Paul Holmes, Steve Farnfield - The Routledge Handbook of Attachment - Implications and Interventions-Routledge (2014)

The Routledge Handbook of
Attachment: Implications and

Interventions
The Routledge Handbook of Attachment: Implications and Interventions offers

an introduction to therapies produced as a result of the popularity of attachment
studies. These therapies can be divided into two categories: those that are ‘attach-
ment-based’, in that they use evidence-based attachment assessments in their
development, or ‘attachment-informed’, in that the theories of attachment have
been integrated into the practice of existing schools of therapy.
The book reviews the ¿eld and provides a range of interventions for children,
adults and parents, beginning with a detailed review of both evidence-based and
evidence-informed interventions including individual psychotherapy, family
therapy and parenting. The remaining chapters provide accounts, from the prac-
titioner’s perspective, of interventions that address issues of attachment from
the level of one-to-one therapy, family and social work to social interventions
involving courts and care proceedings, illustrated with examples from day-to-day
practice.
Discussing how an understanding of formal assessments of attachment can be
used to inform therapeutic, social and legal interventions to assist and protect chil-
dren, The Routledge Handbook of Attachment: Implications and Interventions is
an indispensable guide for clinical psychologists, psychiatrists and social workers
working with children and families, clinicians in training and students.
Paul Holmes is a child and adolescent psychiatrist who also trained as an adult
psychotherapist. He worked in community child and adolescent mental health
teams for many years, and with specialist services for fostered and adopted chil-
dren. He has increasingly applied his long-standing interest in attachment theory
to his work in providing expert psychiatric opinions to the British courts in child
care proceedings.
Steve Farn¿eld is a Senior Lecturer and established the MSc in Attachment Stud-
ies at the University of Roehampton, UK. He is a social worker and play therapist
with many years’ experience and a licensed trainer for the Dynamic-Maturational
Model of Attachment Infant CARE-Index, Preschool Assessment of Attachment
and Adult Attachment Interview developed by Patricia Crittenden.
This page intentionally left bank
The Routledge Handbook
of Attachment: Implications
and Interventions
Edited by
Paul Holmes and Steve Farnfield
First published 2014
by Routledge
27 Church Road, Hove, East Sussex, BN3 2FA
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2014 Paul Holmes and Steve Farnfield
The right of the editors to be identified as the authors of the
editorial material, and of the authors for their individual chapters,
has been asserted in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced
or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
The Routledge handbook of attachment :
implications and interventions /
edited by Paul Holmes and Steve Farnfield.—First Edition.
pages cm
1. Attachment behavior. 2. Child psychotherapy.
3. Dependency (Psychology) I. Holmes, Paul, editor of compilation.
II. Farnfield, Steve, editor of compilation.
BF575.A86R684 2014
155.9'2—dc23
2014003036
ISBN: 978–1–138–01672–9 (pbk set)

ISBN: 978–1–315–76509–9 (ebk set)
ISBN: 978–0–415–70611–7 (hbk)
ISBN: 978–0–415–70612–4 (pbk)
ISBN: 978–1–315–76428–3 (ebk)
Typeset in Times New Roman

by Swales & Willis Ltd, Exeter, Devon
This book is dedicated to those professionals
who are the essential players in improving child
welfare and protection, and to our partners who
have supported us and nurtured us during the
long gestation of this book.
This page intentionally left bank
Contents
Notes on contributors ix
Preface xiii
STEVE FARNFIELD AND PAUL HOLMES
1 Introduction 1
STEVE FARNFIELD AND PAUL HOLMES
2 Attachment theory and its uses in child psychotherapy 32

GRAHAM MUSIC
3 Where the child is the concern: working psychotherapeutically

with parents 53
JEREMY HOLMES
4 The marriage of attachment theory and systemic family therapy

practice: an invitation to join the wedding party 65
CHIP CHIMERA
5 Attachment-based interventions: sensitive parenting is the key

to positive parent–child relationships 83
FEMMIE JUFFER, MARIAN J. BAKERMANS-KRANENBURG AND
MARINUS H. VAN IJZENDOORN
6 Attachment-focused therapeutic interventions 104

DANIEL HUGHES
7 Clinical implications of attachment in immigrant communities 117

ELAINE ARNOLD
viii Contents
8 Attachment: a British lawyer’s perspective 132

MARY ANN HARRIS
9 The applications of attachment theory in the ¿eld of adoption

and fostering 147
JEANNE KANIUK
10 Attachment and social work 166

DAVID HOWE
Index 184
Contributors
Elaine Arnold taught social work students (MSW courses) at Goldsmiths College
and Sussex University, UK. She was Director of Training at Nafsiyat Inter-
cultural Therapy Centre, UK. She researched the adverse effects of separation
and loss and sometimes traumatic reunions among some families of African
Caribbean origin, due to immigration from the West Indies to Britain. She is
Director of the Separation Reunion Forum, the aim of which is to raise aware-
ness of the importance of secure early attachment in the life of the individual;
the phenomenon of broken attachments and traumatic reunions is also appli-
cable to children separated through various circumstances and to other groups
in society. Elaine currently lectures at various colleges and voluntary groups on
the Theory of Attachment, Separation and Loss and its applicability to practice
in the caring professions.
Marian J. Bakermans-Kranenburg is Professor at the Centre for Child and
Family Studies, Leiden University, the Netherlands. She is interested in par-
enting and parent–child relationships, with a special focus on neurobiological
processes and the interplay between genetic and environmental factors. Inter-
vention studies and adoption studies as (quasi-) experimental manipulations
of the environment have their natural place in this line of research. She was
awarded the Bowlby-Ainsworth award of the New York Attachment Consor-
tium (2005) and was VIDI (2004) and VICI (2009/2010) laureate of the Neth-
erlands Organization for Scienti¿c Research. She is a Fellow of The Royal
Netherlands Academy of Arts and Sciences and a Fellow of the Association for
Psychological Science, both since 2012.
Chip Chimera is a systemic family psychotherapist and a psychodrama psycho-
therapist. She is the director of the intermediate level of systemic training at
the Institute of Family Therapy. She is also a founder member of the London
Psychodrama Network. For many years Chip has been interested in the integra-
tion of attachment theory into clinical practice and into systemic training. As
course director of Child Focused Practice at IFT she teaches attachment across
the life cycle as an integral part of the training.
x Contributors
In clinical practice Chip has worked as an expert witness in private law high-
conÀict divorce cases and public law care proceedings, using an attachment-
based approach to family assessment and treatment in complex situations. Chip
has a thriving independent practice with individuals, families, couples and
groups. She also offers consultation and training to professionals. She is based
in London and Surrey and can be contacted at [email protected].
Steve Farn¿eld is a Senior Lecturer in Attachment Studies and convenor of the
MSc in Attachment Studies at the University of Roehampton, UK. He is a
social worker and play therapist with over 40 years’ experience in the ¿eld
of child and family welfare, and formerly taught on the Social Work and Post
Qualifying Child Care Programmes at the University of Reading, UK. Steve is
a licensed trainer for the Dynamic-Maturational Model of Attachment Infant
CARE-Index, Preschool Assessment of Attachment and Adult Attachment
Interview developed by Dr Patricia Crittenden. He has also developed a system
for analysing attachment and mentalising using narrative story stems with pre-
school and school-aged children.
Mary Ann Harris has been a member of the Law Society Children Panel for many
years. She came to Britain from the United States in 1969 and initially worked
as a paralegal and then graduated in Law in 1981. She obtained an LL.M (Can-
tab) in Public and International Law from Cambridge University, UK. She then
lectured in the Law Department at Trent Polytechnic, UK, before qualifying as
a solicitor. Since then she has practised in many small and medium sized law
¿rms in Lincolnshire, a City Council and latterly for a ¿rm in London special-
izing in family and children’s law where she became a partner and joint head
of the Family Department.
Her work ranged from probate work, advising on ecclesiastical law, civil
litigation, divorces, and in the last 20 years specialising in the law relating to
children, including adoption law, domestic violence and forced marriages.
She is now retired and lives on a livestock farm in Lincolnshire where she
and her husband breed British Shorthorn cattle.
Jeremy Holmes is a psychiatrist and psychoanalytic psychotherapist. For 35
years he worked as Consultant Psychiatrist and Psychotherapist in the NHS,
providing a district psychotherapy service in North Devon, focusing especially
on people with Borderline Personality Disorder. He was Chair of the Psycho-
therapy Faculty of the Royal College of Psychiatrists 1998–2002. Now par-
tially retired, he has a small private practice; set up and co-runs a Masters
and now Doctoral psychoanalytic psychotherapy training programme at Exeter
University, UK, where he is visiting Professor; and lectures nationally and
internationally. He has written more than 120 papers and book chapters in the
¿eld of Attachment Theory and Psychoanalysis, and 15 books including John
Bowlby and Attachment Theory (Routledge, 1992), and Oxford Textbook of
Psychotherapy (2005, co-edited with Glen Gabbard and Judy Beck). His lat-
est is Exploring in Security: Towards an Attachment-informed Psychoanalytic
Contributors xi
Psychotherapy (Routledge, 2010). He was recipient of the 2009 New York

Attachment Consortium Bowlby-Ainsworth Founders Award.
Paul Holmes is a Consultant Child and Adolescent Psychiatrist with extensive
clinical experience in community child mental health teams and in specialist
services working with looked-after and adopted children, their families and
their carers. In his private practice he undertook over 500 child psychiatry
assessments for the courts in children’s proceedings where he has used his
expertise in attachment theory to inform his work. He has trained both as a
psychoanalytic and psychodrama psychotherapist and is the author of the Inner
World Outside: Object Relations Theory and Psychodrama and the editor of
three other books on psychodrama.
David Howe is Emeritus Professor in the School of Social Work at the Univer-
sity of East Anglia, Norwich, UK. He has research and writing interests in
emotional development, empathy, developmental attachment theory, and child
abuse and neglect. His most recent books include Child Abuse and Neglect:
Attachment, development and intervention (Palgrave Macmillan, 2005), The
Emotionally Intelligent Social Worker (Palgrave Macmillan, 2008), A Brief
Introduction to Social Work Theory (Palgrave Macmillan, 2009), Attachment
Across the Lifecourse: A brief introduction (Palgrave Macmillan, 2011) and
Empathy: What it is and why it matters (Palgrave Macmillan, 2012).
Daniel Hughes, PhD, is a clinical psychologist with a limited practice near
Philadelphia, PA. He has specialised in the treatment of children who have
experienced abuse and neglect and demonstrate ongoing problems related to
attachment and trauma. This treatment occurs in a family setting and the treat-
ment model has expanded to become a general model of family treatment. He
is engaged throughout the US, Canada, Europe and Australia in conducting
seminars and providing extensive training toward certi¿cation of therapists
in his treatment model, as well as providing ongoing consultation to various
agencies and professionals. Daniel is the author of many books and articles.
These include Building the Bonds of Attachment (2nd ed.) (Jason Aronson,
2006), Attachment-Focused Parenting (W.W. Norton & Co., 2009), Attach-
ment-Focused Family Therapy Workbook (W.W. Norton & Co., 2011) and
Brain-Based Parenting (W.W. Norton & Co., 2012).
Marinus H. van IJzendoorn is a Professor of Child and Family studies at Leiden
University and a Research Professor of Human Development at Erasmus Uni-
versity Rotterdam in the Netherlands. His major research interests include
attachment across the life-span and in various contexts; gene-by-parenting inter-
ventions and differential susceptibility; neural and hormonal concomitants of
parenting and emotional development. He was awarded the Aristotle Prize of
the European Federation of Psychologists Associations (2011), the Bowlby-
Ainsworth Founder Award of the New York Attachment Consortium (2011), an
Honorary Doctorate of the University of Haifa, Israel (2008), the Distinguished
xii Contributors
International Contributions to Child Development award of the Society for

Research in Child Development (2007), and the Spinoza Prize awarded by the
Netherlands Organization for Scienti¿c Research (2004). He is a Fellow of the
Royal Netherlands Academy of Arts and Sciences (elected in 1998).
Femmie Juffer is Professor of Adoption Studies at the Centre for Child and
Family Centre, Leiden University, the Netherlands. She is interested in the
life-long consequences of adoption and foster care, children’s resilience and
recovery from adversity, sensitive parenting, and effects of attachment-based
early childhood interventions for families. Together with colleagues she is
involved in several longitudinal and meta-analytic studies of adopted children
and in studies testing the effectiveness of the attachment-based intervention
developed at Leiden University: the Video-feedback Intervention to promote
Positive Parenting (VIPP). For her efforts to translate science into practice she
was awarded the Piet Vroon Prize in 2004 and a royal decoration of Of¿cer in
the Order of Orange-Nassau in 2010.
Jeanne Kaniuk is Managing Director of Coram’s Adoption Services, based in
London, UK, which has developed since her appointment as Head of Service in
1980. She has a long-standing interest in the needs of children who cannot remain
in their birth families, and was involved in the longitudinal adoption attach-
ment research study undertaken by Great Ormond Street Hospital, the Anna
Freud Centre and Coram (Kaniuk et al. in Adoption and Fostering, 2004, 28.2,
pp. 61–67). She was also instrumental in developing Coram’s concurrent planning
project, which is now in its 15th year. In 2006 Jeanne set up Coram’s adoption
partnership with LB Harrow, the ¿rst such partnership between a local authority
and a voluntary adoption agency in the UK, aimed at ensuring improved adop-
tion outcomes for Harrow’s children. This partnership has now been replicated in
other local authorities including Cambridgeshire, Kent and LB Redbridge.
Graham Music is Consultant Child and Adolescent Psychotherapist at the Tavis-
tock and Portman Clinics and an adult psychotherapist in private practice. His
publications include Nurturing Natures, Attachment and Children’s Emo-
tional, Sociocultural and Brain Development (Psychology Press, 2011) and
Affect and Emotion (Icon Books, 2001). He has a particular interest in explor-
ing the interface between developmental ¿ndings and clinical work. Formerly
Associate Clinical Director in the Tavistock Child and Family Department, he
has worked therapeutically with maltreated children for over two decades, has
managed a range of services concerned with the aftermath of child maltreat-
ment and neglect and organised community-based therapy services, particu-
larly in schools and in GP practices alongside health visitors. He has recently
been working at the Portman clinic with forensic cases. He organises training
for therapists in the Child and Adolescent Mental Health Services (CAMHS),
leads on teaching on attachment, the brain and child development, and teaches
and supervises on the Tavistock Child Psychotherapy Training and other psy-
chotherapy training programmes in Britain and abroad.
Preface
This volume is a companion to The Routledge Handbook of Attachment: Theory

(Holmes & Farn¿eld 2014) and The Routledge Handbook of Attachment: Assess-
ment (Farn¿eld & Holmes 2014).
We have both had a long-standing professional interest in child welfare, child
protection and therapeutic services: Paul Holmes as a child psychiatrist and adult
psychotherapist, Steve Farn¿eld as a social worker, play therapist and university
lecturer. Like many professionals involved in these ¿elds, in recent years we have
become increasingly interested in using attachment theory and the associated evi-
dence-based assessments, presented in these books, to underpin our work as thera-
pists, supervisors and (for Paul Holmes) as an expert witness in children’s legal
proceedings. These three books were designed to cover the areas of expertise we
draw on in this work.
Attachment theory and assessments can be used to assist in making decisions
about the possible therapeutic and social interventions that might assist families
and children. These may be either based on attachment theory and assessments
(i.e. they are logical, evidence-based, developments arising from theory) or attach-
ment-informed, in which existing therapeutic modalities or social interventions
incorporate concepts and knowledge from attachment theory and research.
Attachment strategies, ¿rst developed in infancy to assist in gaining protection
from danger, may later in life no longer assist the individual in the way they once
did. Indeed, they can subsequently be counterproductive to the formation of close,
trusting and secure relationships. Change can occur, through therapy or through
other life experiences, but this is a complex process which can take time.
The authors in this book consider therapeutic, social and legal steps that can
assist in this journey, from individual psychotherapy to, for a child, a change of
carer through fostering or adoption. However, the reorganisation of strategies
towards security or balance can be actually hard, particularly when a child or adult
has been traumatised by abuse or loss. In such cases professionals have to decide if
the problems are better worked through or worked around (Moran et al. 2008).
That said, all the chapters in this book consider interventions that offer the pos-
sibility of growth and change.
xiv Preface
References
Farnfield, S. & Holmes, P. (eds) (2014) The Routledge Handbook of Attachment: Assess-
ment, London and New York: Routledge.
Holmes, P. & Farnfield, S. (eds) (2014) The Routledge Handbook of Attachment: Theory,
London and New York: Routledge.
Moran, G., Bailey, H. N., Gleason, K., DeOliveira, C. A. & Pederson, D. R. (2008) ‘Explor-
ing the mind behind unresolved attachment: Lessons from and of attachment-based inter-
ventions with infants and their traumatized mothers’, in H. Steele & M. Steele (eds),
Clinical Applications of the Adult Attachment Interview (pp. 371–398), New York: The
Guilford Press.
Chapter 1
Introduction
Steve Farnfield and Paul Holmes
A great deal of work needs doing before we can be confident which disorders
of attachment and care-giving behaviour are treatable by psychotherapy and
which not and, if treatable, which of various methods is to be preferred.
(Bowlby 1979/2005: 171)
John Bowlby, the founding father of attachment theory and research, trained both
as a psychiatrist and as a psychoanalyst. His early seminal book Child Care and
the Growth of Love (1953) grew out of a report he wrote for the World Health
Organization commissioned to study the needs of ‘children who are orphaned
or separated from their families for other reasons and need care in foster homes,
institutions or other types of group care’ (Bowlby 1953: 7).
Bowlby’s interest in developing a research-based understanding of the con-
sequences of childhood trauma, loss and separation was always linked to con-
sideration of effective and logical therapeutic interventions. He struggled with
his own personal psychoanalytic heritage and always intended his contribution as
‘an up-to-date version of psychoanalytic object relations theory, compatible with
contemporary ethology and evolution theory, supported by research, and helpful
to clinicians in understanding and treating child and adult patients’ (Ainsworth &
Bowlby 1991: 9).
Clinical applications of his theory were slow to materialise and more has been
achieved since his death, at the age of 83 in 1990, than during his lifetime. It is
impossible to provide a comprehensive over view in a book of this length on all
the implications and treatments associated with issues of attachment. However,
the authors contributing to this volume open windows onto the wide range of
therapies and interventions which use attachment theory and/or research to inform
their practice.
Attachment theory
This book does not aim to provide a detailed account of attachment theory but a
brief summary may be useful.
2 Steve Farnfield and Paul Holmes
Attachment is ¿rst and foremost a relational theory. It has given us a way of

describing what we do when we are anxious and how we use past experience to
make predictions about what is most likely to keep us safe in the future. Bowlby
described this information as being stored as Internal Working Models (Bowlby
1973/1985; Bretherton 2005) whereas Crittenden uses the term Dispositional Rep-
resentations (Crittenden & Landini 2011). These memories of attachment-based
experiences are not things we have in our heads so much as the sum of expecta-
tions of future situations, especially those involving danger, developed in interac-
tion with attachment ¿gures in the past.
The consequences of this process for an individual infant were neatly cap-
tured by Mary Ainsworth and her work on the Strange Situation procedure
(SSP) (Ainsworth et al. 1978) which explored an infant’s responses to a brief
separation from their mother. Ainsworth’s analysis of these observations pro-
vided the ABC notation on which much of the subsequent empirical work has
been based.
• Type A Carers of infants in Type A are predictably rejecting of ‘unneces-

sary’ signals of attachment from their child and tend to be protective but not
comforting. Consequently the infant inhibits the display of anxiety; tries to
¿t in with the expectations of the outside world; takes responsibility for what
happens; and ¿nds intimacy in close relationships makes her defensive. Type
A uses cognition as a source of information, i.e. there is a reliance on cause
and effect at the expense of arousing feelings such as anger or desire for a
cuddle.
• Type B Carers of infants in Type B are predictably protective and comfort-
ing and attuned to their child’s needs. The infant comes to learn that the ex-
pression of arousing negative feelings can lead to resolution of problems after
which attachment-seeking behaviour can be terminated and he can go back to
exploration. Children and adults in Type B develop a high level of emotional
literacy.
• Type C Carers of infants in Type C are inconsistently available to meet
their infant’s needs and may reinforce behaviour in the infant that they say
they do not want, for example smiling approvingly when telling the child off
for doing something ‘wrong’. Life in Type C is never clear: the child’s feel-
ings and own perspective are a better guide to how he should proceed than
the perspective of other people. He uses affective logic to solve relationship
problems and force others to feel what he feels; ¿nding the right distance in
close relationships is a problem.
One starting point – two theories of attachment

Not all infants and children assessed in the early SSP samples ¿tted into one of
these three types. Scrutiny of anomalous examples led to a divergence of theory
by two of Ainsworth’s students, Mary Main and Patricia Crittenden. Main and
Introduction 3
her colleagues developed a fourth category, disorganised-disorientated (Main &

Solomon 1986), setting in motion the development of the ABC + D model of
attachment. Crittenden interpreted the same data in a different way: as alternating
A and C strategies and then early signs of more complex A and C strategies which
she was later to describe in the Dynamic-Maturational Model (DMM) of attach-
ment (Crittenden 1985, 1995), which integrates all types of strategic attachment
behaviour under the three broad headings of A, B or C.
Other related theories

Neither the ABC + D or DMM model offers a phenomenology of attachment.
Yet it is the feeling of being insecurely attached, and how this affects other peo-
ple, which may bring people to therapy and interest professionals when trying to
understand individuals or families.
Object Relations Theory (ORT) provides one way of trying to give subjec-
tive meaning to the internal processes that underpin Bowlby’s ‘inner working
model’ of the world or, to use different language, Crittenden’s ‘dispositional rep-
resentations’. Concepts such as splitting or projective identi¿cation are useful in
explaining not just the internal defences employed in the Type A and C strategies
but also their effect on other people. ORT can Àesh out the meaning attachment
strategies have for speci¿c individuals and the impact on their relationships. It
is thus of considerable clinical use in attachment-informed treatments with both
adults and children (Holmes 1992; Steele & Steele 2008a; Steele et al. 2007;
Fonagy 2001).
The work of Peter Fonagy and colleagues has added the theory of mentalisation
to the classical theories of psychoanalysis and has shifted attention from the clas-
si¿cation of strategies to how people process information. Mentalising refers to
the peculiar human ability to take an intentional stance with regard to our own and
others’ behaviour; our ability to read the minds of other people and think about
our own thought processes. This can happen at a conscious or non-conscious level
and high-level mentalising is associated with secure attachment; the parent–child
relationship is a meeting of minds in which mentalising/secure attachment in the
parent is transmitted to the child (Fonagy et al. 2004; Allen et al. 2008).
What are ‘attachment-based’ interventions?

Writing on clinical work with adults, Obegi and Berant (2009) make the useful dis-
tinction between attachment-informed and attachment-based psychotherapy. The
former refers to the use of attachment theory and research to aid with assessment,
formulation and aspects of treatment but with a reliance on established therapeu-
tic modalities in terms of approach and technique. The latter attachment-based
therapies make explicit use of attachment theory as a conceptual and operational
framework for intervention and use validated assessment procedures to establish
whether changes in attachment behaviour or representations of behaviour have
occurred following a particular treatment. At a minimum this requires pre/post

research designs and at best randomised controlled clinical trials.
The ¿rst reaction to reading the above might be that we should be striving for
attachment-based interventions that meet the demand for evidenced-based prac-
tice. Certainly if increasing attachment security in our clients is the primary aim of
our treatment then we should be able to give an account of our success. However,
the progress in establishing formally attachment-based interventions is patchy at
best. This is partly due to both the dif¿culty and the cost of mounting studies of
effectiveness. But, a more central reason is that, as Music observes in Chapter 2,
attachment theory and research cannot provide a whole theory about therapeutic
work.
Do we need specific attachment-based treatments?

The chapters in this book are a testament to the likely balance between attach-
ment-informed and attachment-based interventions in present clinical practice. In
our opinion only one chapter (Juffer and colleagues in Chapter 5) describes a for-
mal attachment-based intervention, while all the others are attachment-informed.
In the other chapters the authors have used their training as therapists and their
professional experiences to integrate the concepts of attachment into their work
using their clinical judgement and creativity rather than following ‘evidence-
based’ procedures. However, we would hope that therapeutic interventions that
are ‘felt to work’ will result in the establishment of proper evidence-based outcome
studies.
A prominent view, and one that we share, has been that attachment theory
should be used to inform the use of existing interventions rather than create new
ones (see Slade 1999: 577). The authors in this book discuss a number of therapeu-
tic and social interventions informed by attachment studies in this way.
‘Holding therapy’
Even a cursory search of the internet reveals all manner of ‘attachment therapies’
and cures for ‘attachment disorders’ together with other sites devoted to people
complaining that they have suffered at the hands of intrusive and abusive thera-
pists. These sites are reminders of an issue that came to a head in professional
circles around 2005 regarding ‘therapy’ which included enforced holding and eye
contact to recon¿gure the social brain of traumatised children. This produced an
outcry in professional circles (e.g. BAAF 2006; Chaf¿n et al. 2006; Prior & Glaser
2006). Our impression is that in this country the use of overt holding and other
forms of enforced ‘therapy’ has now abated or indeed ceased.
‘Holding’ was certainly the antithesis of a ‘secure base’ and it also reminds us
that psycho-social therapies are not neutral; if they can bene¿t people then they
can also do damage. Doctors and therapists can do harm (Fonagy & Bateman
2006: 1–2).
Introduction 5
Wheels within wheels: systems within systems

This book considers interventions from a wide perspective, moving from one-to-
one individual psychotherapy through family therapy and parent training to the
input of social workers and the interventions of society through legal activity.
Attachment can be conceptualised as an intra-personal, inter-personal and a
social psychological theory which considers different spheres of existence or sys-
tems that all have an interlinked and hierarchical relationship to each other.
System
Genetic That which is inherited but which is open to change after

birth through the epigenetic process.
Biological The nervous, neurobiological, system which grows and adapts
over time from infancy consequent upon life experiences.
Intra-personal The individual’s psychology.
Inter-personal The dynamics of families and close relationships with other
people.
Cultural The dynamics between people in the local community and
national and international relationships.
(adapted from Holmes 1989: 244 and Holmes 1992: 20)
To take a very brief, simple, example:
Inter-personal system The difficulties caused by a distressed and angry act-

ing-out teenager will impact on those closest to him
in a way that might be assisted by family therapy.
Intra-personal system But the stresses in the home might make both the boy
and his mother depressed and have an impact on the
family. Individual psychotherapy or even antidepres-
sant medication might help.
Social system Likewise a change in any one system (say the family)
may impact on the boy’s peers and teachers at school.
Should this lad’s behaviour cross certain social and
cultural boundaries he may become involved with
social services and even the police and the criminal
justice system.
Family systems theory describes how a change in any person in the family will
impact on all the constituent parts of that system (Marvin 2003). This process will
also result in changes in the other systems in the hierarchy. If the family therapy is
successful the boy’s mother might become less depressed (which some would see
as a change in her nervous/biological system). Further pressure could be taken off
the school and social services systems and, indeed, the police.
It must be stressed, however, that there are always reciprocal interactions

between these systems. It is not a case of just blaming this boy or indeed anyone
else. He might be reacting to a depressed mother, marital discord, or dysfunction
in the classroom consequent upon the skills of teachers who are incompetent or
who are overly stressed by changes in the government’s education policy.
Further, our teenager may deploy an insecure (Type C) attachment strategy
developed in infancy, with a tendency to externalise his feelings (‘act out’) with
the result that he exasperates his teachers and other adults caring for him. Likewise
his behaviour in the wider community will reÀect a dynamic interaction between
him, his personality and the culture of his peers, and other social pressures and
inÀuences.
It can be argued that logical, and maybe even effective, interventions could be
provided to every level in this hierarchy, each in its own way designed to tackle
dysfunction in that system but also, as a consequence, having an impact in the
other systems.
Systemic interventions
Genes and biology

