Clinical Applications of Attachment Theory

Authored by Henry Strick van Linschoten

(Psychotherapy aims) to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance. (Bowlby, 1988:138)

Introduction and history

Attachment theory is a combination of ideas in developmental psychology; a set of concepts such as the attachment behavioural system itself, the primary caregiver and the distinct categories of attachment relationships of infants and adults; an approach to psychology that is very open to learning from other disciplines such as biology, medicine, and control theory; suggestions for fruitful directions of research; and an attitude to psychotherapy. Bowlby himself was keen on the scientific method, and many of his co-developers of attachment theory have followed his lead on this point. The whole module and this study aid concern themselves with the application of attachment theory to psychotherapy.

As regards to the parts of attachment theory that have influenced psychotherapy, it may be useful to keep in mind four different paths of influence:

1. The constructs of attachment security and the categories of attachment insecurity are a helpful way of understanding clients and their problems or disorders.
2. The insight provided by the Strange Situation, whether actually applied to infants or applied to clients, can be combined with other developments in infant observation and the knowledge of very early development to afford a better insight in what is happening in the earliest years of life and how this can work through in the issues dealt with in psychotherapy.
3. The research about adult attachment styles, and how the attachment system functions in adolescence and adulthood, can help in the understanding of the psychotherapeutic relationship, of relational functioning, and where relevant of topics specific to couple and family psychotherapy. Adult attachment is different from attachment theory as applied to infants.
4. The attachment categories can specifically be applied to both therapist and client, with fruitful analysis of what they mean for positioning and micro-choices in psychotherapy.

There are further aspects of the rich terrain of attachment theory, not covered by these four points. Bowlby himself was very proud of the interdisciplinary links he had made with biology, especially with ethology and evolution theory. In addition there have recently been a number of links made with neurobiology. It seems clear that these areas of progress have added to knowledge, but less clear in many cases where precisely they will make a difference for the practice of psychotherapy.

Attachment theory is a special area of focus inside the overall fields of psychology and psychiatry. Attachment theory and its view of development and psychotherapy remain substantially influenced by psychoanalysis and psychoanalytic ways of working and understanding. In turn, other developments such as the mentalization theory of Fonagy and colleagues, and even the relational and intersubjective developments in psychoanalysis and psychotherapy, have been substantially helped and boosted by the findings of attachment theory, but cover a larger field than what can still be described as attachment theory proper. In this paper it is suggested that it is better to maintain a definite and bounded meaning of what attachment theory is and where it ends.

John Bowlby (1907-1990) was a psychiatrist and psychoanalyst, who after his university study, in the 1930s, did his training as psychoanalyst at the Institute of Psychoanalysis in London, UK. He developed attachment theory out of his study of the impact of maternal care on the development of children (Bowlby, 1969/1982; 1973; 1980). Bowlby’s work was based on a revised framework of psychoanalytic theory and clinical practice, first generation cognitive psychology centering on information processing, and ethology. Bowlby had a different view of instinct theory from Freud and later object-relations theorists. He believed that one of the infant’s primary needs was attachment, psychical and emotional proximity to the mother (Bowlby, 1982), rather than hunger or sexual desire. He was cautious about generalising from animal research to humans, but confident that it could form the basis for further research, given the striking similarities between humans and other mammals. For a concise historical summary of Bowlby’s work’s trajectory see Fonagy & Target (2003).

Bowlby (1982) was critical of both Freud’s drive model and British object relations theories. In Freud’s account the infant initially exists in a state of “primary narcissism” in which the build-up of libido requires discharge in the desire to feed and suck at the mother’s breast, an expression of infantile sexuality. In this “hydraulic” account of the accumulation and discharge of psychic energy, the mother is conceptualised as an object at which the baby’s libido is aimed. The outcome of the mother not being available is the accumulation of tension which is then experienced as anxiety. Freud’s theory of anxiety would later become elaborated to advance the idea of anxiety as a signal of the potential separation form the loved object: However, the anxiety is still about losing an object that can satisfy a physiological need. Likewise, Melanie Klein’s account of the early relationship linked physiological processes to symbolic ways of relating later in life, but did not assume that the bond between child and caregiver was important in its own right. Bowlby’s views incurred criticism from contemporary psychoanalysts, successors of Freud and Klein, with various accusations about undermining the importance of interiority and the unconscious as well as displacing the central importance of sexuality and the Oedipus complex.

Bowlby was fascinated with ethology and the work of Darwin and Lorenz. He was very interested in animal behaviour, although he was careful about making generalisations from other mammals to humans. He was a Neo-Darwinist, and believed that the time was right for a dialogue between ethology and psychoanalysis. He criticised psychoanalysis for its emphasis on internally perceived danger rather than external danger exemplified by the presence of predators. He saw attachment as a separate behavioural system from feeding and sexuality. Attachment is not a teleological, goal-oriented system like Freud’s, but a system that confers evolutionary advantages because it enhances interpersonal functioning and effectiveness.

In the early decades of attachment theory little was written or developed about its application to psychotherapy (other than the fact that it was born in the mind of a psychoanalytic practitioner, and influenced by the psychoanalytic worldview). At the time of Bowlby’s own (1988) book with the subtitle, “Clinical applications of attachment theory” little had been published in the form of books or even articles. This may be partly due to the tension there had been since the late 1950s between Bowlby’s ideas and more traditional psychoanalysis. In parallel with the development of attachment theory there had been an increasing interest in infant and young child observation studies, and their potential for psychotherapy practice was also seen. This included Trevarthen, D.N. Stern (1985), the work of Tronick, Beebe & Lachmann, and, later, Allan Schore. The first edition of Holmes (2014) came out in 1993, and Slade’s (1999) summary chapter about the clinical applications of attachment theory showed an impressive number of references that had accumulated in the 1990s. Since then the field has considerably grown, as will be clear from the references and material presented here.