurity, depressive symptoms, anxiety, and other negative experiences. Therefore, by building attachments with caregivers in early childhood, future adults can avoid many problems (Diamond et al., 2021). In turn, those who fail to achieve it as children for any reason can work with therapists to rebuild their attachments.
The so-called object of attachment (attachment figure) is one of the central concepts of attachment theory. In many cases, this person is the mother for most people. However, a blood relationship does not play a special role since, in the absence of a biological mother, anyone who is able to establish an attachment relationship with a child can replace her. According to Bowlby, the key function of the attachment figure is not to satisfy the innate need for love (as in classical psychoanalysis) and not to satisfy the physiological needs of the child (as in behaviorism) but to provide protection and security (Green & Scholes, 2018). Therefore, the presence of attachment is a necessary condition for the exploratory behavior and cognitive development of the child.
The working model is another fundamental concept in terms of the attachment theory. Being introduced to rethinking and developing the psychoanalytic concept of relationship it is extremely important in the context of the attachment theory. Green and Scholes (2018) state that Bowlby suggested that in the process of interacting with other people and surroundings, an individual constructs working models of the most significant aspects of the world. Using them, a child perceives and interprets various events. A working model may be visualized as the deep structure of self-consciousness or attitude, although the relationship of this model to consciousness is highly ambiguous (Green & Scholes, 2018). Children do not realize themselves as individuals, but they perceive and understand themselves and the world around them through working models. It should be stressed that a working model does not lend itself to a specific description and scientific analysis as it is a dynamic and adaptive modality.
Discovering Practice Techniques
There are two key processes that are practiced in attachment-based therapy, such as building secure relationships and strengthening the adaptive capacities of a person. These processes refer to those specific feelings, thoughts, and behavioral patterns that were learned in childhood to avoid or facilitate certain connections. Therapists begin the first process by creating trustful and open relationships with clients to ensure their comfort and safety. Diamond et al. (2021) emphasize that the quality of these relationships largely determines the effectiveness of psychotherapy. In particular, they use the elements of security-engendering relationships to create responsive attitudes around difficult issues for clients. Therapists also practice both discovery and communication of emotions and feelings that cause frustration (Diamond et al., 2021). In other words, they focus on what specifically patients cannot feel, think, or perceive in a safe way. It allows for enlarging clients’ adaptive capacities to suppress or emphasize early childhood attachments.
Speaking about practice techniques adopted in attachment-based therapy, it is critical to mention that the recognition of attachment dynamics is its cornerstone. As clarified by Slade and Holmes (2019), “The invitation to give voice to one’s emotions in therapy will invariably activate different defenses in different patients” (p. 161). Therapists are to notice the moment-to-moment efforts of patients and adjust the way they provide sessions. Openness and flexibility foster further exploration of a client’s experiences, also giving a resource to change them in a positive way. Slade and Holmes (2019) also add that a client’s attachment orientation can be approached in different ways. For instance, affective interventions are preferable for preoccupied patients, while avoidant patients would benefit from cognitive interventions. Furthermore, experienced therapists reported that they tended to apply a complementary style of discussion during the first sessions with clients (Slade & Holmes, 2019). However, upon the establishment of trust between them and their patients, they switched to responding in an out-of-their-style manner to facilitate change.
Considering the emphasis on the caregiver-child dyad, a number of interventions for caregivers were developed. In real-life interactions, it is recommended to communicate with children in a positive and sensitive way (Levy & Johnson, 2019). As an example, a “Circle of Security” intervention integrates group discussions, didactics, and video recordings for parents. Another mother-infant therapy strategy implies infant-led play to reinforce a child’s security and autonomy. Levy and Johnson (2019) prioritize caregivers’ ability to “mentalize and increase their own sensitivity, responsivity, and attunement to their children” (p. 190). While this strategy is helpful to children’s attachments, it does not treat caregivers’ psychopathology, specifically depression (Levy & Johnson, 2019). However, the authors also suggest that further research is necessary to better understand the impact of attachment-based parenting on care providers, which is extremely important for high-risk populations.