The authors in this book only consider interventions in the last three of these inter-
locking systems. However, in recent years there have been signi¿cant advances
in knowledge of the importance of genetics, epigenetics and neurobiology and
development of the attachment process (see Fonagy and colleagues and Music in
Holmes & Farn¿eld 2014).
Intra-personal systems
Graham Music in Chapter 2 discusses in detail one-to-one psychotherapeutic work
with very distressed and disturbed (as well as disturbing to others) children and
teenagers. His emphasis is on work with the child alone in the context of his thera-
peutic relationship with her. That is not to say no assistance will have been given
to her parents and carers, either through supportive sessions or perhaps personal
therapy with other professionals and colleagues. In these intense sessions Music
is working with children and teenagers perhaps too disturbed to function in family
therapy sessions. However, as Music describes, his work has a positive impact on
the families in which these children live.
Jeremy Holmes in Chapter 3 also considers therapeutic interventions in the
intra-psychic or individual attachment system of adults, in the context of their
roles as parents. However, he clearly acknowledges the interaction with the dyadic
system of parent and child and the parent’s position from their perspective of
caring for a dif¿cult child.
Holmes also discusses the consequences for a child who is being parented
by an adult with their own marked emotional and psychiatric dif¿culties con-
Introduction 7
sequent upon their own attachment insecurity, and who might have been diag-
nosed as suffering from a borderline personality disorder (BPD). He considers the
impact of the adult’s Àuctuating emotional state on their child’s development
and the possibility of indirectly assisting the child through psychotherapeutic
work with her parent(s) (see also Fonagy and colleagues in Holmes & Farn¿eld
2014).
Holmes also touches on mentalisation-based therapy (MBT), a development of
classical psychoanalysis by Peter Fonagy and his colleagues, which has a close
association with attachment theory. MBT was initially developed to treat adults
diagnosed as having a borderline personality disorder, although its use has now
been widened to many other populations. It has, unlike many schools of psycho-
therapy, a signi¿cant evidence basis for its ef¿cacy (Bateman & Fonagy 2004;
Allen & Fonagy 2006; Allen 2013).
Individual psychotherapy with parents can thus be seen as an indirect way
of assisting, or at least trying to protect, the emotional development of their
children.
Inter-personal systems
The authors of Chapters 2 and 3 acknowledge that their patients exist in wider
family and social systems, albeit their focus is on the individual. There are, how-
ever, numerous well-known and well-documented attachment-informed interven-
tions speci¿cally developed to work in multi-person contexts.
Chimera in Chapter 4 considers systemic family therapy, looking both at how
family therapists might use attachment theory to inform their work and giving
case examples of how an understanding of attachment theory and the assessment
of attachment strategies used by individuals in the family can be used to inform the
treatment. The assessment of attachment in individuals and families is the subject
of Dallos in Farn¿eld and Holmes (2014).
Juffer and her colleagues in Chapter 5 discuss a formal attachment-based treat-
ment Video-feedback Intervention to promote Positive Parenting (VIPP) which
aims to improve both the quality of caregiving (parenting) and the security of
children’s attachment (see also Appendix 1.1). There is a growing body of evi-
dence for the effectiveness of this type of intervention and a summary of some of
the others is given in the appendix.
Hughes in Chapter 6 discusses the complexity of therapeutic work with chil-
dren and teens suffering from attachment trauma and introduces his attachment-
informed Dyadic Developmental Psychotherapy (DDP). DDP includes a basic
therapeutic stance that is characterised by playfulness, acceptance, curiosity and
empathy (PACE) together with close involvement of the child’s parent or carer.
As Hughes indicates this is a population known to be hard to successfully engage
in therapy, resembling those young people Music discusses in Chapter 2 in the
context of individual psychotherapy.
Social and cultural systems

The subsequent chapters in this book consider how attachment theory can inform
interventions in the wider social systems.
Arnold in Chapter 7 highlights the importance of cultural and personal history
on the formation of an individual’s personality and emotional state and considers,
through case examples, the impact of culture, loss and trauma on those who have
moved to new countries to live. Attachment is strongly inÀuenced by culture and
context and Arnold highlights the need to allow clients time and space to tell their
story, and the importance of culture and ethnicity in therapy with recent migrants
and refugees.
Harris, as a lawyer, considers in Chapter 8 the importance of attachment theory
and assessments to the legal process necessary to remove children, an intervention
of last resort, from their birth families. She points to the importance of appropriate
skills and supervision together with transparency about the process if attachment
is to be assessed by social workers prior to the initiation of court proceedings.
Proper attachment-based assessments should assist in establishing the needs of
families and allow the professionals involved with them to form a view about
which interventions are most likely to help the family.
Kaniuk, in Chapter 9, describes how society responds when attempts to address
issues in the intra- and inter-personal systems are deemed to have failed to pro-
tect the child’s safety or development. In these circumstances society (through its
‘agents’ local authorities and social workers) may have instigated processes to
remove a child from their birth family with the aim of providing better care in a
foster family or through adoption.
Finally Howe, in Chapter 10, discusses the uses and abuses of attachment
theory in the context of social work practice and argues that the strength of the
social work profession lies in knowing clients over time. In spite of the increasing
bureaucratic nature of local authority social work, attachment thinking empha-
sises that it is essentially a relationship-based activity which is applicable across
the life span. Howe’s chapter draws together themes, such as mentalising, which
run through those by the other contributors.
The assessment of attachment: an overview

The assessment of attachment is the subject of a companion book to this volume
(Farn¿eld & Holmes 2014).
Formal assessments of attachment can provide very useful information that can
be used in planning interventions designed to assist families and their children,
examples of which form the subject of this book.
These insights can also be used in considering the level of risk parents might
pose to their children’s emotional development. At this stage, when other inter-
ventions have been tried, the level of professional concern might have reached
the point where legal proceedings have been instigated to protect the child. For
Introduction 9
discussions of how to use assessments of attachment in forensic settings see Main

et al. (2011) or Crittenden et al. (2013).
A range of validated procedures is now available for all developmental stages
and they fall broadly into two groups: observation and representational measures.
An important question that a formal assessment might assist in answering is, ‘What
can attachment theory and assessment tell us that will be useful in choosing and
designing treatment?’ The main procedures will now be given a brief introduction
with this question in mind.
Observation
For children under 3 years the only way of assessing their attachment to a particular
parent or carer is by observation. For this it is necessary to induce just enough stress
for attachment-seeking behaviour to be activated, which is why the Strange Situa-
tion procedure (SSP) is so effective. The basic procedure can be used with children
aged 10 months to around 4 or 5 years of age although the level of stress reduces
signi¿cantly for many children after 4 years. An alternative is the Attachment-Q
set which involves the observer (parent or professional) rating aspects of the child’s
behaviour according to statements on a series of cards (Waters et al. 1995). The
SSP is the gold standard with regard to a child’s attachment to a speci¿c person but
gives weak information regarding the caregiving behaviour of the parent.
Parental behaviour is better assessed using a play-based procedure such as the
CARE-Index (Crittenden 1979–2005, 2005) or indeed using knowledge from
such a procedure and observing (ideally with a video-record to assist analysis and
client feedback) the parent(s) and child(ren) in naturally occurring settings for at
least an hour.
Representational measures
From about 3 years of age children can tell stories about attachment-related events
using a few simple props and the help of an attentive adult. Narrative story stems are
typically used up until age 7 or 8 but have been tried with children as old as 12. By
the age of 6 or 7 years formal interviews with children are possible. For example,
the Child Attachment Interview (Shmueli-Goetz et al. 2008) and Can You Tell Me?
(Farn¿eld in press), both developed from a milestone in attachment research, the
Adult Attachment Interview (AAI) (George et al. 1985; Main & Goldwyn 1984).
Representational measures move assessment from behaviour to how people
think about their behaviour. Whereas the information from the SSP is somewhat
limited (the child’s strategy shorn of much of the context), procedures like story
stems and the AAI open a window onto the internal world of attachment, trauma
and loss and are extremely valuable in calibrating interventions which are person-
speci¿c (Steele & Steele 2008a; Steele et al. 2007; Crittenden & Landini 2011).
The other very useful extension to representational assessments are interviews
about caregiving; speci¿cally the adult’s perceptions of themselves, their child, and
their relationship (Slade 2005, 2007; Zeanah et al. 1994; Grey 2010). Added to
observations of the parent’s behaviour with their child these interviews tell us a lot
about why people do what they do. Taken together, in terms of a comprehensive
assessment of parenting, we have crucial information on different aspects of attach-
ment and caregiving which can be tested against each other to aid in formulating a
workable intervention plan (Kozlowska et al. 2012a, 2012b, 2013; Farn¿eld 2008).
The selection of treatment

Attachment research orientates practitioners towards formulation rather than diag-
nosis and prescription; that is, a bridge from assessment to intervention which
makes sense of how the presenting problems can be understood in the context
of the person or family’s history, what needs to be changed and how this will be
achieved (Zeanah 2007; Crittenden & Landini 2011). Of particular importance is
the function of attachment in self-protection. Hence a key question for any planned
intervention is what will help the person, couple, family, wider group or society
feel safer than they do at present?
The question of how attachment strategies can inform the direction and/or
choice of treatment is complex and imperfectly understood (Slade 2008). Even
though the majority of psychotherapy clients are insecurely attached (Dozier et al.
2008) insecure attachment is not an illness (after all, 40–50% of the non-clinical
population are found to be ‘insecure’ on assessment) and correspondence between
particular disorders and attachment strategy are, in the main, dif¿cult to uncover
(Van IJzendoorn & Bakermans-Kranenberg 2008).
Crittenden has argued that treatments should be selected according to the cli-
ent’s attachment strategies. For example, adults or children in Type A learned as a
child to inhibit the expression of feelings they experienced as being forbidden by
adults, in particular anger and the desire for comfort (having had the experience as
infants that openly expressed emotions do not bring them closer to those who care
for them). For them, interventions that encourage them to express these feelings
in a safe environment and, for school-age children, to generate information from
their own perspective not that of other people, may be bene¿cial. Conversely,
treatments such as cognitive behaviour therapy (CBT) may actually reinforce the
use of maladaptive cognition-based attachment strategies (Crittenden, personal
communication).
For adults or children in Type C the opposite may be the case. As children they
learned that freely expressed emotion will, eventually, bring them closer to their
‘secure base’ as their need for comfort is at last recognised. However, such behav-
iour might not always make them easy to live with or, indeed, to teach (Geddes
2006; Bomber 2007, 2011). Such individuals should be encouraged to regulate
their display of anger or desire for comfort and focus on the perspective of others
(Crittenden et al. 2001; Crittenden 1992).
At risk of over-simpli¿cation this would indicate cognitive-behavioural thera-
pies would be bene¿cial for those in Type C but counter indicated for children in
Introduction 11
Type A who might do better with expressive, creative arts-based approaches such
as play therapy or psychodrama. This is broadly in line with observations by Dan-
iel (2006, 2009) on the implications of narrative coherence for therapy.
Two major reviews of adult attachment and psychopathology found some quali-
¿ed support for the hypothesis that internalising disorders, for example borderline
personality disorder (see Bateman & Fonagy 2004) are linked with preoccupied
states of mind and externalising disorders (for example, anti social personality
disorder) with dismissive states of mind on the AAI (Van IJzendoorn & Bakermans-
Kranenberg 2008; Dozier et al. 2008). However, rather than looking for correspon-
dence between the two dimensions (as in an attempt to construct a marrying of
attachment behaviour with the American Psychiatric Association Diagnostic and
Statistical Manuel 5 (DSM 5) (2013)) it might be more useful to see them in terms
of four categories with which ‘to describe the complex reality of clinical patients
with comorbid features’ (Van IJzendoorn & Bakermans-Kranenberg 2008: 89).
On the other hand, the hypothesised relation between internalising-preoccupied
and externalising-dismissing has been challenged by Crittenden and Landini
(2011) who note that Crittenden and Ainsworth (1989) had proposed the opposite
relationship.
Treatment by memory systems

A signi¿cant part of the work on the AAI has been the analysis of the speaker’s
state of mind regarding their childhood attachment in terms of ‘memory systems’.
These refer to a variety of ways in which information from past experience, in
respect of attachment-based experiences, is processed regarding safety, danger
and sexual opportunity in the present.
Memory can either be implicit and unconscious or explicit and thus available
for conscious reÀection. It can also be cognitive or affective.
The Main and Goldwyn AAI focuses on three memory systems – semantic,
episodic and working memory – and the DMM-AAI adds three more: procedural,
imaged and connotative language. People in Type B secure have fuller access
to all systems and are able to integrate them into current thinking and behaviour
whereas people in Types A and C omit or distort information in various ways (see
Farn¿eld & Stokowy 2014).
To extend the simple example above, cognitive-based techniques which affect
semantic and episodic memory are likely to show little ef¿cacy with people in
Type A but will help those in Type C. Family sculpting might bene¿t children in
Type A, because it draws attention to their affective state, but be of limited value
with children in Type C for whom explicit verbal semantic memory needs atten-
tion over nonverbal forms of communication (see Crittenden et al. 2001: Table
18.1; for a detailed example from a DMM-AAI see Crittenden & Landini 2011:
Chapter 14). To put it another way, people may bene¿t from therapeutic assistance
to access and use attachment-relevant information that is not part of their habitual
repertoire. Such a process should allow them access to both Type A and Type C
strategies, and as a consequence they move (integrate and reorganise) towards the
balanced Type B. We would stress that such a shift may be ‘earned’ by other life
events such as a powerful and rewarding close relationship.
Attachment-based interventions – what is the

evidence?
This section offers a brief overview of some of the interventions that are attach-
ment-based; i.e. they can provide empirical evidence regarding their effectiveness
in changing attachment or caregiving behaviour or representations of the same.
The focus is on interventions based on the validated assessments of attachment
and caregiving (covered in Farn¿eld & Holmes 2014) and excludes self-report
measures and also interventions designed to treat Reactive Attachment Disorder
(RAD) in children.
Individual therapy for children

Based on the premise that attachment strategies function to protect the self,
attempting to change a child’s strategy without removing or modifying the danger
seems counterproductive or could even be dangerous. Parents and other caregiv-
ers should ideally be involved in the intervention. If the caregiving environment
can be modi¿ed, attention can then be given to helping the child adapt her strategy
to the new conditions (Crittenden et al. 2001). Mentalisation-based child therapy
‘can succeed only if important adults can be involved’ (Verheugt-Pleiter 2008:
48) and the general effectiveness of play therapy may be increased when it also
involves parents (Bratton et al. 2005).
This is doubly relevant in the light of research indicating that parents of children
with clinical problems are, themselves, likely to be troubled people whose AAIs
are signi¿cantly more likely to be rated insecure and unresolved compared with
the non-clinical population (Van IJzendoorn & Bakermans-Kranenberg 2008;
Crittenden & Landini 2009, reported in Crittenden & Landini 2011)
However, not all parents or carers are amenable to joining in the treatment pro-
cess with their child and some young people become too anxious and disturbed
in family therapy sessions. In such situations individual treatment might be a
good, or the only, alternative. While individual child therapies are effective for a
broad range of presenting problems (Weisz & Kazdin 2010), this enquiry made
no advances on previous reviews which found no systematic evaluations, using
validated measures, of the impact of direct interventions on children’s attachment
(Weisz & Kazdin 2010; Carr 2009; Becker-Weidman 2006; Prior & Glaser 2006;
Tarren-Sweeney 2013; Benedict & Scho¿eld 2010; Zilberstein 2013). Rather than
increasing attachment security the appropriate aim of individual child therapy
might be to improve mentalising (Verheugt-Pleiter et al. 2008).
Given the disruption to the functioning of attachment strategies attributed
to unresolved trauma (Allen et al. 2008) an important role for child therapies
Introduction 13
might be treating post-traumatic stress disorder (PTSD) in children. A variety of

treatments are available with a strong cognitive-behavioural basis. For example,
trauma-focused CBT has been the subject of seven randomised control trials
(Cohen et al. 2010). Where possible it employs a joint child–parent approach and
is reported to be the most researched and best validated in terms of evidenced-
based practice for treatment of child PTSD (Kliethermes et al. 2013; Cohen 2005;
Scheeringa et al. 2011; Deblinger et al. 2012); see also Parent–Child Interaction
Therapy which provides parents with behaviour modi¿cation skills (Urquisa &
Timmer 2013).
One approach that clearly includes attachment and trauma in its remit is Eye
Movement Desensitisation and Reprocessing therapy (EMDR). Reports regarding
a reduction in trauma symptoms in children using EMDR in individual and group
settings are positive (Marcus et al. 1997; Lee et al. 2002; Wesselmann 2012). See
Allen (2013) for a review of EMDR with adults.
Individual therapy for adults

While there are a number of treatments called ‘attachment therapies’ for children
this has not been the case with therapies for adults. On the whole, adult therapists
have adapted aspects of their technique without radically changing their therapeu-
tic orientation or devising new therapies (Obegi & Berant 2009).
Although therapy can improve attachment security in clients, choosing the right
therapy for the right psycho-social problems requires more investigation (see
Berant & Obegi 2009 for a review; also Jacobvitz 2008; Levy et al. 2006) and,
as with parent–child interventions (below), it appears unrealistic to expect that
people with complex problems will quickly reorganise into a secure attachment
status. Put another way, while attachment informs many therapeutic modalities,
treating attachment per se may be unrealistic and in some cases undesirable (Fon-
agy & Bateman 2006) as the intensity of the therapeutic relationship might, in
itself, cause the patient excessive distress and instability.
Among the studies looking at treatment and outcome in terms of attachment
security are the following: Fonagy et al. 1996; Levy et al. 2006; Strauss et al.
2011; Tasca et al. 2007; see also Daniel 2006 for an excellent review.
Mentalisation- based treatments (MBT)

Rather than a new therapeutic modality Allen, Fonagy and Bateman propose MBT
is ‘the least novel therapeutic approach imaginable, simply because it revolves
around a fundamental human capacity – indeed, the capacity that makes us
human’ (2008: 6, their italics). Their approach to mentalising as good therapeutic
technique is laid out in Allen et al. (2008: Table 6.1).
Mentalising is not to be equated with security of attachment even if the two are
associated. Secure attachment enables high order mentalising whereas insecure
attachment and, critically attachment trauma (typically abuse by an attachment
¿gure in childhood) distorts the capacity to mentalise. Attachment is about rela-

tionships and self-protective strategies, whereas mentalising refers to informa-
tion processing and the capacity to be aware of the mental processes of another
person. An improvement in the capacity to mentalise should improve affect
regulation and inter-personal relationships but Fonagy and colleagues note the
mentalising of some people in therapy is actually destabilised by a too intense
attachment relationship with the therapist (Fonagy & Bateman 2006; Luyten &
Fonagy 2014).
Family systems
Coan (2008) notes the paucity of systemic compared with individualised interven-
tions to help people manage affect regulation and that the systemic approaches
may be both more ef¿cient and cost effective.
An attachment-based family therapy (ABFT) has been developed by Diamond
and colleagues (2002, 2010) who found a decrease in attachment-related anxiety
(measured on a self-report scale) in a small group of adolescents (Diamond et al.
2012). Mentalisation-based family therapy is also used with families, children and
adolescents or adults in groups (SMART; Fearon et al. 2006).
Parent–child interventions
Consistent with the emphasis on the importance of children developing secure
attachments from the start of their life, parent–child interventions dominate the
¿eld of attachment-based interventions. Evaluation studies have generated an
ongoing debate with regard to whether services should aim to change parental sen-
sitivity (what parents do) or parents’ perceptions of the relationship they have with
their child (representation) or both. There is also a debate as to whether shorter
interventions are more effective than longer ones – ‘less is more’.
The means by which attachment is ‘transmitted’ from parent to child is imper-
fectly understood. In particular, parental sensitivity (what parents do in response
to their children’s behavioural signals) appears to play a relatively small part (de
Wolff & Van IJzendoorn 1997) whereas a more potent mediator may be reÀective
functioning (how and what parents think when their child is anxious or distressed)
(Slade 2005) which, in turn, is reÀected in their behaviour.
With regard to child maltreatment, abusing parents were frequently abused
when children themselves and are invariably (in AAI terms) unresolved regard-
ing early losses and traumas. Bad things in childhood tend to come back and
haunt parents when confronted with stressful situations involving their own
children. This was highlighted many years ago by Fraiberg and colleagues’
(1975) classic work on ‘ghosts in the nursery’, and is nicely captured in the
phrase ‘shark music’ used by the Circle of Security programme (Appendix 1.1).
Like a seaside scene in a movie, walking with one’s child can feel relaxed and
sunny but play the shark music (the ghosts of abuse and abandonment from the
Introduction 15
parent’s past) and the scene instantly changes to one of fear and dread (Zanetti
et al. 2011).
A growing number of attachment-based interventions focus on taming the
ghosts and sharks in parents’ minds by using parent–child psychotherapy, while
others focus on improving parent/maternal sensitivity. Current evidence strongly
supports the inclusion of video feedback involving the parent and child doing
something together, rather than parent education using ¿lms that feature strang-
ers (Berlin et al. 2008; Zeanah et al. 2011; Zilberstein 2013). Meta-analyses
indicate interventions promoting parent sensitivity do better than those aimed at
representation (mental models of caregiving) in increasing attachment security
in children, and parent sensitivity is easier to change than child attachment (see
Chapter 5).
A summary of some of the attachment-based parent–child interventions is
given in Appendix 1.1. The inclusion criteria meant that some established inter-
ventions which are well validated in domains other than attachment were omit-
ted on the grounds that they do not appear to have published empirical evidence
for changes in attachment security and/or parent sensitivity/representation using
validated procedures. For example, Theraplay (Jernberg & Booth 1999). The
effectiveness of Video Interactive Guidance (VIG; Kennedy et al. 2010, 2011)
in improving parent sensitivity has been supported by small studies in the UK
and Holland (Robertson & Kennedy 2009; Velderman et al. 2013) with larger
studies in preparation (Kennedy, personal communication). Another widely used
intervention is the Incredible Years parent training programme (Webster-Stratton
1984) which is based on social learning theory and does not target child attach-
ment per se. A recent study showed that Incredible Years with antisocial chil-
dren aged 4–6 years did have a signi¿cant and positive impact on parent focused
behaviour (sensitivity) but not on dyadic behaviour (mutuality), nor on security
of child attachment as assessed by the MCAST codings for narrative story stems
(O’Connor et al. 2013).
Adoption and fostering

The most drastic intervention is the removal of a child from her parents into per-
manent substitute care. Not surprisingly Lindhiem and Dozier found that foster
parent commitment to the child was a strong inÀuence on placement stability.
They also found the number of children a foster carer had previously cared for was
negatively correlated with commitment to the current child, and that the younger
the child at the start of fostering the more committed were the carers (Lindhiem
& Dozier 2007).
The attachment strategy of foster and adoptive parents can be assessed using the
AAI and current attachment relationships by using the Attachment Style Interview
(ASI) (Bifulco et al. 2008). Dozier and colleagues, using the Main and Goldwyn
AAI, found a signi¿cant correlation between autonomous (secure) foster moth-
ers and foster children assessed as secure on the SSP, whereas non-autonomous
foster parents had a disproportionate number of children rated disorganised (Doz-

ier et al. 2001). Hodges and colleagues’ longitudinal study of adopted children
and their parents showed all the children made progress in terms of increasing
positive representations of attachment themes using the narrative story stem pro-
cedure, but those whose adoptive parents were secure on the AAI also showed a
decline in negative themes, suggesting resolution of trauma (Steele et al. 2003;
see also a study by Beijersbergen et al. 2012). These results indicated that children
bene¿tted from being placed with alternative carers who were found to be secure
on an AAI assessment.
Using the AAI, different studies have come up with different estimates regard-
ing the distribution of attachment patterns in relatively small samples of foster and
adoptive parents. For example, Dozier and colleagues found attachment among
foster carers did not differ from non-clinical populations (Dozier et al. 2001).
However, the Coram-Anna Freud study (Steele et al. 2008; see also Kaniuk in
Chapter 9 of this volume) found more of the interviews of adoptive mothers were
rated secure than expected, but the opposite was true for adoptive fathers.
A study using the DMM-AAI of prospective adoptive parents found only 7 per
cent AAIs were rated balanced-secure and that mothers who already had a child
of their own were signi¿cantly more likely to be in the range secure/normatively
insecure (most often in Type A2 in the DMM) whereas for fathers who already
had a child the opposite was the case (Farn¿eld 2012).
One conclusion to be drawn is that when it comes to predicting outcomes for
children placed for fostering or adoption, the attachment security of their future
carers matters. Another is that not all substitute parents will be secure regarding
attachment, and assessments of attachment (AAI or ASI) will deepen our under-
standing regarding how previous experience inÀuences their current parenting;
information which in turn can be clinically useful in interventions to support their
tasks as new carers or parents. See, for example, Attachment and Biobehavioral
Catch-up with foster parents (Appendix 1.1 and Bick & Dozier 2008).
Life story work

Life story work is a tool widely used to help young fostered children develop a
self-story of their life experiences but despite its popularity there appears to be
no good empirical evidence as to its effectiveness with regard to either attach-
ment security, placement stability or indeed any other relevant dimension. This
approach is likely applied in various ways but in a study of fostered and adopted
school years children Quinton and colleagues noted that: ‘it is possible that the
premises on which the work is currently based are wrong’ (Quinton et al. 1998:
89). Cook-Cottone and Black (2007) reported a dearth of empirical evidence
although Macaskill found that ‘good quality’ life story work had helped adopted
and long-term fostered children start to grapple with their own family history,
including abuse (Macaskill 2002).
Introduction 17
The process and measurement of change

Not surprisingly, the best outcomes of therapy are achieved with securely attached
clients but they do not represent the majority who receive treatment (Slade 2008;
Berant & Obegi 2009). However, regarding the latter group, a study by Fonagy
and colleagues found dismissing adults (in Type A) may do better in psycho-
therapy than those in other patterns (Fonagy et al. 1996). Dismissing patients have
shown fewer ruptures in the therapeutic alliance than preoccupied patients (in
Type C) patients (Eames & Roth 2000). Projections of childhood experience onto
the therapist (transference) also vary according to attachment pattern (Bradley et
al. 2005).
Changing our behaviour is always threatening. Self-protective strategies func-
tion because they help us feel safe, i.e. it is the strategy not safety itself which
elicits a sense of security. The process of therapy can itself be challenging. For
example, interventions which lead the attention of dismissing children towards
possible attachment ¿gures and preoccupied children away from their attachment
¿gures will provoke anxiety (Main 1995: 452).
In adulthood the AAIs of people who have reorganised from insecure childhood
attachments (A or C) towards Type B balance or autonomy (security) are referred
to as ‘earned B’ to distinguish them from ‘naive B’ AAIs of people who have
always been secure.
It seems unlikely that anyone shifts into secure attachment without bringing
some of their past experience with them. Children who have been abused or
neglected do not make magical transitions into secure attachment with adoptive
parents. Rather they add new strategies (which meet new environmental condi-
tions) but retain the old ones (which were functional to their survival in the past
and may be needed again) (Hodges et al. 2005; Lieberman et al. 1991). The earlier
attachment strategies remain as a ‘default’ position to which the individual may
return when under increasing stress with the associated, albeit often short-lived,
recurrence of old patterns of behaviour.
There is also a question as to whether current attachment assessments such as
narrative stems and the AAI are suf¿ciently ¿nely calibrated to pick up changes
within strategies (Hodges et al. 2005; Slade 2008). And is change in attachment
strategy feasible or even desirable? Jacobvitz, for example, notes that in some
cases ‘The AAI might be used to identify and to help adults at risk work around
rather than work through their problems’ (Jacobvitz 2008: 474, her italics).
The therapist as an attachment figure

Bowlby saw the therapist as a temporary attachment ¿gure with a role that is
‘analogous to that of a mother who provides her child with a secure base from
which to explore the world’ (Bowlby 1988/2005: 159). The primacy of the thera-
peutic relationship as a secure base is central to many therapeutic modalities in
which the therapist, like the ideal mother, learns to attune, mentalise and contain
their client’s anxieties while providing a safe space for reÀection. If parent–infant
interaction is a meeting of minds so is the therapeutic relationship. Harris in Chap-
ter 8 considers this process in the complex relationship between a lawyer and their
client.
A number of issues Àow from this. According to some authors what most counts
towards success in psychotherapy is the nature of the relationship between thera-
pist and client (Beutler 1991; Orlinsky et al. 1994). For example: ‘By virtue of
promoting the patient’s mentalizing capacity, the therapist’s mentalizing capacity,
rather than any particular techniques, will determine the success of the treatment’
(Allen et al. 2008: 222).
There are measurable differences in the impact of therapist attachment pattern
on that of the patient or client (Tyrell et al. 1999; Petrowski et al. 2013) and, not
surprisingly, secure attachment of the therapist increases the effectiveness of the
treatment (Slade 2008). As with foster and adoptive parents, research on how
secure therapists are compared to the general population has produced mixed
results (Lambruschi et al. 2008, cited in Crittenden & Landini 2011; Tyrrell et al.
1999; Diamond et al. 2003).
This strongly suggests that attachment strategy and mentalising should be a
central component of therapeutic trainings (Steele & Steele 2008b).
While the metaphor of the therapist as parent works fairly well with adults
it is inherently problematic when working with children who have actual par-
ents or alternative carers with whom they have, or are developing, an ongoing
attachment.
Although many child therapists do refer to the therapist as an attachment ¿gure
(e.g. Benedict 2006; Becker-Weidman & Hughes 2008), others see their role in
terms such as an ‘identi¿cation model’ who is not a parent substitute and must ‘not
become caught up in a real relationship’ (Verheugt-Pleiter 2008: 50–51). It would
be interesting to investigate how these two types of relationship are experienced
from the child’s perspective.
Conclusion
The inÀuence of attachment theory and research on treatment and intervention
is huge and it has not been possible in this chapter to do justice to the range of
activity in the ¿eld. One conclusion that can be drawn is that attachment behav-
iour involves interrelated social systems in which the attachment strategies of
we, the professionals, play an important part. A second conclusion is that while
many interventions are informed by attachment thinking the number that have evi-
dence-based data on their effectiveness in changing attachment behaviour is much
smaller. Does this matter? Perhaps not, but with a long caveat! Attachment is not
a theory of everything and there are occasions when we may be better leaving
the self-protective strategies of our clients alone. This also means that when we
really are claiming that our intervention improves attachment security we should
be careful to evidence it.
Introduction 19
Appendix 1.1
Parent–child attachment-based interventions

Searches were conducted using the databases PsycInfo, PsycArticles and Psyc-
Books together with the California Evidence-Based Clearinghouse for Child
Welfare.
Video-feedback Intervention to promote Positive Parenting (VIPP)

The model by Juffer, Bakermans-Kranenburg and Van IJzendoorn in Chapter 5 of
this volume promotes the idea that ‘less is more’, i.e. interventions become less
effective after 16 sessions. They also conclude that focusing on parental sensitiv-
ity rather than representation is more productive in terms of promoting secure
attachment in children. VIPP is a home-based parent–child intervention using
video feedback of the subjects. It was piloted with adoptive families then rolled
out with other groups, and appears effective with the ‘mid range’ of family prob-
lems rather than those with multiple risks. They note that: ‘A de¿nite conclu-
sion about the effectiveness of VIPP for enhancing attachment security cannot
be drawn yet’ (p. 93; see Moss et al. 2011 for positive effects of VIPP on child
attachment security).
A critique of ‘less is more’ with regard to the challenge of improving attach-
ment security in multi-risk families has been mounted by Egeland and colleagues
(2000), raising the question as to whether improving attachment security of
children in such families is a feasible goal, at least in the short term (Ziv 2005).
Regarding sensitivity, Moran and colleagues found that mothers who were trau-
matised (unresolved/disorientated on the Main and Goldwyn AAI) were unable
to bene¿t from an otherwise successful ‘less is more’ intervention programme
(Moran et al. 2008).
However, intensive long-term ‘more is better’ approaches also appear to have
mixed results with regard to child attachment security.
The Steps Towards Effective, Enjoyable Parenting (STEEP)

This programme (Egeland & Erickson 2004) included bi-weekly home visits
starting in the second trimester of pregnancy and continuing until the child’s ¿rst
birthday, for the evaluation study, and at least until the second birthday over-
all. Once the baby was born the programme used video feedback and mothers
attended bi-weekly group sessions. STEEP made a positive impact on maternal
sensitivity but there was no signi¿cant difference in the quality of infant–mother
attachment in the intervention group when compared with controls (Egeland &
Erickson 2004). That said, the comprehensive UCLA programme (see below) has
produced improvements in child security (for discussion see Spieker et al. 2005
on the US Early Head Start programme).
Infant or Child–Parent Psychotherapy (CPP)

In CPP the presence of the baby is a crucial part of understanding how the ghosts
in the mother’s past intrude into present time without necessarily making them
explicit. Versatility and Àexibility of psychotherapeutic technique are hallmarks
of this approach; what Fraiberg and colleagues termed ‘psychotherapy in the
kitchen’ (Fraiberg et al. 1975: 394; see also Fraiberg 1982; Lieberman & Zeanah
1999).
In the initial study Lieberman and colleagues used a pre/post SSP to assess the
effectiveness of parent–infant psychotherapy and found signi¿cant improvements
in the attachment of the intervention group compared with randomised controls,
but this did not hold when using the Q-sort with observed toddler behaviour in
the home (Lieberman et al. 1991). Since then a number of studies have reported
signi¿cant improvement in children’s attachment security assessed by the SSP
(Berlin et al. 2008) and with children in kinship and foster care (Van Horn et al.
2011).
Infant–Parent Psychotherapy
Cicchetti and colleagues found that Infant–Parent Psychotherapy or a Psychoeduca-
tional Parenting Intervention signi¿cantly improved attachment security (using the
SSP) in maltreated infants compared with not only controls but also a fourth group
of non-maltreated infants from low-income families (Cicchetti et al. 2006).
Toth and colleagues used the SSP with toddlers (average age 20 months) as a
pre/post measure of attachment to assess the effectiveness of toddler–parent psy-
chotherapy with mothers diagnosed with a major depressive disorder. Followed up
at 36 months the intervention group showed a substantial increase in attachment
security compared with randomised controls or a community group of toddlers
with non-depressed mothers (Toth et al. 2006). An earlier study used narrative
story stems to evaluate preschool–parent psychotherapy (PPP) with maltreated
children and found the attachment representations of the PPP group showed a
greater decline in both maladaptive maternal representations and negative self-
representations than either a group who received psychoeducational home visiting
or standard community services (Toth et al. 2002).
The Circle of Security

This intervention uses small group treatment of ¿ve to six parents/carers in a 20-
week programme with a pre/post SSP to follow changes in the child’s attachment.
Results with both advantaged and high-risk dyads (the children were toddlers or
preschool age) showed a signi¿cant move in child attachment from disorgan-
ised to organised insecure (avoidant or resistant) or secure (Hoffman et al. 2006).
This approach involves both video feedback and what can be construed as men-
talisation-based therapy (MBT) with parents. The study did not have a comparison
non-intervention group.
Introduction 21
Watch, Wait and Wonder (WWW)

The WWW approach involves mother getting down on the Àoor with her infant
and the therapist encouraging her to follow the infant’s lead. The second part
involves a 20-minute session in which the mother explores her observations with
the therapist. Although links may be made with her past experience the focus is on
observation and following the infant’s lead. The SSP was used as one of a series of
pre/post measures with infants aged 10 to 30 months. When compared with more
traditional mother–infant psychodynamic psychotherapy (PPT) attachment secu-
rity improved in both groups, with positive changes coming earlier in a six-month
follow up for the WWW than the PPT groups (Cohen et al. 2002).
University of California at Los Angeles (UCLA) Family Development Project

This project used a mixture of home visiting, parent groups and advocacy with
mothers at social risk (excluding drug use and psychiatric treatment for DSM-
IV axis 1 diagnosis) (Heinicke et al. 1999, 2006; also Heinicke & Levine 2008).
Infant attachment assessed by the SSP at 14 months showed signi¿cantly more
secure children in the intervention group compared with random selected controls;
in fact 77 per cent of the intervention children were assessed as secure compared
with 52 per cent of the controls (Heinicke et al. 1999). The mothers whose state
of mind regarding attachment was assessed as secure, using the Main and Gold-
wyn AAI before their child was born, were more involved in the intervention and
showed better outcomes overall.
Sunderland Infant Programme

This programme used the DMM CARE-Index as a screening tool to assign mother–
infant dyads to low-, medium- and high-risk groups with all groups offered video
feedback and the high-risk group parent–infant psychotherapy. At the 12-month
follow up the dyads again completed a CARE-Index and the children the DMM-
SSP. Results showed signi¿cant improvement in security of attachment of the
intervention group compared with a non-randomised comparison group who did
not receive the intervention (Svanberg et al. 2010).
Attachment and Biobehavioral Catch-up (ABC)

The ABC was developed by Dozier and colleagues (2005) as a brief home visit-
ing programme for foster parents and foster children. It uses video feedback and
attends to a foster carer’s state of mind as assessed by the AAI and their This Is
My Baby interview (TIMB) which assesses commitment to the child, which in
turn predicts durability of placements.1 Intervention children showed more typical
levels of the ‘stress hormone’ cortisol than controls and were not signi¿cantly dif-
ferent from a third group who had never been in care (Dozier et al. 2006, 2008).
Bernard and colleagues (Bernard et al. 2012) used the ABC with parents at risk
of neglecting their young children. It was evaluated using the SSP with 120 chil-
dren aged between 11 and 31 months. Children in the ABC intervention showed
signi¿cantly lower rates of disorganised attachment (32%) and higher rates of
secure attachment (52%) relative to the randomised control intervention (57% and
33%, respectively).
Note
1 TIMB promises to be a simple, easy to use tool: see Dozier et al. 2007: Appendix 4: 1.
References
Ainsworth, M.D., Blehar, M.C., Waters, E. & Wall, S. (1978) Patterns of Attachment: A
Psychological Study of the Strange Situation, Hillsdale, NJ: Erlbaum.
Ainsworth, M.S. & Bowlby, J. (1991) ‘An ethological approach to personality develop-
ment’, American Psychologist, 46(4): 333–341.
Allen, J.G. (2013) Restoring Mentalizing in Attachment Relationships: Treating Trauma
with Plain Old Therapy, Washington, DC: American Psychiatric Publishing.
Allen, J.G. & Fonagy, P. (eds) (2006) Handbook of Mentalization-Based Treatment, Chich-
ester: John Wiley & Sons.
Allen, J.G., Fonagy, P. & Bateman, J.G. (2008) Mentalizing in Clinical Practice, Washing-
ton, DC: American Psychiatric Publishing Inc.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition, Arlington, VA: American Psychiatric Association.
BAAF (British Agencies of Adoption and Fostering) (2006) Position Statement 4: Attach-
ment Disorders, Their Assessment and Intervention/Treatment, London: BAAF.
Bateman, A. & Fonagy, P. (2004) Psychotherapy for Borderline Personality Disorder:
Mentalization-Based Treatment, Oxford: Oxford University Press.
Bateman, A. & Fonagy, P. (2008) ‘8-year follow up of patients treated for borderline per-
sonality disorder: mentalization-based treatments versus treatment as usual’, American
Journal of Psychiatry, 165: 631–638.
Becker-Weidman, A. (2006) ‘Treatment for children with trauma-attachment disorders:
Dyadic Developmental Psychotherapy’, Child and Adolescent Social Work Journal,
23(2): 147–171.
Becker-Weidman, A. & Hughes, D. (2008) ‘Dyadic Developmental Psychotherapy: an evi-
dence-based treatment for children with complex trauma and disorders of attachment’,
Child and Family Social Work, 13: 329–337.
Beijersbergen, M.D., Juffer, F., Bakermans-Kranenburg, M.J. & Van IJzendoorn, M.H.
(2012) ‘Remaining or becoming secure: Parental sensitive support predicts attachment
continuity from infancy to adolescence in a longitudinal adoption study’, Developmental
Psychology, 48(5): 1277–1282.
Benedict, H.E. (2006) ‘Object relations play therapy: Applications to attachment prob-
lems and relational trauma’, in C.E. Schaefer & H.G. Kaduson (eds), Contemporary
Play Therapy: Theory, Research and Practice (pp. 3–27), New York: The Guilford
Press.
Introduction 23
Benedict, H.E. & Schofield, D. (2010) ‘Play therapy for insecurely attached preschool chil-
dren’, in C.E. Schaefer (ed.), Play Therapy for Preschool Children (pp. 47–66), Wash-
ington, DC: American Psychological Association.
Berant, E. & Obegi, J.H. (2009) ‘Attachment-informed psychotherapy research with
adults’, in J.H. Obegi & E. Berant (eds), Attachment Theory and Research in Clinical
Work with Adults (pp. 461–489), New York: The Guilford Press.
Berlin, L.J., Zeanah, C.H. & Lieberman, A.F. (2008) ‘Prevention and intervention programs
for supporting early attachment security’, in J. Cassidy & P.R. Shaver (eds), Handbook
of Attachment: Theory, Research, and Clinical Applications (pp. 745–761). New York:
The Guilford Press.
Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E., Lindhiem, O. & Carlson, E. (2012)
‘Enhancing attachment organization among maltreated children: Results of a randomized
clinical trial’, Child Development, 83(2): 623–636.
Beutler, L.E. (1991) ‘Have all won and must all have prizes? Revisiting Luborsky et al.’s
verdict’, Journal of Consulting and Clinical Psychology, 59: 226–232.
Bick, J. & Dozier, M. (2008) ‘Helping foster parents change: The role of parental state of
mind’, in H. Steele & M. Steele (eds), Clinical Applications of the Adult Attachment
Interview (pp. 452–470), New York: The Guilford Press.
Bifulco, A., Jacobs, C., Bunn, A., Thomas, G. & Irving, K. (2008) ‘The Attachment Style
Interview (ASI): A support-based adult assessment tool for adoption and fostering prac-
tice’, Adoption & Fostering, 32: 33–45.
Bomber, L.M. (2007) Inside I’m Hurting: Practical Strategies for Supporting Children
with Attachment Difficulties in Schools, London: Worth Publishing.
Bomber, L.M. (2011) What About Me? Inclusive Strategies to Support Pupils with Attach-
ment Difficulties Make It Through the School Day, London: Worth Publishing.
Bowlby, J. (1953) Child Care and the Growth of Love, London: Penguin Books.
Bowlby, J. (1973/1985) Attachment and Loss, Vol. 2: Separation: Anxiety and Anger, Lon-
don: Hogarth Press and Institute of Psycho-Analysis.
Bowlby, J. (1979/2005) The Making and Breaking of Affectional Bonds, Abingdon, UK:
Routledge.
Bowlby, J. (1988/2005) A Secure Base: Clinical applications of attachment theory, Lon-
don: Routledge.
Bradley, R., Heim, A.K. & Westen, D. (2005) ‘Transference patterns in the psychotherapy
of personality disorders: Empirical investigation’, British Journal of Psychiatry, 186(4):
342–349.
Bratton, S., Ray, D., Rhine, T. & Jones, L. (2005) ‘The efficacy of play therapy with
children: A meta-analytic review of treatment outcomes’, Professional Psychology:
Research and Practice, 36: 376–390.
Bretherton, I. (2005) ‘In pursuit of the internal working model construct and its relevance
to attachment relationships’, in K.E. Grossman, K. Grossman & E. Waters (eds), Attach-
ment for Infancy to Adulthood: The Major Longitudinal Studies (pp. 13–47), New York:
The Guilford Press.
Carr, A. (2009) ‘The effectiveness of family therapy and systemic interventions for child-
focused problems’, Journal of Family Therapy, 31: 3–45.
Chaffin, M., Hanson, R., Saunders, B.E., Nichols, T., Barnett, D., Zeanah, C. et al. (2006)
‘Report of the APSAC Task Force on attachment therapy, Reactive Attachment Disor-
der, and attachment problems’, Child Maltreatment, 11(1): 76–89.
Cicchetti, D., Rogosch, F.A. & Toth, S.L. (2006) ‘Fostering secure attachment in infants in
maltreating families through preventive interventions’, Development and Psychopathol-

ogy, 18(3): 623–649.
Coan, J.A. (2008) ‘Towards a neuroscience of attachment’, in J. Cassidy & P.R. Shaver
(eds), Handbook of Attachment: Theory, Research, and Clinical Applications (pp. 241–
265), New York: The Guilford Press.
Cohen, J. (2005) ‘Treating traumatized children: Current status and future directions’,
in E. Cardeña & K. Croyle (eds), Acute Reactions to Trauma and Psychotherapy: A
Multidisciplinary and International Perspective (pp. 109–121), New York: Haworth
Press.
Cohen, J.A., Mannarino, A.P. & Deblinger, E. (2010) ‘Trauma-focused cognitive-
behavioral therapy for traumatized children’, in J.R. Weisz & A.E. Kazdin (eds), Evi-
dence-based Psychotherapies for Children and Adolescents, 2nd edition (pp. 295–311),
New York: The Guilford Press.
Cohen, N.J., Lojkasek, M., Muir, E., Muir, R. & Parker, C.J. (2002) ‘Six-month follow-up
of two mother–infant psychotherapies: Convergence of therapeutic outcomes’, Infant
Mental Health Journal, 23(4): 361–380.
Cook-Cottone, C. & Black, M. (2007) ‘A model for life-story work: Facilitating the con-
struction of personal narrative for foster children’, Child and Adolescent Mental Health,
12(4): 193–195.
Crittenden, P.M. (1979–2005) CARE-Index. Infants. Coding Manual, unpublished manu-
script, Miami, FL.
Crittenden, P.M. (1985) ‘Social networks, quality of childrearing, and child development’,
Child Development, 56: 1299–1313.
Crittenden, P.M. (1988–2011) The Pre-school Assessment of Attachment: Coding Manual,
unpublished manuscript, Miami, FL.
Crittenden, P.M. (1992) ‘Treatment of anxious attachment in infancy and the preschool
years’, Development and Psychopathology, 4: 575–602.
Crittenden, P.M. (1995) ‘Attachment and psychopathology’, in S. Goldberg, R. Muir &
J. Kerr (eds), Attachment Theory: Social, Developmental and Clinical Perspectives
(pp. 367–406), New York: The Analytic Press.
Crittenden, P.M. (1995–2008) School-aged Assessment of attachment. Coding Manual
Using the Dynamic-Maturational Method, unpublished manuscript.
Crittenden, P.M. (2005) CARE-Index. Toddlers. Coding Manual, unpublished manuscript,
Miami, FL.
Crittenden, P.M. (2006) ‘A Dynamic-Maturational Model of Attachment’, Australian and
New Zealand Journal of Family Therapy, 27(2): 105–115.
Crittenden, P.M. & Ainsworth, M.D.S. (1989) ‘Child maltreatment and attachment theory’,
in D. Cicchetti & V. Carlson (eds), Handbook of Child Maltreatment (pp. 432–463),
New York: Cambridge University Press.
Crittenden, P.M. & Landini, A. (2011) The Adult Attachment Interview: Assessing Psycho-
logical and Interpersonal Strategies, New York: W.W. Norton & Co.
Crittenden, P.M., Landini, A. & Claussen, A.H. (2001) ‘A dynamic-maturational approach
to treatment of maltreated children’, in J.N. Hughes, A.M. La Greca & J.C. Conoley
(eds), Handbook of Psychological Services for Children and Adolescents (pp. 373–398),
New York: Oxford University Press.
Crittenden, P.M., Kozlowska, K. & Landini, A. (2010) ‘Assessing attachment in school-
age children’, Clinical Child Psychology and Psychiatry, 15(2): 185–208.
Crittenden, P.M., Farnfield, S., Landini, A. & Grey, B. (2013) ‘Assessing attachment
Introduction 25
for family court decision-making: A forensic protocol for empirically-based evidence