Evaluating the Effectiveness of Attachment-Based Psychotherapy
Compared to other traditional psychotherapy models, such as cognitive-behavioral therapy or interpersonal therapy, the body of research regarding attachment-based therapy is limited. Nevertheless, it is possible to discuss a range of recent studies that demonstrate a high level of effectiveness in working on attachments. Waraan et al. (2021) conducted a controlled-randomized trial to analyze the role of the mentioned therapy in treating depression in adolescents. The authors used attachment-based family therapy (ABFT), blinded evaluators at the baseline and post-treatment by means of the Hamilton Depression Scale and Beck Depression Inventory. As a result of analyzing 60 adolescents, the research found a significant reduction in depressive symptoms compared to traditional psychotherapy (Waraan et al., 2021). However, final remission rates showed no distinctive difference between the two mentioned models of psychotherapy. These results indicate that depression in adolescents is complicated and requires a combination of methods to overcome it. At the same time, the authors note that no other model of therapy based on family sessions is more effective for addressing depressive symptoms.
Other scholarly studies also confirm the development of primary adaptive emotions in adolescents through ABFT. Another relevant study by Lifshitz et al. (2021) focused on attachment-based family therapy in 39 suicidal adolescents in terms of a randomized clinical trial. During and after 16 working sessions, the participants demonstrated a shift from general distress to maladaptive shame, which turned to adaptive assertive anger and then to subsequent grief/hurt (Lifshitz et al., 2021). The clinical significance of these results refers to identifying a specific pathway to developing adaptive emotions. The ability of family therapy to impact patients’ perception of self and others is also reported by Levy and Johnson (2019), who point to the reduction of social deprivation and psychological discomfort. For example, many patients report feeling shame as a link to their childhood, and the ability to remember or imagine specific situations is critical as the initial step of attachment therapy (Levy & Johnson, 2019). This strategy allows working with loss, loneliness, pain, and even vulnerability, which appeared in childhood and/or adolescence.
Speaking about the effectiveness of attachment-based psychotherapy for adolescents, it is essential to note that many therapists use its principles. Cognitive-behavioral therapy and interpersonal therapy employ the assumption that attachment constructs between a counselor and a patient largely determine the outcome of treatment (Green & Scholes, 2018). More to the point, transference-focused psychotherapy (TFP) and supportive psychodynamic psychotherapy (SPT) have an emphasis on developing collaborative engagement as the basis for psychotherapy success (Levy & Johnson, 2019). These findings indicate that attachment-based therapy is flexible and adaptive, which means that its principles can be applied in different contexts. In particular, not only major depression but also binge eating disorders, social isolation, and borderline disorders can be approached by means of working with attachments. The mentioned therapies are found to enhance responsiveness and sensitivity in patients, which leads to encouraging interpersonal and intrapsychic effects.
Further research needs to explore the areas in which attachment-based psychotherapy may benefit clients. The so-called in-session effects, as well as attachment constructs, should be targeted as research prospects. In addition, children’s and caregivers’ attachment styles can be examined in future studies so that practitioners can utilize new knowledge regarding current styles adopted by both parties. In general, there is a need to connect research and practice regarding attachment-based psychotherapy since only a few recommendations are presently made for therapists.
Conclusion
To conclude, it should be pinpointed that attachment-based psychotherapy aims to transform negative childhood experiences by building trustful relationships and extending one’s capacity for adaptation. This modality of psychotherapy is based on Bowlby’s theory of attachments, which prioritizes the connection between children’s early childhood and their caregivers. The review of the related literature shows the moderate effectiveness of attachment-based therapy, which is caused by the complicated nature of treating depressive and suicidal symptoms. As a relatively new modality of psychotherapy, the work on attachments presents a promising way for therapists to better understand clients’ needs and choose the best interventions to help them.
References
Diamond, G., Diamond, G. M., & Levy, S. (2021). Attachment-based family therapy: Theory, clinical model, outcomes, and process research. Journal of Affective Disorders, 294, 286-295.
Green, M., & Scholes, M. (2018). Attachment and human survival. Routledge.
Levy, K. N., & Johnson, B. N. (2019). Attachment and psychotherapy: Implications from empirical research. Canadian Psychology, 60(3), 178-193.
Lifshitz, C., Tsvieli, N., Bar-Kalifa, E., Abbott, C., Diamond, G. S., Roger Kobak, R., & Diamond, G. M. (2021). Emotional processing in attachment-based family therapy for suicidal adolescents. Psychotherapy Research, 31(2), 267-279.
Slade, A., & Holmes, J. (2019). Attachment and psychotherapy. Current Opinion in Psychology, 25, 152-156.
Waraan, L., Rognli, E. W., Czajkowski, N. O., Aalberg, M., & Mehlum, L. (2021). Effectiveness of attachment-based family therapy compared to treatment as usual for depressed adolescents in community mental health clinics. Child and Adolescent Psychiatry and Mental Health, 15(1), 1-14.