regarding attachment’, Journal of Forensic Practice, 15(4): 237–248.
Daniel, S.I.F. (2006) ‘Adult attachment patterns and individual psychotherapy: A review’,
Clinical Psychology Review, 26: 968–984.
Daniel, S.I.F. (2009) ‘The developmental roots of narrative expression in therapy: Contri-
butions from attachment theory and research’, Psychotherapy Theory, Research, Prac-
tice, Training, 46(3): 301–316.
Deblinger, E., Pollio, E. & Neubauer, F. (2012) ‘Trauma-related symptoms in children
and adolescents’, in J.G. Beck & D.M. Sloan (eds), The Oxford Handbook of Traumatic
Stress Disorders (pp. 473–490), New York: Oxford University Press.
De Wolff, M. & Van IJzendoorn, M.H. (1997) ‘Sensitivity and attachment: A meta-analysis
on parental antecedents of infant attachment’, Child Development, 68(4): 571–591.
Diamond, D., Stovall-McClough, C., Clarkin, J.F. & Levy, K.N. (2003) ‘Patient–therapist
attachment in the treatment of borderline personality disorder’, Bulletin of the Mennin-
ger Clinic, 67(3): 227–259.
Diamond, G.M., Diamond, G.S., Levy, S., Closs, C., Lapido, T. & Siqueland, L. (2012)
‘Attachment-based family therapy for suicidal lesbian, gay, and bisexual adolescents: A
treatment development study and open trial with preliminary findings’, Psychotherapy,
49(1): 62–71.
Diamond, G.S., Reis, B.F., Diamond, G.M., Siqueland, L. & Isaacs, L. (2002) ‘Attach-
ment-based family therapy for depressed adolescents: A treatment development study’,
Journal of the American Academy of Child and Adolescent Psychiatry, 41: 1190–1196.
Diamond, G.S., Wintersteen, M.B., Brown, G.K., Diamond, G.M., Gallop, R., Shelef, K.,
& Levy, S. (2010) ‘Attachment-based family therapy for adolescents with suicidal idea-
tion: A randomized controlled trial’, Journal of the American Academy of Child and
Adolescent Psychiatry, 49: 122–131.
Dozier, M., Stovall, K.C., Albus, K.E. & Bates, B. (2001) ‘Attachment for infants in foster
care: The role of caregiver state of mind’, Child Development, 72: 1467–1477.
Dozier, M., Lindhiem, O. & Ackerman, J.P. (2005) ‘Attachment and Biobehavioral Catch-
Up: An intervention targeting empirically identified needs of foster infants’, in L.J. Ber-
lin, Y. Ziv, L. Amaya-Jackson & M.T. Greenberg (eds), Enhancing Early Attachments:
Theory, Research, Intervention and Policy (pp. 178–194), New York: The Guilford
Press.
Dozier, M., Peloso, E., Lindhiem, O., Gordon, M.K., Manni, M., Sepulveda, S. & Acker-
man, J. (2006) ‘Developing evidence-based interventions for foster children: An exam-
ple of a randomized clinical trial with infants and toddlers’, Journal of Social Issues,
62(4): 767–785.
Dozier, M., Grasso, D., Lindhiem, O. & Lewis, E. (2007) ‘The role of caregiver commit-
ment in foster care: Insights from the This is My Baby Interview’, in D. Oppenheim &
D.F. Goldsmith (eds), Attachment Theory in Clinical Work with Children: Bridging the
Gap Between Research and Practice (pp. 90–108), New York: The Guilford Press.
Dozier, M., Stovall-McClough, K.C. & Albus, K.E. (2008) ‘Attachment and psychopa-
thology in adulthood’, in J. Cassidy & P.R. Shaver (eds), Handbook of Attachment:
Theory, Research, and Clinical Applications (pp. 718–744), New York: The Guilford
Press.
Eames, V. & Roth, A. (2000) ‘Patient attachment orientation and the early working alli-
ance: A study of patient and therapist reports of alliance quality and ruptures’, Psycho-
therapy Research, 10(4): 421–434.
Egeland, B. & Erickson, M.F. (2004) ‘Lessons from STEEP: Linking theory, research, and
practice for the well-being of infants and parents’, in A.J. Sameroff, S.C. McDonough
& K.L. Rosenblum (eds), Treating Parent–Infant Relationship Problems: Strategies for
Intervention (pp. 213–242), New York: The Guilford Press.
Egeland, B., Weinfield, N.S., Bosquet, M. & Cheng, V.K. (2000) ‘Remembering, repeating
and working through: Lessons from attachment-based interventions’, in J. Osofsky &
H.E. Fitzgerald (eds), WAIMH Handbook of Infant Mental: Vol 4. Infant Mental Health
in Groups at High Risk (pp. 35–89), New York: Wiley.
Farnfield, S. (2008) ‘A theoretical model for the comprehensive assessment of parenting’,
British Journal of Social Work, 38(6): 1076–1099.
Farnfield, S. (2012) ‘Bindung und Anpassung bei Ersatzeltern’, in M. Stokowy & N. Sah-
har (eds), Bindung und Gefahr: Das Dynamische Reifungsmodell von Bindung und
Anpassung (pp. 163–186), Giessen: Psychosozial-Verlag.
Farnfield, S. (in press) ‘Assessing attachment in the school years: The application of the
Dynamic-Maturational Model of attachment to the coding of a Child Attachment Interview
with community and looked after children’, Clinical Child Psychology and Psychiatry.
Farnfield, S. & Stokowy, M. (2014) ‘The Dynamic-Maturational Model (DMM)’, in
P. Holmes & S. Farnfield (eds), The Routledge Handbook of Attachment: Theory
(pp. 00–00), London and New York: Routledge.
Fearon, P., Target, M., Sargent, J., Williams, L.L., McGregor, J., Bleiberg, E. & Fonagy, P.
(2006) ‘Short-term mentalization and relational therapy (SMART): An integrative fam-
ily therapy for children and adolescents’, in J.G. Allen & P. Fonagy (eds), Handbook of
Mentalization-Based Treatment (pp. 201–222), Chichester: John Wiley & Sons.
Fonagy, P. (2001) Attachment Theory and Psychoanalysis, New York: Other Press.
Fonagy, P. & Bateman, A.W. (2006) ‘Progress in the treatment of borderline personality
disorder’, British Journal of Psychiatry, 188: 1–3.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G. et al. (1996) ‘The
relation of attachment status, psychiatric classification, and response to psychotherapy’,
Journal of Consulting and Clinical Psychology, 64: 22–31.
Fonagy, P., Gergely, G., Jurist, E. & Target, M. (2004) Affect Regulation, Mentalization
and the Development of the Self, New York: Other Press.
Fonagy, P., Twemlow, S.W., Vernberg, E.M., Mize Nelson, J., Dill, E.J., Little, T.D. &
Sargent, J.E. (2009) ‘A cluster randomized controlled trial of child-focused psychiatric
consultation and a school systems-focused intervention to reduce aggression’, Journal of
Child Psychology and Psychiatry, 50: 607–616.
Fraiberg, S. (1982) ‘Pathological defenses in infancy’, Psychoanalytic Quarterly, 51:
612–635.
Fraiberg, S., Adelson, E. & Shapiro, V. (1975) ‘Ghosts in the nursery: A psychoanalytic
approach to the problems of impaired infant–mother relationships’, Journal of American
Academy of Child Psychiatry, 14: 387–421.
Geddes, H. (2006) Attachment in the Classroom: The Links between Children’s Early Expe-
riences, Emotional Well-being and Performance in School, London: Worth Publishing.
George, C., Kaplan, N. & Main, M. (1985) Adult Attachment Interview Protocol (2nd edi-
tion), unpublished manuscript, University of California at Berkeley.
Grey, B. (2010) ‘The meaning of the child in parenting interviews: A comparative study
using the Parent Development Interview and the CARE-Index’, Poster and seminar pre-
Introduction 27
sented to the 2nd Biannual Conference of the International Association for the Study of
Attachment, Cambridge: August.
Heinicke, C.M. & Levine, M.S. (2008) ‘The AAI anticipates the outcome of a relation-
based early intervention’, in H. Steele & M. Steele (eds), Clinical Applications of the
Adult Attachment Interview (pp. 99–125), New York: The Guilford Press.
Heinicke, C.M., Fineman, N.R., Ruth, G., Recchia, S., Guthrie, D. & Rodning, C. (1999)
‘Relationship based intervention with at-risk mothers: Outcome in the first year of life’,
Infant Mental Health Journal, 20: 349–374.
Heinicke, C.M., Goorsky, M., Levine, M., Ponce, V., Ruth, G., Silverman, M. & Sotelo, C.
(2006) ‘Pre-and postnatal antecedents of a home-visiting intervention and family devel-
opmental outcome’, Infant Mental Health Journal, 27(1): 91–119.
Hodges, J., Steele, M., Hillman, S., Henderson, K. & Kaniuk, J. (2005) ‘Change and con-
tinuity in mental representations of attachment after adoption’, in D.M. Brodzinsky & J.
Palacios (eds), Psychological Issues in Adoption: Research and Practice (pp. 93–116),
Westport, CT: Praeger.
Hoffman, K.T., Marvin, R.S., Cooper, G. & Powell, B. (2006) ‘Changing toddlers’ and
preschoolers’ attachment classifications: The Circle of Security intervention‘, Journal of
Consulting and Clinical Psychology, 74: 1017–1026.
Holmes, P. (1989) ‘Wheels within wheels and systems within systems: The assessment
process’, Children & Society, 3(3), 237–254.
Holmes, P. (1992) The Inner World Outside: Object Relations Theory and Psychodrama,
London and New York: Tavistock/Routledge.
Holmes, P. & Farnfield, S. (eds) (2014) The Routledge Handbook of Attachment: Theory,
Jacobvitz, R. (2008) ‘Afterword: Reflections on clinical applications of the Adult Attach-
ment Interview’, in H. Steele & M. Steele (eds), Clinical Applications of the Adult
Attachment Interview (pp. 471–486), New York: The Guilford Press.
Jernberg, A.M., & Booth, P.B. (1999) ‘Theraplay: Helping parents and children build better
relationships through attachment-based play (2nd edition), San Francisco, CA: Jossey-Bass.
Kennedy, H., Landor, M. & Todd, L. (2010) ‘Video Interaction Guidance as a method to
promote secure attachment’, Educational and Child Psychology, 27(3): 59–72.
Kennedy, H., Landor, M. & Todd, L. (2011) Video Interaction Guidance: A Relationship-
Based Intervention to Promote Attunement, Empathy and Well-Being, London: Jessica
Kingsley Publishers.
Kliethermes, M., Nanney, R.W., Cohen, J.A. & Mannarino, A.P. (2013) ‘Trauma-focused
cognitive-behavioral therapy’, in J.D. Ford & C.A. Courtois (eds), Treating Complex
Traumatic Stress Disorders in Children and Adolescents: Scientific Foundations and
Therapeutic Models (pp. 184–202), New York: The Guilford Press.
Kozlowska, K., Foley, S. & Savage, B. (2012a) ‘Fabricated illness: Working within the
family system to find a pathway to health’, Family Process, 51(4): 570–587.
Kozlowska, K., English, M., Savage, B. & Chudleigh, C. (2012b) ‘Multimodal rehabilita-
tion: A mind-body, family-based intervention for children and adolescents impaired by
medically unexplained symptoms. Part 1: The program’, The American Journal of Fam-
ily Therapy, 40(5): 399–419.
Kozlowska, K., English, M., Savage, B., Chudleigh, C., Davies, F., Paull, M., et al. (2013)
‘Multimodal rehabilitation: A mind-body, family-based intervention for children and
adolescents impaired by medically unexplained symptoms. Part 2: Case studies and
outcomes’, The American Journal of Family Therapy, 40(5): 212–231.
Lee, C., Gavriel, H., Drummond, P., Richards, J. & Greenwald, R. (2002) ‘Treatment of
PTSD: Stress inoculation training with prolonged exposure compared to EMDR‘, Jour-
nal of Clinical Psychology, 58: 1071–1089.
Levy, K.N., Meehan, K.B., Clarkin, J.F., Kernberg, O.F., Kelly, K.M., Reynoso, J.S.
& Weber, M. (2006) ‘Change in attachment patterns and reflective function in a
randomized control trial of transference-focused psychotherapy for borderline personal-
ity disorder’, Journal of Consulting and Clinical Psychology, 74(6): 1027–1040.
Lieberman, A.F. & Zeanah, C.H. (1999) ‘Contributions of attachment theory to infant–
parent psychotherapy and other interventions with infants and young children’, in J.
Cassidy & P.R. Shaver (eds), Handbook of Attachment: Theory, Research, and Clinical
Applications (pp. 555–574), New York: The Guilford Press.
Lieberman, A.F., Weston, D.R. & Pawl, J.H. (1991) ‘Preventive intervention and outcome
with anxiously attached dyads‘, Child Development, 62: 199–209.
Lindhiem, O. & Dozier, M. (2007) ‘Caregiver commitment to foster children: The role of
child behavior’, Child Abuse & Neglect, 31(4): 361–374.
Luyten, P. & Fonagy, P. (2014) ‘Mentalising in attachment contexts’, in P. Holmes &
S. Farnfield (eds), The Routledge Handbook of Attachment: Theory, London and New
York: Routledge.
Macaskill, C. (2002) Safe Contact? Children in Permanent Placement and Contact with
Their Birth Relatives, Lyme Regis, Dorset: Russell House Publishing.
Main, M. (1995) ‘Recent studies in attachment: Overview, with selected implications for
clinical work’, in S. Goldberg, R. Muir & J. Kerr (eds), Attachment Theory: Social,
Developmental, and Clinical Perspectives (pp. 407–474), Hillsdale, NJ: The Analytic
Press.
Main, M. & Goldwyn, R. (1984) Adult Attachment Scoring & Classification System,
Unpublished manuscript, University of California at Berkeley.
Main, M. & Solomon, J. (1986) ‘Discovery of a new, insecure-disorganized/disorientated
attachment pattern’, in M. Yogman and T. Brazelton (eds), Affective Development in
Infancy (pp. 95–124), Norwood, Ablex.
Main, M., Hesse, E. & Hesse, S. (2011) ‘Attachment theory and research: Overview with
suggested applications to child custody’, Family Court Review, Special issue: Special
issue on attachment, separation, and divorce: Forging coherent understandings for
family law, 49(3): 426–463.
Marcus, S.V., Marquis, P. & Saki, C. (1997) ‘Controlled study of treatment of PTSD using
EMDR in an HMO setting’, Psychotherapy, 34: 307–315.
Marvin, R.S. (2003) ‘Implications of attachment research for the field of family therapy’, in
P. Erdman & T. Caffery (eds), Attachment and Family Systems: Conceptual, Empirical,
and Therapeutic Relatedness (pp. 3–27), Hove, UK: Brunner-Routledge.
Moran, G., Bailey, H.N., Gleason, K., DeOliveira, C.A. & Pederson, D.R. (2008) ‘Explor-
ing the mind behind unresolved attachment: Lessons from and of attachment-based inter-
ventions with infants and their traumatized mothers’, in H. Steele & M. Steele (eds),
Clinical Applications of the Adult Attachment Interview (pp. 371–398), New York: The
Guilford Press.
Moss, E., Dubois-Comtois, K., Cyr, C., Tarabulsy, G.M., St-Laurent, D. & Bernier, A.
(2011) ‘Efficacy of a home visiting intervention aimed at improving maternal sensitiv-
ity, child attachment, and behavioral outcomes for maltreated children: A randomized
control trial’, Development and Psychopathology, 23: 195–210.
Obegi, J.H. & Berant, E. (2009) ‘Introduction’, in J.H. Obegi & E. Berant (eds), Attachment
Introduction 29
Theory and Research in Clinical Work with Adults (pp. 1–14), New York: The Guilford
Press.
O’Connor, T.G., Matias, C., Futh, A., Tantam, G. & Scott, S. (2013) ‘Social learning theory
parenting intervention promotes attachment-based caregiving in young children: Rand-
omized clinical trial’, Journal of Clinical Child and Adolescent Psychology: The Official
Journal for the Society of Clinical Child and Adolescent Psychology, American Psycho-
logical Association, Division 53, 42(3): 358–370.
Orlinsky, D.E., Grawe, K. & Parks, B.K. (1994) ‘Process and outcome in psychotherapy:
Noch einmal’, in A.E. Bergin & L. Garfield (eds), Handbook of Psychotherapy and
Behavior Change, 4th edition (pp. 270–376), New York: Wiley.
Petrowski, K., Pokorny, D., Nowacki, K. & Buchheim, A. (2013) ‘The therapist’s attach-
ment representation and the patient’s attachment to the therapist’, Psychotherapy
Research, 23(1): 25–34.
Prior, V. & Glaser, D. (2006) Understanding Attachment and Attachment Disorders: The-
ory, Evidence and Practice, London: Jessica Kingsley Publishers.
Quinton, D., Rushton, A., Dance, C. & Mayes, D. (1998) Joining New Families: A Study of
Adoption and Fostering in Middle Childhood, Chichester: John Wiley & Sons.
Ray, D.C. (2006) ‘Evidence-based play therapy’, in C.E. Schaefer & H.G. Kaduson (eds),
Contemporary Play Therapy: Theory, Research, and Practice (pp. 136–157), New York:
The Guilford Press.
Robertson, M. & Kennedy, H. (2009) ‘Relationship-based intervention for high risk fami-
lies and their babies: Video Interaction Guidance – an international perspective’, Semi-
nar Association Infant Mental Health, Tavistock, London, 12 December.
Scheeringa, M.S., Weems, C.F., Cohen, J.A., Amaya-Jackson, L. & Guthrie, D. (2011)
‘Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-
through six-year-old children: A randomized clinical trial’, Journal of Child Psychology
and Psychiatry, 52(8): 853–860.
Shmueli-Goetz, Y., Target, M., Fonagy, P. & Datta, A. (2008) ‘The Child Attachment
Interview: A psycho-metric study of reliability and discriminant validity’, Developmen-
tal Psychology, 44: 939–995.
Slade, A. (1999) ‘Attachment theory and research: Implications for the theory and practice
of individual psychotherapy with adults’, in J. Cassidy & P.R. Shaver (eds), Handbook
of Attachment: Theory, Research, and Clinical Applications (pp. 575–594), New York:
The Guilford Press.
Slade, A. (2005) ‘Parental reflective functioning: An introduction’, Attachment & Human
Development, 7(3): 269–281.
Slade, A. (2008) ‘The implications of attachment theory and research for adult psychother-
apy: Research and clinical perspectives’, in J. Cassidy & P.R. Shaver (eds), Handbook
of Attachment: Theory, Research, and Clinical Applications (pp. 762–782), New York:
The Guilford Press.
Slade, A., Bernbach, E., Grienenberger, J., Levy, D. & Locker, A. (2007) Addendum to
Reflective Functioning Scoring Manual for Use with the Parent Development Interview.
Version 3.0, New York: The City College and Graduate Center of the City University
of New York.
Spieker, S., Nelson, D., DeKlyen, M. & Staerkel, F. (2005) ‘Enhancing early attachments
in the context of Early Head Start: Can programs emphasizing family support improve
rates of secure infant-mother attachments in low-income families?’, in L.J. Berlin,
Y. Ziv, L. Amaya-Jackson & M.T. Greenberg (eds), Enhancing Early Attachments:
Theory, Research, Intervention, and Policy (pp. 250–275), New York: The Guilford
Press.
Steele, H. & Steele, M. (eds) (2008a) Clinical Applications of the Adult Attachment Inter-
view, New York: The Guilford Press.
Steele, H. & Steele, M. (2008b) ‘Ten clinical uses of the Adult Attachment Interview’, in
H. Steele & M. Steele (eds), Clinical Applications of the Adult Attachment Interview
(pp. 3–30), New York: The Guilford Press.
Steele, M., Hodges, J., Kaniuk, J., Hillman, S. & Henderson, K. (2003) ‘Attachment rep-
resentations and adoption: Associations between maternal states of mind and emotion
narratives in previously maltreated children’, Journal of Child Psychotherapy, 29:
187–205.
Steele, M., Hodges, J., Kaniuk, J., Steele, H., D’Agostino, D., Blom, I. et al. (2007) ‘Inter-
vening with maltreated children and their adoptive families: Identifying attachment-
facilitative behaviours’, in D. Oppenheim & D.F. Goldsmith (eds), Attachment Theory
in Clinical Work with Children: Bridging the Gap Between Research and Practice
Steele, M., Hodges, J., Kaniuk, J., Steele, H., Hillman, S. & Asquith, K. (2008) ‘Forecasting
outcomes in previously maltreated children: The use of the AAI in a longitudinal adop-
tion study’, in H. Steele & M. Steele (eds), Clinical Applications of the Adult Attachment
Interview (pp. 427–451), New York: The Guilford Press.
Strauss, B.M., Mestel, R. & Kirchmann, H.A. (2011) ‘Changes of attachment status among
women with personality disorders undergoing inpatient treatment’, Counselling and
Psychotherapy Research, 11(4): 275–283.
Svanberg, P.O., Mennet, L. & Spieker, S. (2010) ‘Promoting secure attachment: A primary
prevention practice model’, Clinical Child Psychology and Psychiatry, 15(3): 363–378.
Tarren-Sweeney, M. (2013) ‘Setting the bar higher: What information do we need to estab-
lish the effectiveness of mental health interventions for children with complex attach-
ment- and trauma-related difficulties?’ Clinical Child Psychology and Psychiatry, 18(1):
3–6.
Tasca, G., Balfour, L., Ritchie, K. & Bissada, H. (2007) ‘Change in attachment anxiety is
associated with improved depression among women with binge eating disorder’, Psy-
chotherapy: Theory, Research, Practice, Training, 44(4): 423–433.
Toth, S.L., Maughan, A., Manly, J.T., Spagnola, M. & Cicchetti, D. (2002) ‘The relative
efficacy of two interventions in altering maltreated preschool children’s representational
models: Implications for attachment theory’, Development and Psychopathology, 14(4):
877–908.
Toth, S.L., Rogosch, F.A., Manly, J.T. & Cicchetti, D. (2006) ‘The efficacy of toddler–
parent psychotherapy to reorganize attachment in the young offspring of mothers with
major depressive disorder: A randomized preventive trial’, Journal of Consulting and
Clinical Psychology, 74(6): 1006–1016.
Tyrrell, C.L., Dozier, M., Teague, G.B. & Fallot, R.D. (1999) ‘Effective treatment relation-
ships for persons with serious psychiatric disorders: The importance of attachment states
of mind’, Journal of Consulting and Clinical Psychology, 67(5): 725–733.
Urquiza, A.J. & Timmer, S. (2013) ‘Parent-child Interaction Therapy’, in J.D. Ford & C.A.
Courtois (eds), Treating Complex Traumatic Stress Disorders in Children and Adoles-
cents: Scientific Foundations and Therapeutic Models (pp. 315–328), New York: The
Guilford Press.
Van Horn, P., Gray, L., Pettinelli, B. & Estassi, N. (2011) ‘Child–parent psychotherapy
Introduction 31
with traumatized young children in kinship care: Adaptation of an evidence-based

intervention’, in J.D. Osofsky (ed.), Clinical Work with Traumatized Young Children
Van IJzendoorn, M.H. & Bakermans-Kranenburg, M.J. (2008) ‘The distribution of adult
attachment representations in clinical groups: A meta-analytic search for patterns of
attachment in 105 AAI studies’, in H. Steele & M. Steele (eds), Clinical Applications of
the Adult Attachment Interview (pp. 69–96), New York: The Guilford Press.
Velderman, M.K., Pannebakker, F.D., Kennedy, K., Fukkink, R.G., de Wolff, M.S. & Rei-
jneveld, S.A. (2013) ‘The efficacy of short-term video feedback as a method to improve
parental sensitivity in families at risk for child maltreatment’, Society for Research in
Child Development, Biennial Meeting, Seattle Washington, 18–20April.
Verheugt-Pleiter, A.J.E. (2008) ‘Treatment strategy’, in A.J.E. Verheugt-Pleiter, J.
Zevalkink & M.G.J. Schmeets (eds), Mentalizing in Child Therapy: Guidelines for Clin-
ical Practitioners (pp. 41–68), London: Karnac Books.
Verheugt-Pleiter, A.J.E., Zevalkink, J. & Schmeets, M.G.J. (eds) (2008) Mentalizing in
Child Therapy: Guidelines for Clinical Practitioners, London: Karnac Books.
Waters, E., Vaughn, B., Posada, G. & Kondo-Ikemura, K. (eds) (1995) ‘Caregiving, cul-
tural, and cognitive perspectives on secure-base behavior and working models: New
growing points of attachment theory and research’, with Commentary by Christoph M.
Heinicke and Inge Bretherton. Monographs of the Society for Research in Child Devel-
opment, 60(2–3, Serial No. 244).
Webster-Stratton, C. (1984) ‘Randomized trial of two parent-training programs for families
with conduct-disordered children’, Journal of Consulting and Clinical Psychology, 52:
666–678.
Weisz, J.R. & Kazdin, A.E. (Eds) (2010) Evidence-Based Psychotherapies for Children
and Adolescents, 2nd edition, New York: The Guilford Press.
Wesselmann, D. (2012) ‘EMDR as a treatment for improving attachment status in adults
and children’, European Review of Applied Psychology, 62(4): 223–230.
Zanetti, C.A., Powell, B., Cooper, G. & Hoffman, K. (2011) ‘The Circle of Security inter-
vention: Using the therapeutic relationship to ameliorate attachment security in disor-
ganized dyads’, in J. Solomon & C. George (eds), Disorganized Attachment & Caregiv-
ing (pp. 318–342), New York: The Guilford Press.
Zeanah, C. (2007) ‘Constructing a relationship formulation for mother and child: Clinical
application of the Working Model of the Child Interview’, in D. Oppenheim & D.F.
Goldsmith (eds), Attachment Theory in Clinical Work with Children: Bridging the Gap
Between Research and Practice (pp. 3–30), New York: The Guilford Press.
Zeanah, C., Berlin, L. & Boris, N. (2011) ‘Practitioner review: Clinical applications
of attachment theory and research for infants and young children’, Journal of Child
Psychology and Psychiatry, 52(8): 819–833.
Zeanah, C.H., Benoit, D., Hirshberg, L., Barton, M.L. & Regan, C. (1994) ‘Mothers’ repre-
sentations of their infants are concordant with infant attachment classifications’, Devel-
opmental Issues in Psychiatry and Psychology, 1: 9–18.
Zilberstein, K. (2013) ‘The use and limitations of attachment theory in child psychother-
apy’, Psychotherapy, pp. 1–11.
Ziv, Y. (2005) ‘Attachment-based intervention programs: Implications for attachment
theory and research’, in L.J. Berlin, Y. Ziv, L. Amaya-Jackson & M.T. Greenberg (eds),
Enhancing Early Attachments: Theory, Research, Intervention, and Policy (pp. 61–78),
New York: The Guilford Press.
Chapter 2
Attachment theory and its

uses in child psychotherapy
Graham Music
Introduction
In this chapter I explore some ways in which attachment theory can inform therapeu-
tic work with children. Attachment theory is a hugely inÀuential body of extremely
rigorous research ¿ndings, maybe the most important set of ¿ndings in developmen-
tal psychology, and as a body of theory it can be extremely useful when thinking
about therapeutic work. However, psychotherapy and attachment research are also
separate domains of activity. While I think that we cannot do psychotherapy these
days without an understanding of attachment, psychotherapy will always rely on a
huge range of other ideas to inform clinical technique, while the main preoccupa-
tions of attachment researchers have been to understand developmental processes
and not clinical change. In the main body of the chapter I will give several brief
case vignettes to try to tease out some of the ways in which attachment theory can
be useful in psychotherapy with children. Before this, I will mention some of the
background to the interface between child psychotherapy and attachment theory.
First, though, in the hope that this will illustrate some of the ways in which attach-
ment theory can imbue our understandings of clinical matters, I describe a typi-
cal few moments in a meeting of the clinical team of which I am a member at the
Tavistock Clinic in London, which of course was where John Bowlby developed
attachment theory. The team works exclusively with cases where there has been mal-
treatment of some kind, and where the child is adopted or in foster or kinship care.
Today’s meeting is unusually testing, with normally thoughtful team members
acting in a bristly manner towards each other about a case that has clearly got
under our skin. The case is one where there are a range of serious worries.
Martin, aged 9, was taken into care initially following the discovery of
bruising, reports of violence in the home, serious drug use by mother,
exposure to inappropriate videos and sexual acts, and a distinct pos-
sibility of sexual abuse. Martin was placed with a foster carer, but this
carer was struggling to hold onto him, and it looked like the placement
Attachment theory and its uses in child psychotherapy 33
was breaking down. In addition, two members of the family had come
forward as potential carers, maternal grandmother as well as one of
mother’s sisters. The two have not spoken since a falling out over a
decade ago.
Martin’s Children’s Guardian (a social worker appointed by the
Court to protect the child’s interests in Care Proceedings) has very
clear views about what should happen (that he should be placed with
grandmother) and social services have quite another idea of what is
best for Martin. Conflict is endemic in this case and is spilling out
everywhere.
Martin we know is hypervigilant and unable to relax or trust anyone,
is very aggressive and everyone is worried about him. Although no
formal attachment measures have been done, few would doubt that
he has a disorganised attachment style. How could he not have? He
has been exposed to shockingly frightening and inconsistent parent-
ing, has had negligible attuned input and has had little choice but to be
hyper-reactive, living in what one assumes is a constant state of high
sympathetic nervous system arousal and little if any belief that adults
can be trustworthy, kind or reflective.
While we heatedly discuss Martin, another colleague is tapping on the table

restlessly and is desperate to talk about Sally, a 15-year-old girl in foster care.
Sally is clingy, anxious and needy, and her foster carer is finding her
a burden. She has been cutting herself, recently took a minor over-
dose, and has been threatening once again to self-harm. Her mother
had abused alcohol and was also inconsistent, at times providing good
thoughtful care, and at others being neglectful and both emotionally
and, often, physically absent. Sally had learnt to be very watchful of
her mother’s moods, carefully monitoring to see if her mother had
been drinking or was about to become depressed, as that was the only
way she could stay safe and retain proximity to her primary caregiver.
When her mother suddenly would disappear Sally would become fran-
tic with worry, and be unable to calm down. Nothing but the physical
presence of a caregiver seemed to help her feel relaxed. Sally, one
would surmise, had an underlying ambivalent attachment style. She
constantly needed to make sure that the adults in her life were okay,
34 Graham Music
as knowing this was how she tried to make herself feel safe. She took
on caregiving in a rather parentified ‘tend and befriend’ way that could
feel intrusive to others, but she also could make adults feel good.
The team had heard about Sally many times before, and the truth was
that people did not really want to hear about her today. The psychia-
trist had assessed her for suicide risk on numerous occasions and was
unlikely to take her seriously. In effect the team was today, like often,
re-enacting an attachment pattern. Here Sally’s needy and clingy self
was being rejected. This time the person feeling for Sally was my finger
tapping colleague who was working with her, and the person chairing
the meeting and the rest of the team seemed to represent the wish
to retreat from Sally’s clinginess and not take her emotional state
seriously.
True to the kind of re-enactments we often see, there is no time to discuss Sally
as we have to think about new referrals. As we do each week, we hear about a
range of cases that all seem urgent. Most of us have our heads lowered when we
are asked if we have spaces to take cases. I ¿nd myself trying to ¿nd a good reason
why one case should really be seen by another team.
This was of a severely learning disabled girl who had been extremely
neglected, who was left to her own devices for much of her infancy
and had severe developmental delay. While it is true that our learning
disability service might well work effectively with her, what was also
true was that I did not have space in my mind for this particular girl’s
problems. I had in effect shut her out. Again maybe this is not surpris-
ing. Afterwards I cannot even remember her name, but I would bet
serious money on her having an avoidant attachment pattern.
These three cases in a brief period of a single team meeting are typical, in that
nearly all the cases we see or hear about can have a helpful light shone on them
from the perspective of attachment. However, for the psychotherapist of course
attachment patterns are not just patterns of behaviour which are objects of study.
They are very predictive of how children live their lives and interact with people
close to them, they also have real, emotional impacts on the other people in chil-
dren’s lives, and these attachment patterns can offer vital clues about a child’s
needs and the best ways of interacting with, and responding to, them.
Child psychotherapy and attachment theory

One might intuitively assume that attachment theory and psychoanalytically
informed therapeutic work with children would be perfect bedfellows, each
inÀuencing the other in helpful ways. In fact, though, these two disciplines
have developed quite separately, with distinct ways of conceptualising the issues
children present with, each using different languages and having their own under-
standings and preoccupations. Rather than a match made in heaven, this relation-
ship was for a long time marked by mutual suspicion, rivalry and tension. The
roots of this rift stretch right back to Bowlby’s time. While, as is well known,
Bowlby developed attachment theory at the Tavistock Clinic, what is maybe less
known is that he also founded the Tavistock’s child psychotherapy training. Yet,
as has been documented carefully elsewhere, Bowlby’s use of an overtly scien-
ti¿c and empirical paradigm was not well received by his Tavistock psychoana-
lytic colleagues. Psychoanalytic psychotherapy has always been preoccupied
with inner worlds, the unconscious, fantasy, defences and processes such as
projection, and in the early days there was less room for conventional scienti¿c
methods, for research or experimentation. Maybe more importantly, the more
behavioural orientation of early attachment theory was particularly anathema
to psychoanalytic therapists, who wanted to focus on ‘deeper’ and unconscious
forces.
Early attachment theory, well before Main’s Adult Attachment Interview (AAI)
(Main and Goldwyn 1995), paid little heed to thoughts and fantasies, and although
Bowlby did have a concept of internal working models, these were viewed as a
rather concrete internalisation of real parental relationships, a somewhat crude and
blunted version of the more elaborated and sophisticated forms of fantasies one
saw in children’s play, and the complex internal relationships being interrogated
by child and adult psychotherapists.
In the following decades, attachment theory and child psychotherapy tended
to follow diverse paths. Attachment theory became one of the more rigorous and
best researched bodies of thought about how children develop. Later, subtle ways
of understanding representational worlds, such as AAIs for adults and story-stem
research with children (Hodges et al. 2003), allowed a rapprochement between a
focus on behaviours and inner world of representations. Despite hugely inÀuenc-
ing whole areas of policy and practice, whether in childcare, adoption, assessing
families or organising nurseries, attachment theory is ¿rst and foremost a body
of research, and not a way of intervening. In the decades that attachment theory
was developing, psychoanalytically informed child psychotherapy ploughed an
equally auspicious furrow, pushing the boundaries of the kind of cases that could
be seen for therapy, beginning to work with some of the most troubled children
in society (Boston and Szur 1990), extending its ¿eld of practice to children who
have been in the care system (Kenrick et al. 2006), to autistic children (Alvarez
and Reid 1999) and those who have suffered all manner of other forms of psycho-
logical and emotional deprivation (Alvarez 2012).
36 Graham Music
In the meantime the world of developmental science was being turned upside
down. Building on the early work of Sander (2007), Stern (1985) and Brazelton and
Cramer (1991) we have seen an extraordinarily swift expansion in related ¿elds. For
example, work in neurobiology (Schore 2012), ¿ne-grained research about maternal
depression (Murray and Cooper 1999) or how infant minds grow (Reddy 2008) and
the biological systems linked with this (Panksepp 2007). Overall knowledge from
the ¿eld of developmental psychology has grown exponentially (cf. Music 2010).
Some of the most important ¿ndings have been made by skilled clinicians who
have also undertaken careful research into early infancy and its effects, thus making
careful links between research and clinical practice (Tronick 2007; Beebe and Lach-
mann 2002). Mentalisation (Fonagy et al. 2004) also linked therapeutic practice and
developmental ¿ndings. Yet, despite this, few therapists have until recently seriously
taken the research ideas of attachment theory directly into their therapeutic theory
and practice. There are a few exceptions, such as Jeremy Holmes in adult psycho-
therapy (Holmes 2001) and Juliet Hopkins in child psychotherapy (Hopkins 1990),
and although there have been others, this group has been surprisingly sparse.
On the other hand, there has been a whole gamut of forms of therapy that claim
to be based on attachment theory and which often endorse practices which few
attachment researchers would countenance, indeed often based on ideas that such
researchers would barely recognise.
The most controversial examples are the various forms of both holding and
regression therapies (Simmonds 2007). Such therapies have often been viewed as
part of a worrying fringe movement, one that those seriously interested in attach-
ment theory want to distance themselves from (Prior and Glaser 2006). There have
also been some well researched brief interventions which have attachment theory
at their core (Marvin et al. 2002; Juffer et al. 2008), and these have mainly tended
to be brief, structured interventions with young mothers and their infants, focusing
on enhancing parental sensitivity and facilitating more secure attachment styles.
Thus, on the one hand we have a rigorous body of attachment research ¿ndings
being developed in research laboratories, and on the other hand we see therapeutic
practice which often is working to principles very similar to attachment theory but
is seemingly making little direct use of the ideas. Increasingly child psychothera-
pists have been inÀuenced by the new developmental ¿ndings, such as the now
inescapable knowledge that babies are interpersonal and reciprocal from birth
(Bråten 2006), that they imitate and learn from their ¿rst minutes (Meltzoff 2007),
that they respond to rhythm and prosody (Trevarthen 2004) and that relational
templates are taking root in the ¿rst months of life (Beebe and Lachmann 2002),
in the form of procedural memories.
Alvarez (1992), for example, had adapted and transformed her psychoana-
lytic child therapy technique due to the inÀuence of such ¿ndings, and we see
other work inÀuenced by similar ideas (Green 2003), while Greenspan (2008)
has always espoused a more developmental approach. Yet when closely exam-
ined, these therapists are not explicitly using attachment theory, although its ideas
are often taken for granted. Rather, they are inÀuenced by other areas of infancy
research, such as how we come to understand other minds, how empathy devel-
ops, how we internalise expectations of relationships, how trauma might affect the
nervous system, and people’s hormonal cocktails.
The reasons for this might in part be that attachment theory as a body of scien-
ti¿c research on its own could never be a whole theory about therapeutic work. The
term ‘attachment’ of course can be used more loosely, to describe people’s rela-
tionship styles, or why parents are important, and in that looser sense attachment
is and has always been central to therapeutic work. Therapy has always focused
fundamentally on the ways in which people negotiate intimate relationships, the
transference relationship with the therapist being one important example.
An excellent example of such an approach is Mills’ work on Attachment Pathol-
ogy (Mills 2005). Attachment theory in its more rigorous research variants has a
more back-seat role in terms of psychotherapy practice, alongside related ¿elds
such as neurobiology, infancy research, the science of play or new understand-
ings of how memories and expectations of relationships form. Attachment makes
a hugely important contribution to therapeutic practice, but it will always only be
part of the story. I will now introduce some clinical issues and case examples to
try to develop these ideas more.
Clinical cases
Trevor
While I am sitting anxiously, about to meet Trevor, who I see weekly
for psychotherapy, I notice my heart is beating fast, my stomach is
tight and my breathing seems to go barely lower than my neck. I have
all the symptoms of sympathetic nervous system arousal (Porges 2011)
even before Trevor arrives, and in his presence I often find that I am
bracing myself for something bad to happen. I had had an anxious jolt
as I thought about him on my way into work, and now I am remember-
ing last week’s session, the toys flying close to my head, the fact that I
confiscated the scissors just in time, how Trevor managed to force his
way into another staff-room on his way to his therapy, inevitably the
room of a very eminent colleague who I assumed glared disapprovingly
at me. In some weeks the sessions have become so difficult that I have
had to stop them and take him back to the waiting room. He has also
been known to run down the stairs and out into the street, to let off
fire extinguishers and deliberately flood the toilets. The reception and
ancillary staff all know Trevor well.
Trevor has been the victim of domestic abuse; his mother was a
prostitute and her partner a violent man, dealing in drugs, sex and
38 Graham Music
fear. He was taken into care at two years old, and has already had a
string of foster placements. Trevor had no further contact with his
mother after he was taken into care, as his mother had never turned
up for contact meetings. He was placed for adoption but no one came
forward for him and now, at six, he is in the process of being approved
for long-term foster care. Much as the neuroscience would predict,
he is a hypervigilant, rarely still boy, who expects danger everywhere,
and with whom one must be cautious, not moving too fast, not varying
anything too quickly. He was a bit of a whirlwind anyway but has been
in a tumultuous mood since he was told he will not be staying with
his current carers. They, in fact, feel too old to give him the ongoing
care he needs. At the point of referral he was already at serious risk
of exclusion from school. He was violent with other children, had few
friends, was often a bully in the playground, and he struggled to con-
centrate or to learn. He had a statement of educational needs with 18
hours a week of one-to-one support, but still the school were unclear
about whether they could hold onto him.
In the initial assessment I found Trevor was wary and charming with
an edge of potential threat about him. He seemed unable to play sym-
bolically and said that the toys in the box were ‘for girls’. As I have
found so often with such boys, an inordinate amount of time was spent
playing football. In our football games he always wanted to win and he
made sure he did so. He would score a goal, clench his fist in triumph,
yelp triumphantly and look disdainfully in my direction. He would often
coax me into believing that he would let me have a tiny moment of
glory, suggesting I might be able to score one meagre goal to his hatful,
but he always at the last moment quashed my hopes and left me feel-
ing tricked, betrayed and stupid. He was projecting something of his
own horrible experience into me and took malicious delight in this. It
felt better of course for me to be the victim, and his world primarily
consisted of victims or perpetrators. I thought he was on the cusp of
hoping that I (as projected into) could somehow make sense of the
experiences he was trying to get rid of, being tricked, abused, manipu-
lated; however, he was also on the cusp of becoming addicted to the
‘secondary gain’ of the pleasure in the power and violence.
He had enough understanding of my thoughts and feelings to work
out how to trick me, but this is very different from real empathy. For
him, other people were not there to be liked or to be interested in,
but were a means or an obstacle to his end.
Interestingly, when psychopathic adults watch people’s faces or actions, their

brains (Deeley et al. 2006; Hein and Singer 2008), show different patterns of
activation from those of the general population. They display less capacity for
empathy and less ability to understand the emotions of others or awareness of their
own feelings. I suspect that Trevor’s brain might show similar abnormal neuronal
activation. Indeed his potential for cruelty was at times chilling.
We know that securely attached children generally have high empathy, get on
well with peers and are able to be reÀective and Àexible. Not so disorganised boys
like Trevor. As so often happens with children like Trevor, his language was delayed
and certainly he had little emotional vocabulary. He also had little capacity to reÀect
on his life, barely any autobiographical capacity (he could not imagine himself into
a future and had no real stories about his life up until now) and, like many such
children, he lacked a capacity for symbolic play. At the same time he could barely
ever be still, was very vigilant and reactive and was always getting into trouble.
It is easy to see how he might be given diagnoses of Autistic Spectrum Disorder
(ASD), Attention De¿cit Disorder (ADHD) and Conduct Disorder, and too often
maltreated children are wrongly diagnosed (see DeJong 2010) as psychiatric clas-
si¿cations rarely capture the complexity of these children’s problems (see Gutjahr
in The Routledge Handbook of Attachment: Theory (Holmes and Farn¿eld 2014)).
In my work with Trevor I found that I had to address him at a very basic
level (Alvarez 2012), trying to name emotions, but with feeling (‘That
made you very very cross!’). I would try to resist the deadening pull
of constant football and when we played, try at least to expand on the
characters. Didier Drogba and John Terry were his heroes, ruthless and
triumphant figures with whom he identified. It was possible to momen-
tarily wonder about the feelings of these alpha-male footballing pro-
tagonists, or about their character traits, which he would allow briefly
before stating, ‘Can we play properly now?’ Moments of thought could
be only occasionally allowed into the sessions. When he did not like the
fact that I scored he might say, ‘No, I was not ready’, and at best I could
just about talk about how upsetting and annoying it was when things did
not go his way. Much of the play felt dead and sterile, interspersed with
sadistic attacks and sudden outbursts which could be frightening.
Today in the room he speedily takes a toy, a female doll about the
age of his carer, and makes to destroy it. I take a step back, aware
of the possibility of an eruption but knowing I must steel myself, and
take a huge deep breath, and say loudly but calmly, ‘Why on earth
should you believe anyone cares, it’s just not fair’. He continues to
tear at the doll, but less wildly, half glancing at me. I say, ‘Of course
you sometimes want to lash out and don’t know why’, but I realise I
40 Graham Music
have made a mistake, and he glares with menace. For kids like Trevor
just the word ‘you’ can feel accusatory and persecutory. I take a step
back, remember to try to re-find my body, take a deep breath and then
begin to talk aloud, with feeling, as if to myself. ‘Sometimes we can
have huge jumbly feelings inside and we want to just explode, they can
seem to come from nowhere’. He is still glaring, but there is a sense
of a lowering of the temperature. At a stretch one might think of this
as attunement; I was certainly trying to reflect back to him something
of his own experience, but sufficiently digested that he might take it
in (Bion 1962b). I breathe again and watch, and I notice him watch me,
and surprisingly, he takes a deeper breath himself. He reaches back
into the toy box and takes out some vehicles, including the ambulance.
I think that I have reached and re-found a slightly trusting part of him,
and he has remembered that rescuers, in the form of the ambulance,
exist. It is not always that way, and rarely lasts long at this stage.
In a session some six months later, partly out of frustration but
also maybe with a little hope that some potential shift was occurring,
I began to get toy animals out myself, in a rather desperate hope that
he would start to play a bit. In one session, I got out a baby pig and
said, ‘Oh here is a little pig’. The other toys included a crocodile and
he took this, taped its mouth with Sellotape and in just a few seconds
the protection afforded to the other animals by the tape had been
rendered useless. A series of killings of large and small animals took
place, gleefully and triumphantly. Chilling as this was, it allowed me to
talk about feelings and what was happening, which in turn enabled him
to continue playing, albeit for only a few minutes. By this time he was
in a Pupil Referral Unit, excluded from his mainstream school. He had
begun to be able to talk a little more, to explain some tiny things to
me when asked, but his speech remained rudimentary. He said, ‘There
is this boy’, as if I would know who he meant. I asked, ‘Yes Trevor, this
boy . . .’, and he said, ‘Food all over his face’. The start of a meaningful
story perhaps, but a very minimal one. Small moments of hope were
creeping in. In one session he was about to take a shot at goal and he
momentarily hesitated. Normally I would have missed the moment
but this time I asked where his mind was. He looked surprised that I
asked, and then said, ‘I was thinking about my old school’. Maybe there
was a sign here of the tiniest beginnings of a thinker who could think
thoughts (Bion 1962a). I said, ‘Wow Trevor, you really are having
thoughts, and we can get to know your thoughts’.
This led in a few sentences to how he wished he was still at his old school and
how, ‘I think about it lots of the time’. He had never had the kind of attuned atten-
tion (Stern 1985) that forms the basis of a developing sense of self in relation to
others (Beebe and Lachmann 2002).
These changes were fairly slight. He was still extremely challenging at

school and at home and people remained worried about him. A few
weeks later there were hopeful moments when he talked about how
‘bad’ he had been (probably told to do so by his carer). I was able to
be slightly playful with him and with his help we gave a name to this
‘Cross Trevor’, and I tried to guess what ‘Cross Trevor’ was feeling
when he got so angry in a recent incident. He said, ‘You sound funny’
but seemed visibly to relax, I think at the idea that ‘Cross Trevor’
might not be all of him. At the same time I saw some tiny examples
of him being less reactive. The end of his pencil kept breaking, some-
thing that would have made him very angry previously, but this time
he said, ‘Okay I can do it’ as he again sharpened it. Some belief that
things could come right was forming, and some idea that he need not
be overwhelmed. I said, ‘Well it is not so bad, that’s a new Trevor, not
Cross Trevor’, and he said, ‘No that’s Boy Trevor’ and a new charac-
ter had formed. ‘Boy Trevor’ was to play a role in our therapy for the
remaining time. Boy Trevor grew out of a sense of self-developing, and
a belief that he could have some control over his life, that mismatches
and ruptures in relational moments (Tronick 2007) were repairable
and not disastrous.
A few weeks later in the midst of a football game he turned the light
on and I observed a slight flicker of interest and asked him what he
noticed and he said, ‘The colour’. I said, ‘Isn’t that amazing, the room
seems to change colour when you turn the light on’. He did it again and
looked at me and then said, ‘The room goes sort of pink’. I said, ‘Yes
the whole room seems to change, and what is so-oo interesting is that
Trevor, you noticed it’. I thought this was the nearest he had been to
aesthetic appreciation (Meltzer et al. 1988). He looked pleased, did it
again and said, ‘It makes a sound’. I said, ‘Wow yes, you have noticed
the sound it makes when you turn the light on’, as I cocked my ear
dramatically, and he did it again. Then he said, ‘It’s like a star’, which
I repeated and said how interesting it was when we noticed things.
I think this is the kind of early attuned input that most lucky babies
receive, but not children like Trevor who so often manifest a wide
42 Graham Music
array of serious developmental deficits. Interestingly at the end of this

session, for the first time ever, he ‘helped’ me to put away his things
into the box, maybe not the most altruistic gesture ever but another
tiny change. Similarly school and home had both spotted examples of
increased thoughtfulness, such as offering to help clean something up
that was spilt at home.
Trevor like all children is unique, but also shares many similarities with
others who develop disorganised attachment patterns. All attachment patterns are
adaptive, including the disorganised pattern. In fact these children can be highly
organised, and are perpetually on high alert in case of danger. They can look like
they have no strategy but their responses make sense, given their environment.
Trevor was also typical in other ways. He had a low threshold for frustration,
poorly developed abilities to self-regulate, and a hypervigilant and very easily
aroused sympathetic nervous system. Like many with disorganised attachments,
he could Àip from being very controlled and rigid to extremely chaotic behaviour.
My single hour a week was hard work, but I had it easy compared to others, with
the luxury in that hour of only concentrating on him. I do not have 30 other kids
to teach, or the washing up to do at home, or umpteen other kids on my social
work caseload and reports to write. In my hour a week with Trevor I saw my role
as trying to ¿nd a small oasis of calm, a place of safety in the room and in him-
self, which we might build and grow. This is the window of tolerance that Ogden
describes (2006), a window that for such children is often very narrow. For Trevor
it takes little to Àip out of this window of tolerance into very tense, angry states,
sometimes also frightened ones. It is hard to believe that I or anyone else can
really be trusted or thoughtful. However, as this window slowly became more of
a trusted place, some narrative and reÀection also became possible, and he in fact
became more likeable as he began to be able to concentrate a bit, and even be a
little more empathic. He began, while in this window, to show signs that we often
see in secure attachment, such as empathy, curiosity, con¿dence, trust in others,
belief that he could be cared for, interest in others and even enjoyment. These
remained very shaky and rudimentary but were coming alive as real potentials.
Lucas
After Trevor, I see nine-year-old Lucas. Lucas was born into a family
with parents who were distant and could not bear emotions. Neigh-
bours reported him being strapped in a baby stroller for hours, left
to his own devices, rarely picked up, having baby bottles shoved in
his mouth and being given little stimulation or interpersonal contact.

It is fascinating that my body, mind and feelings are completely differ-
ent with him, compared to Trevor, as if I am another person. While
I wait for him I note myself feeling deadened and distracted. I know I
take longer to answer the receptionist’s phone, that I am not looking
forward to seeing him, and I feel wooden in my body as I go to collect
him. I predict correctly the ensuing ritual, where he will be sitting, his
posture, his looks, his words, and how the start of the session will go.
I steel myself in a different way with Lucas than with Trevor, to help
bring some aliveness and hope. It took me a while until I could admit
to myself that I found him dull. My guilt was lessened when I learnt just
how others such as his teachers, and more worryingly, his parents, felt
about him. His adoptive parents have another child, a daughter who
has a more ambivalent attachment pattern, who was traumatised and
who acts out dramatically, and who claims most of their attention. He
is rather too ‘easy’ and in some ways they are relieved when Lucas is
up in his room playing play station and reading Argos catalogues. This
is rather like his teachers, who are glad there is a boy sitting quietly
at the back of the class not causing trouble, even if he is not learning.
They are not drawn to him, and in fact few people are, and he has few
friends. He does not easily elicit worry or concern or interest. He is
in many ways typical of many of the neglected children we work with,
who can so easily continue to be neglected as they get older, because
they do not inspire interest, or concern, or enjoyment.
Both Lucas and Trevor affect all those around them in very different ways,
but each affects us profoundly. We need to be affected by them to know them, as
well as having tools to understand the meaning of their behaviours. I think only in
this way can we hold them in our minds. Lucas is typical of many with avoidant
attachment styles. He had been brought to therapy but certainly did not think he
had a problem. To his parents he was a mystery and they felt disconcerted that they
could make so little contact with him. They were warm and affectionate people
but received little back from him, and found themselves becoming hurt and angry,
or withdrawing. He evoked frustration and hopelessness in them, feelings I soon
understood too. At school, too, he was seen as a little odd and something of a
loner. He was described, sometimes to his face, as ‘lazy’ and ‘stubborn’. Sessions
were dull, and he would sit, stare, look compliantly, and then hesitantly tell me
what he was going to do that day. Each session was neatly divided up: he might
start by saying, ‘I will talk about my dreams for three minutes, things at home for
44 Graham Music
four minutes, play a game of hangman for ¿ve minutes, talk about worries for four
minutes’.
Attachment patterns are of course adaptive and Lucas had adapted to a very
bleak world. Unfortunately he did not really believe that another, more lively,
human or emotional world existed. I found myself at quite a loss as to how I
might ever have any impact on him and his detached attachment style. What I
have learnt from working with such children is that one has to carefully watch the
feeling stirred up in the therapist, what we call our countertransference, maybe of
boredom, irritation or drifting away. Being bored, watching the clock, mentally
writing shopping lists, these are all useful sources of information but when we
indulge in them then that is an enactment or acting-in (Aron 2001). On one occa-
sion when I was in a kind of half-alive torpor I managed to concentrate hard on
what he seemed to be experiencing, and surprisingly found myself feeling some
sympathy. I am fairly sure in response to a change in my feeling tone, he looked
up and smiled, a small moment to cherish, one from which some genuine relating
followed; for once there was a smile which seemed real, not compliant. At such
moments when I spoke I know my voice had more urgency, but also genuineness,
I was ‘calling him back’, ‘reclaiming’ (Alvarez 1992) him, and he could respond.
Slowly he seemed to slightly loosen up, as I found a way to empathise

and feel my way into his world, and as a result I realised I could find
myself liking him. Then I could be more actively challenging of him in a
way that he would not feel as critical and judgemental. Sometimes my
attempts to engage him were all too clearly expressions of my frustra-
tion, and then my less than sympathetic tone precluded real contact.
When my attempts to reach him had urgency but not frustration, and
challenged him warmly, then real contact was made. When as I leaned
forward slightly I said, ‘Huh, when you turn away like that it is like I am
too much for you, and you forget I can be someone you can talk to’,
he looked up and his tone changed. These small changes nearly always
seemed to result from immersing myself in an aspect of his being that
I found almost unbearable, but that it helped to know. As he bounced
his leg, I bounced mine in response and he looked up at me and awk-
wardly smiled.
There was maybe the beginning of ‘reciprocity’ (Brazelton and
Cramer 1991) as he stopped jigging his leg, and I did too, he then
looked up again, jigged and waited for me to respond. Here developed
an ordinary rhythmic to-and-fro that most babies engage in with their
parents, but which Lucas had lacked. He was developing the beginnings
of a capacity for conversation in which eventually slightly more difficult
feelings could be processed. It made no sense to him when I talked, as

I did too much, of breaks between sessions, or of holidays. However,
when in a game I enacted being suddenly stopped in my tracks and
expressed frustration, he seemed to enjoy this. He looked awkward,
then laughed, and in the next session he did a slightly wooden ver-
sion of the same thing, showing a capacity for both introjections and
for ‘deferred imitation’ (Meltzoff 1988). He had also become slightly
humorous, which as we know is always a hopeful sign. He had begun to
be interested in what I was making of him, starting to believe that I had
a story in my mind about him, the kind of story that securely attached
kids take for granted that their parents have about them.
As Lucas began to seem more lively in his play I sometimes saw
rather disturbing and sickly scenes being enacted, such as horrible
deaths and torture. Animal and human toys were lined up, hurt and
killed. If I interpreted this in a way that revealed any hint of disapproval
his play ground to a halt. When I realised what was happening, I could
stay with the play more, and it at times did turn into a sickening frenzy
of death and destruction, although still expressed in his rather wooden
and slightly deadened way.
As horrible as it could seem, there was some ‘wanting’, some ‘desire’, in his
play which needed encouraging. Sometimes when something frozen begins to
thaw out, what replaces it might be traits that we ¿nd abhorrent. In the cases I
have seen, tolerating this has been a stepping stone in development, rather than
the unleashing of psychopathic monsters. What such kids lack, as well of course
as the belief that other people can be interested and responsive, is that life can be
richer and that vitality and interest can be enjoyable and not anxiety provoking.
Beatrice Beebe found that many such children, as mere four-month-old babies,
could not look at their mothers when they smiled at them, they had their heads
‘cocked for escape’ and self-soothed (Beebe and Lachmann 2002). Gently show-
ing that the relational world is safe, and even pleasurable, is a big part of working
with avoidant children.
In time he began to show some initiative, and a sense of agency, but

maybe more importantly, seemingly the beginnings of fun. Fun and
positive emotions are neglected in the psychoanalytic literature (Music
2009), but for children like Lucas who have not been really enjoyed,
they are crucial. Alvarez (1992) suggested that while the child who
46 Graham Music
jumps on the chair and shouts ‘I am king of the castle’ might be being
defensive, for some children this act might be the first experience of
feeling strong and confident, and they need this to be validated. I had
to be very careful with Lucas to try to ensure that the tiny signs of
hope and self-belief were noticed and mirrored. I am quite sure that
I often felt so dulled in his company that I completely missed them.
Slowly, though, his communications became slightly louder, firmer and
clearer, as if he was beginning to believe that there were other people
who could be interested in him. In his attempts to make things with
the therapy toys, he seemed to have developed more determination
and began to try harder, to not give up so easily, and he developed
confidence that he could make things happen. Often when he tried to
do something, like build a tower, and he seemed to be failing, he would
quickly give up. I would then begin to actively encourage him (‘yes you
can do it, no need to give up, wow, you are doing well’). He was rather
like the children of depressed mothers that Murray (1992) or Field and
colleagues (2006) studied, who tend to be passive, with little sense of
agency or self-belief.
Old attachment templates never disappear, but new ones can slowly grow and
I think this was happening with Lucas. His parents also became more relaxed. It
was not just because Lucas was changing, but also that we had helped them to
understand Lucas, to make sense of why he was as he was, to link this with his
past. This allowed them to feel sympathy and warmth towards him and less self-
blaming. Therapy was of course only part of the story. Playing a lot with his more
demanding adoptive sister also had quite an effect, I am sure. One really positive
sign was that he was invited to a couple of parties, which had not happened before,
and suggested that he was entering the world of peer relationships in a new way.
I still certainly felt bored at times, and frustrated, and my heart never raced like it
did with Trevor. However, some aliveness was de¿nitely forming.
Grace
Later I looking forward to seeing 16-year-old Grace; she was an easy
person to be with after Lucas and Trevor. She smiled at me slightly
nervously in the waiting room, looked at me longer than usual and
followed me to the room. She was very careful to ensure that she
left enough space when someone else came along the corridor in the
opposite direction, looked down and smiled awkwardly. In the room

she sat with her body half turned away and half turned towards me and
she asked me, ‘How are you?’ This was not the first time she had done
this, but today it was as if she had something on her mind. I asked, ‘How
come you are wondering this today?’ She replied, ‘I thought you looked
tired’. She provided me with a classic psychoanalytic dilemma. I in fact
was tired, as I had been working away all weekend and had had no time
off. As relational analysts have pointed out (Aron 2001), often patients
know something about us before we know it about ourselves, and then
it is not helpful to just bat back their questions or be evasive. I find this
to be commonly the case with people who have ambivalent attachment
styles. Rather like Sally who I mentioned in the introduction, Grace
had learnt to monitor the important adults in her life very carefully.
She was brought up as an only child by a single mother who was very
needy and often depressed. Grace had felt responsible for her mother’s
moods, something it seems her mother encouraged. Her mother could
also be subject to angry outbursts which, as a child, Grace had found
very frightening. Often when I have a serious expression on my face she
can suddenly look very worried. Her ambivalent attachment style was
an extraordinarily nuanced adaptation to her early environment, but
our early presuppositions about relationships are hard to unlearn.
Grace was doing well academically and also had a lot of friends at
school. Yet she often felt very alone. Her friends relied on her a lot
and she had developed an adeptness at using ‘tend and befriend’ ways
of keeping people at ease and making sure that they were not too
upset. Yet she reported often feeling terribly rejected and hurt. A
typical example was when she was not invited to a party of a friend
and was mortified. She could not stop thinking about this for weeks, it
went round and around in her head. She even, somewhat masochisti-
cally, found herself walking down the road where the party was being
held. Such desperation was not uncommon. Following a split up from
a brief relationship she would haunt the areas where she thought her
former boyfriend might be, hoping to bump into him ‘accidentally’.
In therapy I found that breaks were particularly tough and she would
often get tearful just before. She was of course far too polite to pro-
test, and indeed she was in many ways the perfect client. She always
arrived exactly on time, almost never even a minute early or late, and
on the rare occasion that she was about three minutes late she apolo-
gised profusely.
48 Graham Music
Her comment about me being tired challenged me. She obviously

had accurately picked up something about me. I decided to say that
yes, I probably was a bit more tired than usual. Rather than asking her
how she felt about that, I decided to remark on just how very good
she was at picking up my feelings, as she was with other people too.
It seemed, I said, to be like a basic survival response, as if the world
would feel terribly unsafe if she did not know. She looked relieved and
lent back into the chair, a bit more relaxed. I said how hard it seemed
to believe that I might still have her in my mind even if I was a bit
tired. I said that she really believed that if she did not look after me,
or whoever she was with, she would be rejected or dismissed or just
be dropped from our minds. She began to cry. She had often cried, but
in a rather desperate way. This time the crying was deep, from the pit
of her belly. Afterwards she looked brighter in her face, more at ease,
and she began to talk about memories of her childhood. I had heard
some of what she talked about before, but even though some of the
content was the same, there was a slightly new feel to it, one that had
been creeping into the sessions in recent weeks. She felt angry and
aggrieved that she had wasted so much of her childhood looking after
her mother and being fearful of what would happen if she did not. The
anger seemed to suggest a new sense of self-worth starting to form. It
need not be her lot in life, she was beginning to believe, to always be
the one who looked after others.
She still had to look carefully at me after this, check I was with her,
that she was not being too much. These patterns take a long time to
change. Slowly though she began to trust that she could relax a bit,
take the guard down. My main clue that this was genuine came when I
noticed that I felt more at ease, which was linked to not being moni-
tored quite so much. In effect a new template of emotional relating
was beginning to develop in Grace. It was not going to replace the old
ones of course, but could slowly and steadily take root and begin to
grow. Silences began to occur in our sessions, in the way that Winni-
cott described, a sense that one could be alone in another’s presence
(Winnicott 1958). This, of course, is what one sees in a secure attach-
ment relationship. Children feel free to leave their caregiver and go
off and play, knowing that, when needed, there will be someone there
for them. This was not what Grace had initially learnt to believe about
the world.
Such changes were slow and incremental, with many backward steps. Luckily
we had time and Grace came for several years. One session just after a summer
break I expected her to come in quiet and contrite, as she often would, checking
that I was okay, monitoring my mood. Instead she barely glanced at me and told
me in no uncertain terms that she was very angry that I had gone away at this time.
She knew, she said, that her feelings were irrational but she had needed me. In the
past this might have been said in a forlorn self-pitying way at most. However, this
was a ¿rst, an expression of anger, albeit of a very tentative kind. Winnicott again
had something to say about such moments (Winnicott 1971). He understood that
children needed to know that the full force of their emotions could be received by
another, who could bear and survive these feelings, whether of distress or particu-
larly of rage and hatred. Only this allowed children to feel genuinely separate from
the other. Children with ambivalent attachments rarely feel this but hopefully with
Grace it was beginning. She was getting interested in herself as a feelingful person
with hopes and dreams, whom others might take seriously. She could begin to
believe that others might be there for her when needed, that she did not have to
constantly monitor them, that she could sometimes forget about them, and that her
life might be lived from an inner sense of trust and belief, again much as we are
likely to see in securely attached people.
Summary
Each of these cases, and indeed probably all of the cases seen in our team, can be
thought about in attachment terms. Attachment theory of course does not explain
everything about these children. We need to understand in addition many other
things to work with such children, such as the power of pernicious introjects,
forms of transference and countertransference, the ways defences form and are
maintained, the power of resistance to change, and of course the whole complex
world of therapeutic technique, of what and how to say things, how to be with
clients, when to challenge, when to be empathic, what kind of feeling tone to
adopt, and so much more. However, attachment theory does help to make sense
of the kinds of relational patterns that children have developed, and gives us an
understanding of why such entrenched ways of relating have developed. Child
psychotherapy works primarily and fundamentally with relationship templates as
they manifest themselves in the consulting room, as well as in other areas of a
child’s life.
As will already have been gathered from these examples, attachment theory can
really help to make sense of a child’s expectations of relationship, what Daniel
Stern called RIGs or Representations of Interactions Generalized (Stern 1985),
what Bowlby described as internal working models (Bowlby 1969), but this under-
standing is by no means mainly cognitive or abstract. Child psychotherapy works
with such patterns as they become alive in the therapy room, and in our relation-
ships with these children. If our understanding is to be helpful, it has to be of an
emotional kind. When therapy is going well we are able to make emotional sense
50 Graham Music
of the kinds of feelings and ideas that we ¿nd are affecting us while we are with a
child; we can remain open and curious about the ways in which we ¿nd ourselves
prodded into acting in certain ways in a child’s presence (Sandler 1993), and we
can process rather than act on the thoughts and feelings that are evoked in us. The
child psychotherapy consulting room, as I see it, is a kind of crucible for psy-
chological, indeed psychobiological, enactments that need to be born, processed,
internally modulated and helpfully used in the service of the child’s development
(Bion 1962b). Like with metal or glass, in the heat of the therapeutic relation-
ship opportunities arise for new patterns to be forged, new relational shapes to
be experimented with, and new hopes and beliefs about attachment, intimacy and
trust, to come alive and take a solid form. Of course the old templates remain, but
they hopefully slowly diminish in power. Our attachment styles are interpersonal
and our relationship styles are learnt with real people. Just as a child might have a
secure relationship with one parent and an insecure one with another, new, secure
relationship representations can grow from within a therapeutic relationship to
become internalised as structured aspects of the personality. I hope this was hap-
pening with Trevor, Lucas and Grace.
References
Alvarez, A. (1992) Live company (London: Routledge)
Alvarez, A. (2012) The thinking heart: Three levels of psychoanalytic therapy with dis-
turbed children (Oxford: Routledge)
Alvarez, A. and Reid, S. (1999) Autism and personality: Findings from the Tavistock
Autism Workshop (London: Routledge)
Aron, L. (2001) A meeting of minds: Mutuality in psychoanalysis (New York: Analytic
Press)
Beebe, B. and Lachmann, F. M. (2002) Infant research and adult treatment: Co-constructing
interactions (New York: Analytic Press)
Bion, W. R. (1962a) A theory of thinking, Melanie Klein today: Developments in theory
and practice 1: 178–86
Bion, W. R. (1962b) Learning from experience (London: Heinemann)
Boston, M. and Szur, R. (1990) Psychotherapy with severely deprived children (Stylus
Publishing, LLC)
Bowlby, J. (1969) Attachment and loss. Vol. 1, Attachment (London: Hogarth)
Bråten, S. (2006) Intersubjective communication and emotion in early ontogeny (Cam-
bridge: Cambridge University Press)
Brazelton, T. B. and Cramer, B. G. (1991) The earliest relationship: Parents, infants, and
the drama of early attachment (London: Karnac Books)
Deeley, Q., Daly, E., Surguladzes, S., Tunstall, N., Mezey, G., Beer, D. et al. (2006) Facial
emotion processing in criminal psychopathy: Preliminary functional magnetic resonance
imaging study, The British Journal of Psychiatry 189: 533
DeJong, M. (2010) Some reflections on the use of psychiatric diagnosis in the looked after
or ‘in care’ child population, Clinical Child Psychology and Psychiatry 15: 589–99
Field, T., Diego, M. and Hernandez-Reif, M. (2006) Prenatal depression effects on the fetus
and newborn: A review, Infant Behavior and Development 29: 445–55
Fonagy, P., Gyorgy, G., Jurist, E. L. and Target, M. (2004) Affect regulation, mentalization,
and the development of the self (London: Karnac Books)
Green, V. (2003) Emotional development in psychoanalysis, attachment theory and neuro-
science: Creating connections (London: Routledge)
Greenspan, S. I. (2008) A dynamic developmental model of mental health and mental
illness. In A. Fogel, B. J. King and S. G. Shanker (eds), Human development in the
twenty-first century: Visionary ideas from systems scientists (pp. 157–75) (Cambridge:
Cambridge University Press)
Hein, G. and Singer, T. (2008) I feel how you feel but not always: The empathic brain and
its modulation, Current Opinion in Neurobiology 18: 153–8
Hodges, J., Steele, M., Hillman, S. and Henderson, K. (2003) Mental representations and
defences in severely maltreated children: A story stem battery and rating system for
clinical assessment and research applications. In R. N. Emde, D. P. Wolf and D. Oppen-
heim (eds), Revealing the inner worlds of young children: The MacArthur Stem Battery
and Parent–Child Narratives (pp. 240–67) (Oxford: Oxford University Press)
Holmes, J. (2001) The search for the secure base: Attachment theory and psychotherapy
(London: Routledge)
Holmes, P. and Farnfield, S. (eds) (2014) The Routledge handbook of attachment: Theory
(London and New York: Routledge)
Hopkins, J. (1990) The observed infant of attachment theory, British Journal of Psycho-
therapy 6: 460–70
Juffer, F., Bakermans-Kranenburg, M. J. and Van IJzendoorn, M. H. (2008) Promoting
positive parenting: An attachment-based intervention (New York: Taylor & Francis
Group)
Kenrick, J., Lindsey, C. and Tollemache, L. (2006) Creating new families: Therapeutic
approaches to fostering, adoption, and kinship care (London: Karnac Books)
Main, M. and Goldwyn, R. (1995) Interview-based adult attachment classifications: Related
to infant-mother and infant-father attachment, Developmental Psychology 19: 227–39
Marvin, R., Cooper, G., Hoffman, K. and Powell, B. (2002) The Circle of Security project:
Attachment-based intervention with caregiver-pre-school child dyads, Attachment &
Human Development 4: 107–24
Meltzer, D., Williams, M. H. and Trust, R. H. (1988) The apprehension of beauty: The role of
aesthetic conflict in development, violence and art (Clunie Press for Roland Harris Trust)
Meltzoff, A. N. (1988) Infant imitation and memory: Nine-month-olds in immediate and
deferred tests, Child Development 59: 217–25
Meltzoff, A. N. (2007) ‘Like me’: A foundation for social cognition, Developmental Sci-
ence 10: 126–34
Mills, J. (2005) Treating attachment pathology (New York: Jason Aronson)
Murray, L. (1992) The impact of postnatal depression on infant development, Journal of
Child Psychology and Psychiatry 33: 543–61
Murray, L. and Cooper, P. (1999) Postpartum depression and child development (New
York: Guilford Press)
Music, G. (2009) What has psychoanalysis got to do with happiness? Reclaiming the posi-
tive in psychoanalytic psychotherapy, British Journal of Psychotherapy 25: 435–55
Music, G. (2010) Nurturing natures: Attachment and children’s emotional, social and
brain development (London: Psychology Press)
Ogden, P. (2006) Trauma and the body: A sensorimotor approach to psychotherapy
(W. W. Norton & Co.)
52 Graham Music
Panksepp, J. (2007) Can PLAY diminish ADHD and facilitate the construction of the social
brain? Journal of the Canadian Academy of Child and Adolescent Psychiatry 16: 57–66
Porges, S. W. (2011) The polyvagal theory: Neurophysiological foundations of emotions,
attachment, communication, and self-regulation (New York: W. W. Norton)
Prior, V. and Glaser, D. (2006) Understanding attachment and attachment disorders:
Theory, evidence and practice (London and Philadelphia: Jessica Kingsley Publishers)
Reddy, V. (2008) How infants know minds (Harvard: Harvard University Press)
Sander, L. (2007) Living systems, evolving consciousness, and the emerging person: A
selection of papers from the life work of Louis Sander (London: Routledge)
Sandler, J. (1993) On communication from patient to analyst: Not everything is projective
identification, International Journal of Psycho-Analysis 74: 1097–107
Schore, A. N. (2012) The science of the art of psychotherapy (New York: W. W. Norton)
Simmonds, J. (2007) Holding children in mind or holding therapy: Developing an ethical
position, Clinical child psychology and psychiatry 12: 243–51
Stern, D. N. (1985) The interpersonal world of the infant (New York: Basic Books)
Trevarthen, C. (2004) How infants learn how to mean. In M. Tokoro and L. Steels (eds), A
learning zone of one’s own (p. 39) (Amsterdam: IOS Press)
Tronick, E. (2007) The neurobehavioral and social emotional development of infants and
children (New York: W. W. Norton)
Winnicott, D. W. (1958) The capacity to be alone, International Journal of Psycho-
Analysis 39: 416–20
Winnicott, D. W. (1971) The use of an object and relating through identifications. In
Playing and Reality (New York: Basic Books)
Chapter 3
Where the child is the

concern
Working psychotherapeutically
with parents
Jeremy Holmes
Parents are only as happy as their least happy child

(traditional saying)
Introduction
A fundamental postulate – perhaps the fundamental postulate – of attachment
theory is that children, when threatened, tired, or sick, seek out an ‘older, wiser’
Secure Base for protection and succour (Bowlby 1971; Holmes 2013). Recipro-
cally, parents are programmed to respond to their infants’ and children’s distress
with nurturing behaviours such as physical contact, hugging, comforting, warm-
ing, cleansing, and feeding.
In addition to this ‘emergency’ aspect of the attachment relationship, there is
a ‘non-emergency, ordinary’ (Waters 2008) everyday aspect, in which the care-
giver attends to the child’s developmental needs by close attention, providing scaf-
folding and supporting the child’s agency and independence. A crucial component
in both is ‘affect regulation’ (Mikulincer et al. 2003) in that the child’s distress
is modulated by a variety of parental manoeuvres such as containment, sooth-
ing, distraction and/or stimulation, but also that positive affects are contained and
modulated, and responded to with pleasure, thereby instilling the capacity for
mutual fun and joyfulness. As development proceeds, these become internalised
by the child, who learns both to manage her own feelings when she can, and to
recruit others for help when needed. Authors such as Waters (2008) and Schore
(2004) see both dimensions as integral to the attachment dynamic, although it can
be argued that the inter-subjective developmental aspects of early relationships
are distinct from the security-providing attachment component.
Staying with the ‘emergency’ vector, the sequence of stress/distress followed
by soothing/recovery proceeds fractally throughout development, at micro and
macro levels. In the early weeks and months of life, several times per day, there
will be mini-stresses and disruptions to be contained, focused on and overcome.
At a macro level, children can be expected to negotiate a series of developmental
hurdles – separation and stress (parents away or ill; starting school; bullying; fears,
54 Jeremy Holmes
phobias and frightening experiences, etc.), as well as physical illnesses and inju-
ries, usually self-limiting. The cycle of stress, mental or physical pain, soothing
and recovery, when things go well, fosters resilience, The developing child is
strengthened emotionally, with a growing sense that adversity can, with appropriate
help, be faced and overcome (Fonagy et al. 2004). A comparable maturation occurs
for parents, who gain con¿dence in their capacity to provide effective nurture
and support for their children, as, together, they face the quotidian vicissitudes
of family life.
Chronic illnesses, physical or mental, pose particular dif¿culties for both par-
ents and children within this model. Unlike self-limiting illnesses or physical
trauma, there is often no clear recovery point. Rather than complete cure, optimal
outcomes are likely to be those of adjustment, acceptance, and courage in the face
of adversity. These considerations apply equally to ill parents and parents of ill
children.
Intergenerational transmission of attachment

patterns
Most psychotherapeutic practice relies on hunches and heuristics, permeated by a
mild ‘cult of personality’, rather than established facts. In establishing the attach-
ment paradigm, Bowlby’s self-effacingness, and strict adherence to scienti¿c prin-
ciples of evidence and refutation, mitigated against both: one of the great strengths
of attachment theory is its empirical base, eschewing appeal to authority.
A signi¿cant breakthrough came in the 1990s when a number of researchers
found evidence of continuity between attachment patterns in the parental genera-
tion and their children in the next. The classic Fonagy, Steele and Steele (1991)
study measured attachment dispositions in a non-clinical sample of ‘pregnant par-
ents’ using the Adult Attachment Interview (AAI); then, based on the Strange Sit-
uation procedure (SSP) (Mary Ainsworth’s ¿rst formal measure of infant/mother
attachment) the resulting offspring were assigned attachment categories some
15 months later. For a detailed discussion of the Strange Situation assessment
measures see The Routledge Handbook of Attachment: Theory (Holmes & Farn-
¿eld 2014) or The Routledge Handbook of Attachment: Assessment (Farn¿eld &
Holmes 2014).
Parents whose narrative styles were ‘free/autonomous’ were statistically more
likely to have children who were securely attached, while those with dismissing
narrative styles tended to have children who were classi¿ed as insecure-avoidant
in the SSP.
This seminal study opened up two decades of study of how attachment patterns
might be transmitted from one generation to the next. The current view rests on the
prevailing gene × environment perspective. Given the inherent polymorphism of
the human genome, some children are relatively robust and can achieve a degree
of attachment security and psychological health notwithstanding adverse parent-
ing styles or trauma. By contrast, infants with ‘plasticity’ genes are powerfully
Where the child is the concern 55
affected by their parents’ handling, for good or ill (Steele & Siever 2010). The
ongoing parent–child dynamic has to be conceptualised in terms of a subtle set
of self-maintaining developmental pathways to which genetic and environmental
factors and the relationship itself contribute.
The early attachment literature saw the differences between secure and inse-
cure children in terms of parental ‘sensitivity’ (Ainsworth 1973). Fonagy and co-
workers now specify aspects of this quality under the rubric of ‘mentalising’
(Fonagy & Luyten 2009; Holmes 2010). Mentalising is a complex group of inter-
and intra-personal skills which include the ability to: (a) view oneself and others
as sentient beings with desires, projects and motivations, (b) reÀect on one’s own
and others’ motivations, and (c) understand how beliefs about self and others,
because ¿ltered through the mind, are inherently error-prone, and in need of nego-
tiation and correction.
In the original Fonagy/Steele study, mothers able to mentalise (with high levels
of ‘reÀexive function’, as it was then called), even when their own upbringing had
been troubled, tended to have secure offspring. Those without that capacity were
more likely to have insecure children, especially if their own developmental his-
tory had been problematic. Parents who can see their children as separate sentient
beings, who can differentiate their own feelings from those of the child, see the
child in a developmental context, and recruit appropriate help when needed, are
likely to be rated as ‘sensitive’ and therefore able to foster secure attachment in
their care-providing practices.
Neuroscience techniques help to further illuminate these ¿ndings. In a recent
study Strathearn et al. (2009) identify two features which differentiate secure from
insecure mothers as measured on the AAI. When exposed in an fMRI setup to
smiling or sad pictures of their infants’ faces, brain patterns in the two groups
were signi¿cantly different. Compared with their insecure counterparts, mothers
with secure attachment dispositions showed increased activation of mesocortico-
limbic reward brain regions on viewing their own infant’s smiling face. They also
showed an increased peripheral oxytocin response while interacting with their
infants, which was correlated with activation of oxytocinergic and dopamine-
associated reward processing regions of the brain (hypothalamus/pituitary and
ventral striatum). Thus it might be said that secure mothers ¿nd interactions with
their babies more rewarding than the insecure.
Even more remarkable was the ¿nding that ‘striking differences in brain acti-
vation were seen in response to their own infant’s sad facial affect’ (Strathearn
et al. 2009: 2662). Securely attached mothers showed greater activation in reward
processing regions of the brain, whereas ‘insecure/dismissing’ mothers showed
increased activation of the anterior insula, a region associated with feelings of
unfairness, pain, and disgust.
For securely attached mothers, infant cues (whether positive or negative) rein-
force and motivate responsive maternal care. By contrast, insecure mothers, it
seems, when exposed to negative cues in their infants, react with withdrawal and
aversion when the expected positive feedback from their child is absent. This in
56 Jeremy Holmes
turn evokes negative feelings in the mother, including disgust. This ¿nding is
consistent with the typical dampening-down of feeing seen in avoidant/deactivat-
ing children: to manifest separation distress runs the risk of further alienating the
care-giver, and exposing the child to danger as parental Secure Base provision
is withdrawn. In such sub-optimal care-giving environments affect suppression
maintains proximity, and therefore a degree of safety, but at an emotional cost.
This formulation is consistent with the ¿nding that negativity is a more salient
feature in insecurely attached children than in the securely attached (Belsky et al.
1996). But negative affect, although suppressed, remains subliminally present,
adversely colouring the child’s mental universe.
Insecure attachment in children is not itself problematic. At least 30 per cent
of non-clinical populations demonstrate insecure attachment. This may, indeed,
be an adaptive response to sub-optimal care-giving environments (which are of
course widespread, and reÀect prevailing social and political structures). It is
important that professionals respect such resilience, and eschew as far as possible
imposing their own ‘middle class’ social and ethical norms, both in research and
clinical contexts.
However, the case of Disorganised attachment (labelled D in attachment the-
ory), especially when combined with severe patterns of hyperactivating insecurity
is somewhat different. Disorganisation is highly predictive of later psychological
dif¿culties including poor peer adaption, disruption in school, and externalising
and dissociative disorders in middle childhood and adolescence. It is these children
who are most likely to come to the attention of educational, medical, social care,
and criminal justice agencies (see Shemmings in Holmes & Farn¿eld 2014).
Disorganised attachment seen from the parent’s

perspective
Disorganised attachment as measured in the SSP between 12 and 18 months pre-
dicts psychopathology in later childhood and early adulthood (Van IJzendoorn
et al. 1999). Lyons-Ruth has pioneered studies looking at the characteristics of
mothers of D children, and on the basis of a number of ‘communication errors’,
classi¿es them into two broad groups: frightened/withdrawn and hostile/intrusive
(Lyons-Ruth et al. 1999). Both groups report signi¿cant amounts of childhood
trauma in their own development, the withdrawn group more likely to have been
sexually abused, the hostile group physically abused.
In the withdrawn group the mother appears unable to respond to her child’s
distress, leaving the infant to ¿nd some means of self-soothing, however uncoor-
dinated – appearing dissociated, rocking, head banging, etc. In the hostile-intru-
sive pattern the mother typically attacks and blames the child for being distressed.
‘You’re only doing this to wind me up’ would be a characteristic hostile-intrusive
response to an infant’s attachment-seeking behaviours. The relevance of this to
later responses to chronic illness might be either a helpless ‘giving up’ on the
part of the parent, or ‘blaming the victim’ where the child’s illness is seen as self-
inÀicted, leading often to futile attempts to get the child to behave ‘normally’.
Neither the child’s nor the parent’s (herself often a victim of abusive or insensitive
parenting) attachment needs are met in these self-defeating interactions.
Such dysfunctional patterns were originally conceptualised primarily from the
child’s point of view as ‘fear without solution’ (Main & Hesse 1990). The child is
presented with an insoluble paradox, reminiscent of the supposed ‘schizophreno-
genic’ ‘double bind’ (cf. Holmes 2010) in which the very person who would alle-
viate attachment arousal is also the source of the threat, and the child thus faces an
unresolvable approach-avoidance dilemma.
Within the context of this chapter, Disorganised attachment needs also to be
seen from the point of view of the parent. From this perspective, the care-giver
herself feels either disempowered and helpless, or suffused with unassuaged rage.
The parent’s care-giving attachment dynamic is activated, but cannot be assuaged
– the child remains unwell, despite the parent’s best efforts at alleviation. The
withdrawn ‘given up’ posture is an expression of helplessness in the face of an
unresolvable situation; conversely the hostile-intrusive pattern can be seen in
terms of a desperate parent, longing for diminution of attachment arousal, verbally
(or sometimes physically) attacking the child in the hope that rage will somehow
alleviate her unbearable feelings.
Further, children in Type D are typically found beyond infancy to be ‘control-
ling’, often with role-reversal between themselves and their parent (O’Connor et al.
2011). This can be understood from the child’s point of view as a means of locating
their own vulnerability in the other and thus feeling a measure of freedom from fear
and mental pain. From the parent’s perspective this can be disempowering, rein-
forcing feelings of helplessness and incompetence. An analogous pattern may exist
with chronically ill children, for example with eating disorders or chronic fatigue
syndrome (CFS), where parents may cow-tow and pander to their child’s every
need in the hope of recovery, but end up feeling bafÀed and frustrated.
Parents suffering from Borderline Personality

Disorders
The discussion thus far has focused on children designated as Disorganised in the
Strange Situation, the parental handling associated with that classi¿cation, the impact
on the parent, and their long-term consequences for child mental health. In this
section we will look at the converse: the implication for their children of mothers
with mental health dif¿culties, especially Borderline Personality Disorder (BPD).
Murray and co-workers (Murray et al. 2011) have studied the implications of
maternal depression on attachment patterns in children, showing that depressed
mothers are more likely to have insecurely attached children, but that when
the mood disorder is successfully treated, the child’s attachment pattern often
becomes secure. Personality Disorders are, by de¿nition, more long-lasting than
so-called ‘Axis 1’ illnesses such as depression. The implications for the child of
being brought up by a mother suffering from BPD are thus highly signi¿cant.
58 Jeremy Holmes
From the point of view of parenting, important features of BPD include affec-
tive instability; an unstable sense of self; substance abuse; and episodes of delib-
erate self-harm. All of these are likely to compromise effective and sensitive
parenting. Dif¿culties with mentalising are at the heart of the Fonagy-Bateman
model of BPD (Fonagy & Luyten 2009), and their interventions are targeted
around efforts to enhance it. If parental mentalising is the key to the fostering of
secure attachment in children, then clearly the children of BPD-suffering parents
will be at risk. A person’s ability to help regulate their child’s feelings is likely
to be compromised if they themselves are subject to unstable moods, and their
mentalising capacities de¿cient if they lack a secure sense of self which provides
a vantage point from which to view their own needs and those of others, including
their children. In addition parental intoxication and deliberate self-harm (DSH)
are potentially traumatic for children. In the absence of a mentalising care-giver,
such children will suffer not only from the trauma itself, but, given the absence of
an affect-regulating parent, lack of someone with whom to process the feelings it
engenders.
A number of studies have looked at the impact of BPD on developmental pro-
cesses in sufferers’ offspring. Feldman et al. (1995) con¿rmed clinical impressions
that children aged 11–18 of BPD sufferers are at risk of psychopathology, showing
more delinquency, aggression and depression than comparable offspring of non-
BPD sufferers. Hobson and colleagues have studied the possible developmental
antecedents of these clinical ¿ndings. Children of BPD mothers have high levels
of Disorganised attachment at 18 months (Hobson et al. 2005). The origins of this
are illuminated by studies which show that such mothers show more intrusiveness
and insensitivity, are more likely to be withdrawn and fearful when their infants
become distressed, and are limited in their capacity for reÀexive functioning (i.e.
mentalising) compared to children whose mothers are not so diagnosed (Crandell
et al. 2003; Hobson et al. 2009). We see here the possible routes by which BPD
may be transmitted from one generation to the next, and also the developmental
dif¿culties that children of BPD mothers are likely to encounter.
Intervention studies
Interventions can be broadly classi¿ed under three headings. First, preventive mea-
sures aiming to reduce the likelihood of Disorganised attachment in the offspring
of at-risk parents, whether due to low socio-economic status or physical or mental
illness. Second, there are treatment programmes aimed at helping mothers once an
‘at-risk’ child is identi¿ed, especially with Disorganised attachment. Third, parents
who are themselves ill, especially those with BPD, can be helped with the aim to
improve not just their mental health but, indirectly, that of their children.
Integral to the attachment perspective is the hypothesis that infant security is
causally linked to, rather than merely correlated with, parental sensitivity. If so,
interventions to enhance parental sensitivity should increase security of attach-
ment in their infants. In an early meta-analysis, Van IJzendoorn et al. (1999)
found that this was the case, but there were a number of paradoxical effects. First,
short-term interventions appeared to be more effective than longer ones. Second,
increasing parental sensitivity did not always impact on infant attachment security
and, conversely, attachment security could be improved without changes in par-
ents’ sensitivity. Third, causal links, although demonstrable, were weak and did
not account for the total variance.
Van IJzendoorn’s group dub this the ‘transmission gap’. Recent genetic ¿nd-
ings mentioned above go some way to explain this – if only a proportion of target
infants have ‘plasticity genes’ (see above), the overall impact of interventions
will be thereby lessened (Bakermans-Kranenburg & Van IJzendoorn 2007). A
subsequent review (Berlin et al. 2008) summarised a number of intervention pro-
grammes, varying from simple behavioural measures such as giving mothers a
soft sling with which to carry their babies around, to more sophisticated and pro-
longed psychoanalytically informed programmes aiming to enhance mentalising.
Their ¿ndings suggest that relatively brief, sensitivity-focused interventions in
high-risk groups, where the base-line level of Disorganised attachment is greatest,
show the most gains. However, the evidence for the bene¿ts in terms of maternal
sensitivity and child attachment security of long-term psychoanalytic child psy-
chotherapy interventions is rather weak. The authors concede this may be due
to the broad-spectrum impact of this approach, with general rather than speci¿c
bene¿ts, and that there may be ‘sleeper effects’ which would reveal themselves
with longer term follow-up.
Clinical implications
The studies summarised above are based mostly on attachment-informed inter-
ventions in the early years, and many are mother–infant, rather than parent-only
programmes. In this section I shall comment from a research-informed clinical
perspective on two types of problem: working with parents suffering from BPD,
and working with parents of children suffering from chronic illnesses.
Both groups may bene¿t from a ‘pedagogic’ psycho-educational exposition of
the attachment model. It can be a relief to hear that constant worry and inability
not to think about an ill child is a normal biologically driven aspect of the attach-
ment dynamic. One parent with an eating-disordered daughter confessed guiltily
that while taking a deserved break away for a night in a health spa, she found that
she had forgotten to think about her daughter for at least 10 minutes! Such guilty
feelings are common in the bereaved; having an ill child could be seen as a spe-
cies of bereavement, but one with no de¿nite end-point. This is consistent with
Bowlby’s (1980) formulation of bereavement in terms of irreparable separation.
Equally BPD parents can be helped with the thought that some of their feelings of
fear and helplessness when confronted with a needy child are normal responses,
not signs of intrinsic inadequacy or madness.
Another aspect is the attachment view that attachment behaviour and explo-
ration are mutually incompatible (Holmes 2010). As a result, parents who are
60 Jeremy Holmes
chronically aroused with worry about their children, may ¿nd it dif¿cult to ‘accept’
– i.e. to think about and experiment with – the help that is being offered, since their
thoughts and feelings are so dominated by the search for, and seeming impossibil-
ity of ¿nding, a solution to their child’s dif¿culties. In one case, after apparently
helpful sessions in which strategies for living with a depressed teenaged son were
discussed, his mother would repeatedly, as she made for the door, blurt out: ‘Well,
will he get better or not? I want and need an answer – why won’t you give me
one?’
Bakermans-Kranenburg et al. (2005) see preventive interventions as having
one or more of three objectives: enhancing parental sensitivity, improving attach-
ment security in the IP (identi¿ed patient) child, and using the therapeutic relation-
ship as a model for secure parent–child interaction. As mentioned, ‘sensitivity’
remains a somewhat mysterious capacity.
Ainsworth’s early formulations focused on the rapidity and ease with which
mothers responded to and assuaged their infants’ distress. More recent approaches
emphasise ‘affect regulation’ and ‘mentalising’, and the idea that to the extent that
these are available in the parent–child relationship in infancy and early childhood,
they become gradually internalised by the growing child.
Affect regulation entails the ability of the parent to identify a child’s emotional
states and to mobilise a regulatory appropriate response. A crucial aspect of ‘men-
talising’ is the parent’s ability to see her child not as an extension of herself and
her own needs, but as an autonomous sentient being with his or her own projects,
desires and wishes. Mentalising is thus contra-narcissistic, and implies the ability
to ¿nd an internal vantage point from which to view and reÀect on one’s own and
others’ thoughts, emotions and actions.
If we postulate a ‘parallel process’ (a concept borrowed from the supervisor-
therapist/therapist-patient constellation, cf. Holmes 2012) between therapist–
parent and parent–child relationships, then the therapist’s ‘sensitivity’ to the
presenting parent will be a mutative ingredient in helping the parent to be more
sensitive to her child. Therapists need to tune into and identify verbally parents’
feelings, to contain and hold them, to acknowledge and soothe where appropriate.
A further aspect entails including the parent’s partner, if there is one. An ill child
often drives a wedge into a family, prising couples apart. The needs of the other
siblings are often overlooked. Working with the parent of the IP will also mean
focusing on the couple relationship, and helping the parent to recruit her partner
(usually the father) as a Secure Base to whom she can turn with her worries and
troubles, and who will also take over when she herself is miserable or exhausted.
The neuroimaging data on the ‘disgust’ reaction on the part of the parent when
failing to elicit an expected positive response from their child, contrast with secure
mothers who can accommodate and encompass their children’s unhappiness. In
insecure relationships the parent might say something like, ‘Look, I do everything
for that child, drive him/her to school, supply his meals, bail him out when he’s
got no money, cook wash and clean – and all I get is sulks and monosyllables.
It’s intolerable! He’s got to get his act together’. This might be a typical avoidant
child–parent pattern; the child gets a degree of protection, but with diminished
parental ‘sensitivity’. The price paid is the suppression or diverting of distress,
rather than its resolution, with both parent and child’s affect unassuaged. All
this goes on non-consciously: avoidant children show physiological evidence of
arousal in the SSP as manifest by elevated cortisol levels, and tachycardia (Dozier
& Rogers Kobak 1992) although outwardly they appear equable.
Therapeutic work informed by this would concentrate: (a) on the therapist
acknowledging and accepting parents’ worry, misery, and ‘disgust’, (b) helping
the parent similarly to ‘name and contain’ their children’s dif¿cult feelings. A
typical interaction with, say, an eating-disordered teenager might be:
Child: I hate myself, I’m fat, fat, fat . . .

Parent: You’re NOT fat – you’re thin! If you just put on some weight you’ll stop
feeling so bad about yourself”.
An attachment-guided alternative response (which could be tried out in role-

play) might be:
Parent: It sounds like you’re feeling really terrible and unhappy today . . . shall
we have a look at those diet websites together and see if we can work
something out? . . .
An interesting ¿nding that emerged from the Bakermans-Kranenberg et al.

(2005) meta-analysis was that video-feedback was particularly effective in enhanc-
ing both maternal sensitivity and infant security. Observing oneself on video is
inherently mentalising, if the latter is viewed as the ‘ability to see oneself from
the outside and others from the inside’ (Holmes 2012). Since arousal is inimical
to mentalising, the stressed parents of ill children are often too agitated to be able
to reÀect on the impact they are having on the child, let alone the past traumas the
child’s illness may be activating from their own childhood.
Quietly observing oneself on video, however painful it might be, provides such
an opportunity for observation and learning. In one-to-one therapy, ‘role-play’
with a therapist can work in similar ways. The therapist might move from conven-
tional dialogue into role-plays in which the therapist alternates between enacting
the parent’s role, with the mother ‘being’ the child, and vice versa. The same sce-
nario can be repeatedly played this way, with participants alternating: playing it
‘as it was’, and then with a different hoped-for outcome. It is important, however,
to observe the dictum that when working with parents, a therapist should never
make them feel that he or she makes a better job of being a parent than they do.1
A ¿nal point comes not from attachment research but from a systemic-
psychoanalytic perspective. It concerns the ‘location’ of the presenting problem.
A systemic point of view sees the family as a system, with individual members
playing parts in a drama where the target dysfunction is the family itself, rather
than the individuals who make it up (cf. Lock et al. 2010).
62 Jeremy Holmes
This is consistent with the psychoanalytic notion of ‘projective identi¿cation’,

in which feelings, conÀicts and desires may be transferred unconsciously from
one member of an intimate system to another, typically in the Kleinian model
from baby to mother, but equally, and especially when problematic, vice versa.
Seen this way, ‘badness’, and especially negative affect, is no longer located in
any one individual, but in the system as a whole. Thus when a patient refers to the
needs of her children – for instance is worried about ‘child care’ for her baby – it is
a useful heuristic to think that it is the patient’s ‘inner child’ that needs therapeutic
attention. Working with parents of ill children, part of the therapeutic task is to
help the parent grasp and identify her own un-met childhood needs, manifest in
her child as she perceives him.
Conclusion
According to maestro (a degree of ‘cult of personality’ is admissible!) Daniel
Barenboim (Barenboim & Said 2004) ‘music’ arises at the intersection of two
axes: vertical, instantaneous and harmonic; horizontal, temporal and melodic/
rhythmic. Comparably, families have their own music. At any given moment
there are harmonies and discords whose overtones reverberate throughout the sys-
tem. At the same time family members are bound together in an ongoing story or
‘script’ (Byng-Hall 1999) which is transmitted and modi¿ed from generation to
generation. Both melody and harmony have attachment overtones.
Early psychoanalytic theorising tended to see the developmental process in terms
of two generations – the IP, and his or her parents. Fraiberg’s (1980) ‘ghosts in the
nursery’ acknowledged that at any clinical situation a minimum of three genera-
tions are involved – the patient, the patient’s parents, the parents’ parents, and if
the patient is a parent, their children. Lacan (Leupnitz 2009) similarly shows how
at the moment of birth, a child has a pre-assigned ‘place’ in the family and parental
system/psyche, and that the child, and his or her dif¿culties, must be seen as a link
in a family chain stretching back into the past and forwards into the future.
Therapists tend to be highly attuned to these self-perpetuating patterns of pathol-
ogy, but sometimes miss an opposing trend – the inherent self-righting capacity
of both individuals and families. A parental generation plagued by abuse might,
by the third generation, be once more on a more secure track. The key to this self-
rightingness is the capacity of parents to mentalise their own dif¿culties, and thus
to hold them in check as they work for the best for the next generation. It is the task
of the science and art of psychotherapy, and especially the mentalising approach
based in the attachment paradigm, to foster this self-righting process, and to study
those conditions that make it more, or less, likely to be achieved.
Note
1 The author often gets round this by comparing watching an ‘action replay’ of a missed
open goal in football on the television – easy to get it right from the comfort of one’s
armchair; equally easy to miss in the real-life heat of the moment.
References
Ainsworth, M. (1973) The development of mother–infant attachment. In Review of Child
Development Research Vol. 3 (Eds B. Caldwell & H. Ricciuti), pp. 1–49. Chicago: Uni-
versity of Chicago Press.
Bakermans-Kranenburg, M. & Van IJzendoorn, M. (2007) Genetic vulnerability of dif-
ferential susceptibility in child development: the case of attachment. Journal of Child
Psychology and Psychiatry 48: 1160–1173.
Bakermans-Kranenburg, M., Van IJzendoorn, M. & Juffer, F. (2005) Disorganised attach-
ment, infant attachment and preventive interventions: a review and meta-analysis. Infant
Mental Health Journal 26: 191–216.
Barenboim, D. & Said, E. (2004) Parallels and Paradoxes: Explorations in Music. Lon-
don: Bloomsbury.
Belsky, J., Spritz, B. & Crnic, K. (1996) Infant attachment security and affective-cognitive
information processing at aged 3. Psychological Science, 7: 111–114.
Berlin, L., Zeahnah, C. & Lieberman, A. (2008) Prevention and intervention programs
for supporting early attachment security. In Handbook of Attachment (Eds J. Cassidy &
P. R. Shaver) 2nd edition, pp. 745–761. New York: Guilford.
Bowlby, J. (1971) Attachment. London: Penguin.
Bowlby, J. (1980) Loss and Bereavement. London: Penguin.
Byng-Hall, J. (1999) Family couple therapy: towards greater security. In Handbook
of Attachment (Eds J. Cassidy & P. R. Shaver) 1st edition, pp. 625–645. New York:
Guilford.
Crandell, L. E., Patrick, M. P. H. & Hobson, R. P. (2003) ‘Still-face’ interactions between
mothers with Borderline Personality Disorder and their 2-month-old infants. British
Journal of Psychiatry 183: 239–247.
Dozier, M. & Rogers Kobak, R. (1992) Psychophysiology in Attachment Interviews: con-
verging evidence for deactivating strategies. Child Development 63: 1473–1480.
ment. London and New York: Routledge.
Feldman, R. B., Zelkowitz, P., Weiss, M., Vogel, J., Heyman, M. & Paris, J. (1995) A
comparison of the families of mothers with borderline and nonborderline personality
disorders. Comprehensive Psychiatry 36(2): 157–163.
Fonagy, P. & Luyten, P. (2009) A developmental mentalisation-based approach to the
understanding and treatment of Borderline Personality Disorder. Development and Psy-
chopathology 21: 1355–1381.
Fonagy, P., Steele, H. & Steele, M. (1991) Maternal representations of attachment during
pregnancy predict the organization of infant–mother attachment at one year of age. Child
Development 62: 891–905.
Fonagy, P., Steele, M., Steele, H., Higgitt, A. & Target, M. (2004) The theory and practice
of resilience. Journal of Child Psychology and Psychiatry 35: 231–257.
Fraiberg, S. (1980) Clinical Studies in Infant Mental Health. New York: Basic Books.
Hobson, R. P., Patrick, M., Crandell, L., GarcÕa-Perez, R. & Lee, A. (2005) Personal
relatedness and attachment in infants of mothers with Borderline Personality Disorder.
Development and Psychopathology 17: 329–347.
Hobson, P., Patrick, M., Honson, J. et al. (2009) How mothers with Borderline Personality
Disorder relate to their year-old infants. British Journal of Psychiatry 195: 325–330.
Holmes, J. (2010) Exploring in Security. London: Routledge.
64 Jeremy Holmes
Holmes, J. (2011) Superego: an attachment perspective. International Journal of Psychoa-

nalysis 92: 1221–1240.
Holmes, J. (2012) Storr’s The Art of Psychotherapy (3rd Edition). London: Hodder.
Holmes, J. (2013) John Bowlby and Attachment Theory (2nd Edition). London: Routledge.
Holmes, P. & Farnfield, S. (eds) (2014) The Routledge Handbook of Attachment: Theory.
Lear, J. (2003) Therapeutic Action: An Earnest Plea for Irony. London: Karnac.
Leupnitz, A. (2009) Thinking in the space between Winnicott and Lacan. International
Journal of Psychoanalysis 90: 957–981.
Lock, M., Le Grange, D., Agras, S., Move, A., Bryson, S. & Booil, J. (2010) Randomized
clinical trial comparing family-based treatment with adolescent-focused individual
therapy for adolescents with anorexia nervosa. Archives of General Psychiatry 67:
1025–1032.
Lyons-Ruth, K., Bronfman, E. & Parsons, E. (1999) Maternal frightened, frightening, or
atypical behaviour and disorganised infant behaviour patterns. Monographs of the Soci-
ety for Research in Child Development 64: 67–209.
Main, M. & Hesse, E. (1990) Parents’ unresolved traumatic experiences are related to infant
disorganised attachment status: is frightened and/or frightening parental behaviour the
linking mechanism? In Attachment in the Preschool Years (Eds M. Greenberg, D. Cic-
chetti & M. Cummings), pp. 161–182. Chicago: University of Chicago Press.
Mikulincer, M., Shaver, P. & Pereg, D. (2003) Attachment theory and affect regulation:
the dynamics, development and cognitive consequences of attachment-related strategies.
Motivation and Emotion 27: 77–102.
Murray, L., Arteche, A., Fearon, P., Haligan, S., Goodyear, I. & Cooper, P. (2011) Mater-
nal postnatal depression and the development of depression in their offspring up to 16
years of age. Journal of the American Academy of Child and Adolescent Psychiatry 50:
460–470.
O’Connor, E., Bureau, J.-F., McCartney, K. & Lyons-Ruth, K. (2011) Risks and outcomes
associated with disorganised/controlling patterns of attachment at age three years in the
National Institute of Child Health and Human Development study of early child care and
youth development. Infant Mental Health Journal 32: 450–472.
Steele, H. & Siever, L. (2010) An attachment perspective on Borderline Personality Dis-
order: advances in gene-environment considerations. Current Psychiatry Reports 12:
61–67.
Strathearn, L., Fonagy, P., Amico, J. & Montague, P. (2009) Adult Attachment predicts
maternal brain and oxytocin response to infant cues. Neuropsychopharmacology 34:
2655–2666.
Van IJzendoorn, M., Schuengel, C. & Bakermans-Kranenburg, M. (1999) Disorganised
attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae.
Development and Psychopathology 11: 225–249.
Waters, E. (2008) Live long and prosper: attachment and evolution. Available online at
http://www.psychology.sunysb.edu/attachment/gallery/live_long/live_long.html
Chapter 4
The marriage of attachment

theory and systemic family
therapy practice
An invitation to join the wedding party
Chip Chimera
Introduction
Family therapists work with the family group, subsystems within it and individual
members of the family. Families come to therapy for many reasons, however it
is this writer’s clinical experience, spanning over 20 years, that at the heart of
most family problems lie attachment dilemmas. Working with the family system,
whether the whole or parts, allows attachment issues to be explored in a way that
honours each person’s attachment experience and attachment truth. Opportunities
for change can be discovered and new, more satisfying ways of relating can be
tried. Systemic practice gives speci¿c attention to the inÀuence of relationships on
other relationships within the family and the wider network. In what follows two
case examples will illustrate the use of attachment as a focus in family therapy
together with the theoretical connections.
For many years there has been a passionate affair between some quarters
of systemic family therapy and attachment theory. John Byng-Hall (1995) and
more latterly Arlene Vetere and Rudi Dallos (Dallos 2006; Dallos and Vetere
2009) in particular have done much to join the two theories into a coherent
practice.
This chapter examines how attachment theory can be used within the many
models and approaches contained within systemic family therapy that are in cur-
rent practice in Britain and the wider world. It proposes that it is not necessary to
have a separate and distinct form of ‘attachment family therapy’ but that the ideas
can be used across the board in systemic practice from whatever orientation a
systemic therapist adopts.
It aims to show that by orienting themselves to attachment issues, those work-
ing with families who present with a variety of clinical problems can use the whole
array of systemic approaches effectively. At the same time those using primarily
an attachment-based approach can bene¿t from the integration of systemic theo-
ries and techniques.
Like all good marriages there are times when compromise is essential.
66 Chip Chimera
How attachment enhances a systemic approach

Attachment theory invites us to look at how meaning and affect are arranged in the
family. It gives a structure within which the expression of feelings and the ways
relationships are enacted make sense. Many family therapists will have a ‘hidden
history’ with attachment, having come across it in other trainings and ¿nding an
acquaintance with the ideas more or less useful.
Attachment researchers from Bowlby onwards have made careful and repeated
observations. Theory and assessment is deduced from observations, not from
report. This is very useful for practitioners who work with families together in
parts and wholes.
Observation rather than report has also been at the heart of family therapy
models throughout the development of family therapy practice (Minuchin and
Fishman 1981; Cecchin 1987; Andersen 1987). Changes to theory and practice
have been introduced based on these observations and the therapists’ own interac-
tion with families.
The use of recording equipment, a key feature of family therapy clinical train-
ing, makes it possible to analyse interactions in retrospect. Therapists in training
work as part of a team with a number of people and a live supervisor behind a
one-way mirror. This teamwork makes it possible to have the bene¿t of multiple
lenses of observation. What each team member brings to the observation enables
an understanding of how their personal attachment styles and strategies affect
what they see. Hence the social constructionist maxim that what you see depends
on how you look at it (Burr 1995) has particular resonance for therapists in devel-
oping therapeutic self-reÀexivity. This refers to the therapist’s knowledge of their
own history and emotional responses which is put into action in the therapy room
and brought to supervision. An appreciation of personal attachment experiences,
strategies and style is essential for developing a therapeutic approach of one’s
own. This understanding of our own inner working models is crucial in helping to
create a secure base for the family in therapy. The core concepts of mutual inÀu-
ence and relational reÀexivity (Burnham 2005) allow us to observe the family
relationships and simultaneously experience how our own attachment system is
being activated.
While close observation is possible for family therapists the uniqueness of each
family and the different issues brought for therapy make the laboratory conditions
set up by Ainsworth (Ainsworth and Bell 1970) in her meticulous infant research
projects impossible, both practically and ethically. Unlike Ainsworth and her col-
leagues, systemic therapists consider themselves as part of the system that is under
observation. We consciously work intensively with the family dynamics in the
room. Relationships, including attachment strategies, are played out before us.
Coming to therapy is in itself a stress-inducing activity. Therefore, the attach-
ment system is activated by the act of coming into the therapy room in most cases.
Trying to understand the situation and not jump to ‘premature certainty’ (Mason
1993) helps us to slow down, observe carefully and allow relationships to unfold.
Attachment theory and systemic family therapy 67
Attachment as a systems sensitive model of individual

development
Systemic theory does not provide a model of individual development per se.
Becoming a Systemic Psychotherapist, like other psychotherapy trainings,
involves undertaking an advanced quali¿cation, achieved by most practitioners
after they have quali¿ed in a previous related profession, such as psychiatry, psy-
chology, social work or teaching. It is generally expected that knowledge of child
development is gained in these previous professional trainings, and therefore no
overarching system of human development is taught on most family therapy quali-
fying courses.
However, family therapists do have ideas about family development and life
cycle (Carter and McGoldrick 1989). These are well documented and have been
broadened and revised over the years to take into account the wide diversity of
family forms. With the inÀuence of social constructionist ideas the notion of a
normative model of family life is considered unhelpful. The criteria for adequate
family functioning includes the notion that children are able to grow and develop
in a way that meets their needs and ful¿ls their potential, giving consideration to
the context in which the family is situated. It is recognised that a wide variety of
family forms may have speci¿c challenges but nevertheless ¿t the bill of raising
children to maturity in order to reproduce successfully.
‘Staying safe and reproducing constitute the basic biological imperatives of
any species’ (Crittenden 2008: 11). Anthropological studies have identi¿ed some
1,200 different past and present cultures (Van IJzendoorn and Sagi 1995: 731). In
the cultures that have been studied attachment has been shown to be normative,
i.e. existing in all cultures, though the ways in which attachment needs are met
may vary.
Attachment offers a model of development which transcends culture and fam-
ily form in that it can be understood by exploring how safety and comfort are
achieved (or not). Unlike previous models of psychological development, which
posit that persons become ‘stuck’ at certain points, attachment reÀects a trajec-
tory of continuous development with opportunities along the way for readjust-
ment, realignment or taking a different path and a new trajectory. The Dynamic-
Maturational Model of Attachment (DMM) (Crittenden 2008) in particular empha-
sises this. Bowlby writes:
Attachment theory emphasises:

(a) the primary status and biological function of intimate emotional bonds
between individuals, the making and maintaining of which are postulated
to be controlled by a cybernetic system situated within the central nerv-
ous system, utilizing working models of self and attachment ¿gure in
relationship with each other
(b) the powerful inÀuence on a child’s development of the ways he is treated
by his parents, especially his mother-¿gure, and
68 Chip Chimera
(c) that present knowledge of infant and child development requires that a
theory of developmental pathways should replace theories that invoke
speci¿c phases of development in which it is held a person may become
¿xated and/or to which he may regress.
(Bowlby 1988: 135–6)
Thus the model of individual development inherent in attachment theory is fun-

damentally in tune with systemic principles: what the child/person brings from
their history and experience interacts with their present context to create their
reality.
At one time the popular understanding of attachment theory was that once attach-
ment was ‘set’ at about a year or 18 months of age, it formed a deterministic path
on which the person would relate to the world and important relationships within
it for the rest of their life. Bowlby never said this was the case. Quite the contrary,
he stressed that patterns of attachment persist where interactions between the child
and the attachment ¿gures persist. Where nothing changes, patterns remain the
same. Where the interaction changes for the better, there are opportunities for
repair and a different developmental pathway may be taken. Longitudinal stud-
ies have shown that patterns of attachment persist, unless something happens to
change them. ‘[E]stablished patterns of adaptation may be transformed by new
experiences while, at the same time, new experiences are framed by, interpreted
within, and even in part created by prior history of adaptation. Bowlby’s was
a dynamic view of development’ (Sroufe 2005: 350). They can change for bet-
ter or worse, depending on the person’s life experiences and interaction with
their context. Therapy is one important interaction that can inÀuence attachment
strategies.
I remember well a parent and child who attended a day assessment and treat-
ment unit I worked in some years ago.
Janet, the mother, had been adopted from a Barnardo’s institution in

her late infancy. She felt ‘lucky to be chosen’ and grateful to her adop-
tive parents, who had died some years earlier. This story of gratitude
is one that was often given to children who were rescued from institu-
tions by well-meaning adopters who received little ongoing support.
She never expressed curiosity about her family of origin. When she
married in her teens she did reasonably well with her first two children
who were boys. There was some involvement with social services due
to delinquency when they became adolescent. However, it was minor
and there was never a threat to remove the boys. Her husband was a
good provider but a somewhat distant father, as was a common cul-
tural expectation of the time.
Janet’s last child, who arrived a few years behind the boys, was a
little girl and the relationship was always difficult. Maggie was a fussy
baby, never very rewarding. She was clingy as a toddler and showed
aggression to her mother and siblings. School age did not bring change:
she was aggressive to other children and demanded a great deal of
teacher time. She was excluded from school as a six year old. There
were questions of neglect by her mother who was by now openly
rejecting. I remember their first day at the centre. Meeting them on
the doorstep I was introduced to Maggie, then seven, as ‘this is the
little bitch.’
They attended for six months, somewhat longer than usual. The
day involved school in the morning for the children while the parents
attended groups and individual therapy. In the afternoon there were
family activities and family therapy. During this time Janet was chal-
lenged to re-examine her beliefs about her daughter and the narrative
of her own childhood. In deconstructing her experience a different
story emerged of her adoptive parents treating her harshly and being
punitive to her at the least provocation. She was frequently unfavour-
ably compared to males in the family and was acceptable only when she
showed ‘gratitude’. Being able to examine some of these experiences
and begin to come to terms with them in the safe and containing envi-
ronment of the centre where she was valued and encouraged, enabled
her to change her position in relation to Maggie. She would often com-
ment on how tiring the day was, and that she could not understand
it because she ‘hadn’t done much’. She could not recognise the very
difficult psychological restructuring she was undertaking as work.
The result however was dramatic. Maggie returned to school and at
six month follow up was doing fine, catching up on lost learning time
and getting along reasonably well with her peers. There were some
blips but the parents responded well and appropriately to these. Jan-
et’s parting words were ‘thank you for giving me my daughter back’,
even then not appreciating that it was she herself who had done the
work to repair the relationship.
No formal assessments of attachment were undertaken, however
the following hypothesis can be made.
Janet was using avoidant (A) strategies. These had been helpful to
her in her childhood where she was unable to express her negative
feelings for fear of punishment, and had to concentrate on pleasing the
attachment figures in order to avoid rejection. She focused on being
70 Chip Chimera
a good girl. Her pre-adoption circumstances are not known though it

can be assumed that there were times when she felt very unsafe, and
very likely experienced abandonment.
As a young adult she chose a partner who was also avoidant of inti-
macy, i.e. who also adopted A strategies. The expression of strong
negative feelings and emotions was not in his repertoire and he used
withdrawal rather than confrontation to manage any difficulties in
the relationship. This strategy seemed to work for the couple. Janet
adopted a role as mother in which expectations of the children’s
behaviour took priority over comfort and affection, a replicative script
(Byng-Hall 1995), though she was by no means an unemotional mother.
This worked adequately with her boys (though they had some difficulty
in adolescence) but giving birth to a daughter seemed to trigger her
own unmet needs and as she did not know how to be with a girl infant,
she used her avoidant strategies to keep the unwanted emotions at
bay. The child’s calls for attention were experienced by her mother as
excessive and unreasonable. The father was not equipped to help her
understand this, leaving responsibility for parenting to the mother, a
traditional gender role. This led to further feelings of inadequacy and
failure on the part of the mother who then increased her efforts to get
Maggie to conform to her expectations of behaviour.
For her part the child, experiencing a distant and misattuned par-
ent, had to rely on her own emotional state to try to get needs for
safety and security met. Her alternating coy and controlling behaviours
(C strategies) were not understood by her mother as a need but seen
through her mother’s experience as naughty and in need of punish-
ment; hence the dance of misattuned attachment began and escalated.
The more her mother applied strict rules and expectations accompa-
nied by punishment, the more Janet felt misunderstood, abandoned
and rejected. She began to believe the story of herself as a bad child.
Her behaviour deteriorated as she had no other strategies, and prob-
lems were seen to be located within her.
Here systemic ideas of symmetrical escalation, applying more of a
failed attempted solution (Watzlawick et al. 1974), repetitive scripts
(Byng-Hall 1995), and Narrative therapy (White 1988) were integrated
with attachment ideas to help address the underlying relationship
problems which were understood as being both between and within
the mother and child.
Crittenden (2008) has shown how attachment strategies, i.e. the person’s tool-
kit for keeping safe, develop across the life cycle. She augments Bowlby’s and
Ainsworth’s original ideas of developmental pathways and shows how these are
related to both the child’s maturational processes and the contexts in which they
¿nd themselves. She identi¿es ¿ve stages of maturation: infancy, pre-school,
school age, adolescence and adulthood. Within each stage speci¿c maturational
processes are available to the child to help maintain safety and connection to a pro-
tective ¿gure. In the above vignette the child’s maturational stage made higher and
more behaviourally challenging ambivalent (C) strategies available to her which
could not be ignored. Fortunately they were able to be dealt with therapeutically:
the escalation was stopped so that reattunement of the mother and child could be
attempted.
Using attachment as a systemic lens

Jeremy Holmes (Holmes 2001: 6) identi¿es six domains of attachment theory.
Each of these can be utilised from a systemic perspective. The six domains
are:
• Secure base,
• Exploration and enjoyment,
• Protest and anger: rupture and repair, differs across the spectrum,
• Loss,
• Inner working models, and
• ReÀexive functioning.
A systemic perspective allows these to be explored with families in a safe and

non-blaming way. Any and all models of systemic family therapy can be utilised
to explore these areas and most overlap to greater or lesser extent.
Using a structural approach (Minuchin 1974; Minuchin and Fishman 1981) the
attachment domains can be explored in the way decisions are made, boundaries
are organised and the priority given to child care needs. Together with how roles
are allocated and power is negotiated, both overtly and covertly, a picture can be
built of how the family is organised. Do they pull together in the face of danger
or become blaming and chaotic? Of particular interest are role reversals and care
and control battles, both of which can be understood more fully using an attach-
ment approach. These issues are often enacted in the therapy room, particularly
with younger children. Emphasising and reinforcing rules and boundaries which
increase safety and hence the ability to explore, express feelings, manage loss and
have positive and optimistic expectations of relationships are all attachment inter-
ventions undertaken from a structural perspective.
Strategic approaches focus on how the family is organised around the problem
and how the problem organises the family. For instance where attachment strate-
gies in a child of either helplessness or control (ambivalent type C strategies:
72 Chip Chimera
Crittenden 2008) are being used, one would look at how other parts of the system
respond. What does the main attachment ¿gure do in response, how does that
response ripple through the rest of the system?
For example, where parents have separated and a child is refusing to see one
parent, one might look at how the child’s strategies are functioning to keep the
main care-taker close and at the same time maintain a high level of anxiety in
the system. The intervention would be to help the family understand the child’s
anxieties in a different way and experiment with different approaches to help the
child overcome them. Strategic approaches consider whether the problem may be
a failed solution to a worse problem. The use of speci¿c attachment assessments
such as the Adult Attachment Interview (Crittenden and Landini 2011) or the
School Age Assessment of Attachment (Crittenden 2008) give insight into the
person’s internal world and the way they employ attachment strategies.
In both structural and strategic approaches the concept of triangulation (Bowen
1978; Fivaz-Despeursinge and Corboz-Warnery 1999) is useful in thinking about
how attachment dilemmas are enacted in the family system. Triangulation is an
ordinary process that occurs in all families. Most parents will have had the expe-
rience of a child asking for something (ice cream, new trainers, going out with
a friend, etc.) being told ‘no’ and then going to another source of authority in
the hope of a different answer. Where there is intense conÀict between parents,
triangulation of a child into the conÀict is emotionally damaging. In damaging
triangulation the child cannot have a free and unfettered relationship with either
parent without having to consider the impact on their relationship with the other
parent. In divorced and separated families this can become highly problematic
and at its most extreme can result in the child cutting off contact with one par-
ent in order to meet the (covert) needs of the other parent (Kelly and Johnson
2001).
These approaches focus on family rules and how the system organises around
a problem. In particular it is thought that the problem may consciously or uncon-
sciously ful¿l a function in the system. The classic example of this is a child whose
refusal to attend school arises from fear for the parent at home which cannot be
directly expressed.
The strategies a parent developed in their own childhood will play a key role
in how the next generation develops strategies. It is important to gain an under-
standing of how the two parents’ family of origin experiences have come together
in their family of procreation: another example of the impact of relationships on
relationships. Often where parents are over-punitive, the problem may be de¿ned
by professionals as over-chastisement, a form of physical abuse. Using an attach-
ment lens to focus on issues of safety, a more severe problem from which the
over-chastising parent is trying to save the children may be revealed; for example,
in the vignette cited below the father’s over-chastisement was largely a measure
of his deeper concern about his children’s safety.
In applying attachment theory to family belief systems as in the Milan and post-
Milan approaches, the family’s beliefs around safety and security and the roles
different family members are expected to play in relation to these are explored.
Beliefs impel actions and how the family members situate themselves in relation
to their beliefs will be an organising factor.
In the case of Janet and Maggie described above, the meaning of Maggie’s
aggression to her mother had to be changed from her being a mad, crazy and
unlovable child who needed to be punished, to her being a lonely and frightened
child who did not know how to connect with people and needed her mother’s help.
Such changes in orientation can be made in a context of therapy which is itself
nested in a system of protection in which violence or punishment of any kind is
not condoned.
These approaches focus on making beliefs more explicit. Such beliefs are often
outside of consciousness: ‘It’s just the way we are.’ When beliefs can be decon-
structed and examined they can also be considered, modi¿ed and changed. Beliefs
emanating from the attachment system might centre on how children should be
raised, how danger should be faced, what is appropriate comfort to give and at
what age this becomes inappropriate.
Experiential approaches will borrow from all of the above and try to elicit how
thinking, feeling and doing are tied up together. Experiential approaches are based
in action and will be concretely focused on identifying and strengthening family
resources.
Similarly, using a Narrative orientation, the emergence and development of fam-
ily stories of staying safe, overcoming danger, eliciting and receiving comfort and
expectations of relationships can be explored. Developing new attachment stories
that are coherent and integrate both cognition and affect is the therapeutic task.
Making sense of experience in a way that has logic and contains feelings and facts
without omissions or distortions will help the family and the individuals within it to
integrate dif¿cult experiences. They can then begin to move on from them in a way
that allows experience to be assimilated into the family story, therefore reducing
the likelihood of repetition. Transgenerational stories, family scripts (Byng-Hall
1995), can be edited and re-edited to ¿t with changing contexts and times.
Conversations about how safety is negotiated in the family will elicit stories
which may be rich and well developed or thin and in need of expansion. The
idea is that there are healthy stories in families that are undeveloped but exist in
embryonic form (White and Epston 1990). Often these are stories of strength and
overcoming adversity. Inviting a story about how the family stays safe and has
done so in the past may elicit untold stories of strength and resilience and indicate
paths for further development.
Obviously the foregoing is a very brief sketch and there is considerable overlap
between systemic approaches.
The role of the therapist

Clearly, in each of the attachment domains cited above there is a key role in how
the therapist orients him or herself in relationship to the family. The therapist’s
74 Chip Chimera
prime responsibility is to create a secure base for therapy. This promotes reÀex-
ive functioning – the ability to speak coherently about oneself and one’s dif¿cul-
ties. There is a strong link between this and secure attachment and it is of crucial
importance in family psychotherapy.
Emotion and action are central ideas in attachment-based family therapy. The
therapist who can initiate constructive action in the therapy room, between all
members of the family who are present, will increase the likelihood that positive
attachments will be promoted.
The N family
The following case goes some way to illustrate the integration of systemic
approaches using an attachment focus.
I was asked by the Court to undertake an independent assessment for

rehabilitation of a family with three children who had been removed
following the physical abuse of the two youngest boys.
The family consisted of the mother, Angela, the Father, Julius, an
older daughter, Laura, 13, and two boys, Jeremy, aged 8, and James,
aged 7. The family was Christian and from West Africa. Angela was
born in England and returned to West Africa when she was 2. As
a young adult she met Julius. They married and came to England
where she completed her training as a nurse and the children were
born.
Julius, while having no formal qualification was an intelligent and
ambitious man who was motivated to provide for his family. He turned
his hand to a number of jobs including working as a care assistant
in residential care, a car mechanic and undertaking electrical repairs.
Angela worked as a theatre sister on the night shift at a large London
teaching hospital.
Both parents worked hard and the family were eventually able to
move from their two-bedroom rented flat and start buying a three-
bedroom house with a garden in East London.
One Saturday, a few weeks after the move, Julius returned home
from work and found that the boys had taken the key to the back
garden, which they were forbidden to enter and had gone outside.
Worse, they had brought the garden hose into the house, turned it
on and soaked a good deal of the carpet and furniture before they had
been able to turn it off. Angela was in the house at the time; however,
she was unaware of what the boys had done until it was too late to
stop it.
The boys were in trouble and they knew it. Julius was angry that they
had disobeyed him, had put themselves at risk and had damaged the
new home. Some electric flex was close by from a repair job he had
finished. He told the boys to hold out their hands and hit them each
three times on the back of their hands. That was their punishment and
they accepted it.
On Monday they went to school. There were very few black children
in their area of London. Teachers noticed the marks and, there having
been some previous concerns, an urgent child protection investigation
was started. A medical examination revealed some further older marks
on Jeremy’s back which he could not explain. When asked, Jeremy con-
firmed that he was sometimes frightened of his father.
All three children were then placed in emergency foster care: the
boys together and Laura separately. The parents were informed of this
after school by the local authority social workers and the police who
undertook the investigation.
My involvement started eight months later following contested care
proceedings in which the parents sought the return of the children and
the local authority sought care orders.
The psychiatrist who undertook the original assessment recom-
mended family therapy with a view to rehabilitation. There were no
identified mental health problems in either parent.
I started by seeing the different family members separately. Each
assessment is different and whether it is started with a whole-
family meeting or meeting with sub-groups or individuals is depend-
ent on clinical judgement. There is no hard and fast rule. My decision
to see members separately at first was based on my knowledge of the
situation and my need to understand the individuals’ perspectives and
positions.
Each parent was interviewed regarding their histories of being
parented, following the format of the Adult Attachment Interview
(Crittenden and Landini 2011).
Although the resulting interview transcripts were not formally rated the inter-
view in itself is a wonderful clinical tool for understanding and orienting to
attachment issues. In my experience, this interview often helps parents to begin
76 Chip Chimera
a reÀective process on how their early experiences have impacted on the kind of
parents they have become. However, taking a good clinical history of the person’s
experience of being parented with an attachment orientation, asking about com-
fort, care and especially about the person’s perception of and response to danger,
may also reveal signi¿cant attachment information on which to base attachment
hypotheses.
The father’s experiences were of growing up in a high status Christian family.
He had a dif¿cult relationship with his mother who was the power in the family.
He found her mean spirited and they were not close. He was critical of the way
she treated others. He was close to his father by whom he felt understood, loved
and protected. At the same time he described his father as strict and somewhat
rigid in applying rules. However, he remembered several incidents of warmth and
gentleness from his father and genuine caring. He became tearful on several occa-
sions in recalling these. He seemed to use the Adult Attachment Interview (AAI)
to begin a reÀective process on how his relationship with his father inÀuenced him
as a father.
Both boys were then interviewed in their foster home. They were unhappy in
foster care and wanted to go home. They did, however, repeat that they were
sometimes afraid of their father. Jeremy in particular said that his father could turn
and be nice one minute, then angry.
Laura was seen separately and showed no ambivalence at all. While she liked
the foster carers she was with she wanted to be home with her brothers and par-
ents. She was not frightened of her father and was held in high esteem in the fam-
ily. She missed the activities she did with her family, in particular singing in the
church choir of which her father was the leader.
The ¿rst whole-family meeting was spent discussing issues of safety and dan-
ger. Stories were elicited about the many challenges the family faced by being
culturally different in a predominantly white, working-class area of London. Fam-
ily rules and norms for managing danger were discussed. The parental decision-
making subsystem and how the family organised around problems and dif¿culties
were also explored.
Towards the end of the ¿rst family session the following discussion took
place.
I asked why the children were not allowed into the garden, a fairly obvious
question which had not been addressed in the voluminous Court papers. Julius
spoke about the context of living in their new neighbourhood in which a number of
frightening things had happened. He recounted several stories of danger. Around
the time they moved in, a child who lived down the street was abducted by two
men with guns who ¿red a number of shots into the house where the boy was liv-
ing. Thankfully no one was killed. At this point Laura started coughing and went
out to get some water. Clearly anxiety was being awakened for all the children.
James had been moving closer to their father during the conversation, and seemed
to need physical contact. When Laura returned their father continued.
Chip: (picking up where we left off) So the police were putting a letter through
everybody’s letter box.
Julius: It said everybody should be very careful about their children. (pause)
And the third one that scared me most, it happened to me; thank God it
was me and not any of them (meaning the children). They were chasing
somebody, the police were chasing somebody, I don’t know what the
person has done. And from the other side of the house this guy has been
jumping the fence to each house and he jumped the fence and now hides
at my garden. (pause) I don’t know what happened; I was coming home
from my day work.
(James climbed into his father’s lap and was trying to interrupt him
to join in the conversation. The father patted him on the leg and
encouraged the physical connection while continuing the conversa-
tion. I noted the gentleness with which the father touched him and the
reassuring way he put an arm around him, allowing James to seek
comfort. Jeremy continued drawing on a low table in the centre of the
room.)
Let me ¿nish (to James who clearly wanted to say something). As I
open the door, the police, they ask me, they say ‘Is there anyone in the
house?’ (using an animated and challenging tone of voice). I say ‘No,
there is nobody in my house.’ I close the door again and as soon as I
open the back door, I see this giant man and immediately I saw him, I
don’t know what to do. I was shivering because he has a big stick and
I was shivering, seriously. By the time I got round to calling the police
he jumped back round again to the other house (this was said in an ani-
mated and excited tone of voice).
Chip: Were the children there at the time?
Julius: Yes.
Angela: They were still at home then.
Julius: But they were not in the garden.
Chip: Thank goodness.
Angela: Inside.
Chip: (Addressing the children) Did you know what happened then?
(This was followed with general noise, all the children talking at once,
saying they did know about it.)
Julius: I explained to them that that’s why I’m kind of strict with them. I say
‘Listen.’ I say to them ‘Don’t go to the garden without the supervision
of any adults.’
Jeremy: That’s why we can’t go in the garden.
Comment
It was clear that although Jeremy had been more contained than James during the
conversation, he had been listening intently. His reiteration of the family rule ‘we
78 Chip Chimera
can’t go into the garden’ was an indication of a Type ‘A’ orientation to attach-
ment. That and James’ ability to wait until his father had ¿nished talking before
talking more made me think of James as a child who wanted to be a good boy and
follow the rules. Laura’s response had been to go out of the room to lower her
arousal level by getting a drink of water.
I noted that the father’s language was animated, emotive and imaged – ‘a big
man’ with the emphasis on ‘big’ and ‘I was seriously shivering’ for instance. He
also spoke at times in the present tense, as if this was happening now and not in
the past. This language led me to hypothesise that Julius’ orientation to attach-
ment was one in which he was more reliant on his gut feelings and instinct, than
on pure logic. This was consistent with the emotional expression of his AAI
narrative.
I then turned back to James who was still on his father’s lap.
Chip: What did you want to say to your Daddy, James?

James: Daddy, you know that cat that keeps going over our fence from
Nancy’s? (their neighbour).
Julius: Yeah, and (picking up James’ story and talking directly to me)
there’s a cat that they are kind of . . . when you see them they look
like a wild cat; you chase them and they will chase you.
(I noted that the father was able to join with James in his concern
about the cat, which was of a much lower order of danger than
he had been describing. This seemed to join the family together.
However James then tried to leave the room, whether this was
because his arousal level was too high I never fully understood.
The father brought him back to his lap and James accepted this
without resistance.)
Chip: We need to think about ending and ¿nishing off the session now.
What I’m hearing is that some very scary things have happened
outside the home. (General agreement to this from all family
members.) And that you were very concerned about the children’s
safety.
Jeremy: Was there anything scary happening inside the house?
(This comment from Jeremy who had remained quietly drawing
throughout the session in the middle of the room, came as a sur-
prise to both parents and to me.)
Both parents: Sorry?
Jeremy: (repeating) Was there anything scary happening inside the
house?
Angela: Let me ask you, has there been anything scary happening inside
the house?
(Angela had been quiet in this part of the session until this moment.
She leaned forward slightly in asking this question and her voice
was challenging.)
Jeremy: No.
(Shaking his head ‘no’, Jeremy seemed to realise the potential of
his question in showing his parents in a bad light. His retraction
was unconvincing.)
Julius repeats: Has there been anything scary inside the house?
Jeremy: No, has anything happened that is scary inside the house?
Comment
Jeremy, aged 8, seemed to ¿nd himself in a hole and kept digging. The atmosphere
immediately changed from one of cooperation and the family joining together
against outside threats, to one of being unbalanced and having to face the pos-
sibility of danger existing within the family. We were two minutes away from the
end of the session and there was no possibility of exploring Jeremy’s comment
thoroughly. Several things happened simultaneously in my mind. I felt I had gone
some way to engaging these parents in a process of reÀection on their parenting
and on the children’s needs, particularly the father. I could see many strengths in
the father’s parenting that could be built upon and was eager to understand how
events had developed. Therapy needed to be established as a safe base for all
family members and myself as a temporary secure attachment ¿gure who could
be trusted. If this therapy was to be successful in establishing a containing envi-
ronment that could hold the anxiety of all family members, I needed to take care
of each person’s need for safety. The future of the family staying together was
dependent on the therapy being successful. I was mindful that the boys had told
me the previous week that they were sometimes frightened of their father. It would
have been inappropriate to put the child on the spot in this context to explain his
statement. I had also met with the parents independently and formed the view that
they had the capacity to care for their children with sensitivity to their needs. The
children’s identity and sense of self was clearly rooted in their family connections.
Tentatively I took the following relational risk with the parents.
Chip: I think there have been some scary things that have happened and that’s
why I think we are here, to talk about those scary things.
Julius: What?
(He seemed genuinely perplexed, which I understood, as until then our
conversation in the session had been about him as a protective father.)
Chip: Well, I think when they were hit it was scary. When you hit them. And
even understanding that you were concerned about their safety and want-
ing to keep them safe, it was still frightening for them to be hit by you
and I think I am right about that. But I know it’s very hard for the chil-
dren to say that. And one thing that we have to work on here is to talk
about how you can keep them safe and also not make them scared of
you at the same time, because being scared of you then wipes out your
protectiveness. You know what I mean?
80 Chip Chimera
Julius: (Nodding agreement) By being too harsh we do not bring the safety that
one is working towards.
(Both parents relax.)
Chip: (Inwardly breathing a huge sigh of relief and being af¿rmed that this
father was someone who could use the intervention – I was not yet sure
of the mother.)
I think the children know you want them to be safe, don’t you?
All: Yes.
(All vigorously nodding, especially Jeremy.)
Chip: It’s just that it’s back¿red and didn’t work the way it was supposed to
work.
(Julius agreed with this statement and the session ended on a coopera-
tive and hopeful note.)
Julius’ comments were consistent with his AAI in which he described his
father as setting rules which must be obeyed without question but as having the
children’s welfare at the centre of his actions. I was able to strongly recommend
working towards these children’s return home. Subsequently I was joined by a
colleague to continue the work. Over the next nine months – the children return-
ing home after three months – we worked with the family to develop understand-
ing of emotional states and for the parents to help the children with their fears
and anxieties.
We created a circle of safety using the family drawings of strengths.

These included the things they did together, such as singing, watching
television and family outings, as well as what they were each good at
such as cooking a particular meal for the family or achieving a certifi-
cate at school. At each session we offered the family the opportunity
to add to their strengths. They were very good at drawing and it was
something they enjoyed doing together.
We asked each person to make a list of their worries and used
psychodramatic enactments to explore different, more positive, end-
ings to stories of danger both inside and outside the home. These
ranged over many issues and included the children’s worries about the
parents arguing in the home and Jeremy experiencing racial bullying
at school. The enactments involved different members of the family
taking the role of ‘director’ under our guidance and staging a recon-
struction of worrying episodes of family life and working out a more
satisfactory outcome in action. This family engaged readily in this work
and over the months we saw positive changes and deeper emotional
connections and understandings between family members. Many of the

changes enacted in the sessions were incorporated into daily life.
At the end of the work we were able to present them with a book
containing all of the strengths they had drawn, leaving blank pages for
the ones to come.
Conclusion
An attachment orientation to family therapy allows affect and cognition to be
examined in a way that can bring the covert and hidden family rules and behav-
iours out into the light. Creating a therapeutic base that is secure for all members
of the family can help them to re-examine their positions and consider how change
may be bene¿cial.
Attachment helps us to look below the surface and excavate meanings and
beliefs as well as illuminating feelings of fear and anger which might be unknown
to the family itself, or previously too unsafe to voice.
Attachment conversations are those conversations and activities that address
safety and protection from danger, including comfort. Danger that comes from
inside the family may be the most dif¿cult to name. Many such conversations are
possible depending on the systemic therapist’s orientation. The premise here is
that attachment and systemic ideas are mutually bene¿cial and complement each
other to bene¿t the family.
Attachment theory and systemic family therapy have had a long and Àirtatious
courtship. Whether this ongoing relationship is a genuine love match or a marriage
of convenience remains to be seen.
References
Ainsworth, M. D. S. and Bell, S. M. (1970) Attachment, exploration, and separation: illus-
trated by the behaviour of one-year-olds in a Strange Situation. Child Development, 41:
49–67.
Andersen, T. (1987) The reflecting team: dialogue and meta dialogue in clinical work.
Family Process, 26(4): 415–428.
Bowlby, J. (1988) A Secure Base, London and New York: Routledge.
Bowen, M. (1978) Family Therapy in Clinical Practice, New York: Jason Aronson.
Burnham, J. (2005) ‘Relational reflexivity: a tool for socially constructing therapeutic rela-
tionships’, in C. Flaskas, B. Mason and A. Perlesz (eds) The Space Between, London:
Karnac.
Burr, V. (1995) An Introduction to Social Constructionism, London: Routledge.
Byng-Hall, J. (1995) Rewriting Family Scripts, New York: Guilford Press.
Carter, B. and McGoldrick, M. (eds) (1989) The Changing Family Life Cycle: a framework
for family therapy, 2nd ed., London: Allyn & Bacon.
82 Chip Chimera
Cecchin, G. (1987) Hypothesising, circularity and neutrality revisited: an invitation to curi-

osity, Family Process, 26: 405–413.
Crittenden, P. (2008) Raising Parents: Attachment, parenting and child safety, Devon:
Willan Publishing.
Crittenden, P. and Landini, A. (2011) Assessing Adult Attachment, New York and London:
W. W. Norton & Co.
Dallos, R. (2006) Attachment Narrative Therapy, Maidenhead: Open University Press.
Dallos, R. and Vetere, A. (2009) Systemic Therapy and Attachment Narratives, London:
Routledge.
Fivaz-Despeursinge, E. and Corboz-Warnery, A. (1999) The Primary Triangle: A develop-
mental systems view of mothers, fathers and infants, New York: Basic Books.
Holmes, J. (2001) The Search for the Secure Base: Attachment theory and psychotherapy,
New York and London: Routledge.
Kelly, J. B. and Johnson, J. R. (2001) The alienated child: a reformulation of parental
alienation syndrome, Family Court Review, 39: 249–266.
Mason, B. (1993) Towards positions of safe uncertainty, Human Systems, 4: 189–200.
Minuchin, S. (1974) Families and Family Therapy, London: Tavistock Publications.
Minuchin, S. and Fishman, C. (1981) Family Therapy Techniques, Cambridge, MA:
Harvard University Press.
Sroufe, L. A. (2005) Attachment and development: a prospective, longitudinal study from
birth to adulthood, Attachment & Human Development, 7(4): 349–367.
Van IJzendoorn, M. H. and Sagi, A. (1999) ‘Cross-cultural patterns of attachment: uni-
versal and contextual dimensions’, in J. Cassidy and P. R. Shaver (eds) Handbook of
Attachment: Theory, research and clinical applications, New York and London: Guil-
ford Press.
Watzlawick, P., Weakland, J. and Fisch, R. (1974) Change: Principles of problem forma-
tion and problem resolution. New York: W.W. Norton & Co.
White, M. (1988) The externalising of the problem and the re-authoring of lives and rela-
tionships, Dulwich Centre Newsletter, Summer 1988, reprinted in Selected Papers, Dul-
wich Centre Publications, 1991.
White, M. and Epston, D. (1990) Narrative Means to Therapeutic Ends, London and New
York: W. W. Norton & Co.
Chapter 5
Attachment-based interventions
Sensitive parenting is the key to
positive parent–child relationships
Femmie Juffer, Marian J. Bakermans-Kranenburg
and Marinus H. van IJzendoorn
Introduction
In this chapter we present attachment-based parenting interventions from the
perspectives of attachment theory and relevant empirical research. In a series of
meta-analyses of the pertinent intervention studies we have tested how effective
these interventions are and which features of the interventions contribute to their
effectiveness.
Based on attachment theory and research, and after extensive experience, we
have developed an intervention model with video feedback that was rigorously
tested in various samples of parents and children at risk. We elaborate on how
to use this attachment-based video-feedback intervention in practice to support
sensitive parenting and positive parent–child interactions.
We focus here on attachment-based parenting interventions and we do not
include parent behaviour-management interventions aimed at helping parents
of children with severe behaviour problems or conduct disorders (e.g. Scott &
O’Connor 2012; Webster-Stratton et al. 2004, 2011). We also do not address
‘attachment therapy’ and similar approaches such as ‘holding’ or ‘trauma therapy’
offered at numerous internet sites for parents of troubled children. Unfortunately,
many so-called attachment therapies not only miss a solid theoretical foundation
and empirical evidence-base, but they may even be harmful and dangerous for
children (Chaf¿n et al. 2006; Pignotti & Mercer 2007).
Attachment security
The key is sensitive parenting

Departing from an evolutionary perspective and drawing on research that exam-
ined the effects of separations of (primate) infants from their parents (e.g. Harlow
1958), John Bowlby (1982) developed attachment theory. According to that the-
ory, infants are biologically predisposed to use their parents as a haven of safety
to provide comfort and protection when they are distressed, and as a secure base
from which to explore the world (Waters & Cummings 2000). Securely attached
84 Femmie Juffer et al.
children feel free to play and to express their positive and negative emotions
because they trust their parents to support them whenever they need help.
However, not all children experience their parents as a haven of safety and a
secure base. Mary Ainsworth (Ainsworth et al. 1978) observed that children vary
in their attachment behaviour and she suggested that sensitive parenting might be
the key to children’s attachment security. Ainsworth de¿ned parental sensitivity
as the ability to accurately perceive and interpret the child’s behavioural signals
and to respond to these signals in a prompt and adequate way (Ainsworth et al.
1978). In Ainsworth’s study, and replicated in many empirical studies and a meta-
analysis (De Wolff & Van IJzendoorn 1997), children who had experienced insen-
sitive parenting tended to develop insecure (avoidant or ambivalent) attachment
relationships with their parent whereas children who had received sensitive care
had a greater chance to become securely attached.
In a longitudinal adoption study we found that sensitive parenting not only mat-
ters for young children. Maternal sensitive support in early childhood and adoles-
cence predicted continuity of secure attachment from 1 to 14 years, whereas less
maternal sensitive support in early childhood but more maternal sensitive support
in adolescence predicted children’s change from insecurity in infancy to security
in adolescence (Beijersbergen et al. 2012). We concluded that both early and later
sensitive parenting are important for the continuity of attachment across the ¿rst
14 years of life. By using an adoption design, we ensured that no effect of parent-
ing could be attributed to genetic transmission from adoptive parent to child.
To date, Ainsworth’s concept of parental sensitivity has proven to be useful not
only because it sheds light on the aetiology and continuity of the different patterns
of secure and insecure attachment relationships but also because it offers an essen-
tial framework for the development of attachment-based interventions to support
parents of young children. Later in this chapter we will present our video-feedback
intervention and show how Ainsworth’s concept of parental sensitivity has been
translated and integrated in the intervention approach, structure, and themes.
While Ainsworth distinguished the categories of children’s secure, insecure
avoidant, and insecure ambivalent attachment, Mary Main added a fourth cate-
gory: insecure-disorganised attachment (Main & Solomon 1990). Main and Hesse
(1990) proposed that in stressful situations insecure-disorganised children want
to seek comfort and protection from their parent while, at the same time, feeling
frightened by the parent, which results in an irresolvable paradox. As a conse-
quence the child may (momentarily) show bizarre or contradictory behaviours.
They proposed that parents of disorganised children suffer from unresolved loss or
trauma and parents’ negative memories and fears may suddenly intrude into their
consciousness and behaviour, resulting in frightening, frightened or dissociated
behaviour toward their child (Main & Hesse 1990). Unresolved loss or trauma
can also negatively affect the parent’s ability to perceive the child’s signals accu-
rately and to respond in adequate ways, leading to (extreme) insensitivity. Fright-
ening, disconnected and (extremely) insensitive parenting behaviours may thus be
complementary to and only partially overlapping (in the lower range) with paren-
Attachment-based interventions 85
tal sensitivity. Frightening and disconnected parental behaviour was found to be

related to disorganised attachment (Hesse & Main 2006; Madigan et al. 2006; Out
et al. 2009; Schuengel et al. 1999), while in its turn disorganised attachment was
associated with elevated risk for later child psychopathology (Van IJzendoorn
et al. 1999).
Compared to insecure attachments, early secure attachment relationships have
been associated with better social competence in both genetically related families
(e.g. Sroufe et al. 2005; Thompson 2008) and genetically unrelated adoptive fami-
lies (Jaffari-Bimmel et al. 2006), ruling out genetic confounding in the latter case.
Further, a series of meta-analyses has shown that attachment insecurity predicts
both more externalising and internalising behaviour problems in childhood and
adolescence although effect sizes were modest (Fearon et al. 2010; Groh et al.
2012).
Because insecure and disorganised attachment can be seen as risk factors in the
development of child psychopathology, both attachment security and the related
concept of parental sensitivity are relevant for the clinical ¿eld, and for the devel-
opment and evaluation of attachment-based interventions in at-risk and clinical
families. In particular, parental sensitivity as the best-documented and evidence-
based determinant of children’s attachment security has been the focus of inter-
vention efforts tested in multiple studies. But what do we know about the success
and effectiveness of these efforts, and do we know which intervention meth-
ods and models work best? To ¿nd answers to these theoretically and clinically
signi¿cant questions, we adopted a meta-analytic approach.
Meta-analyses of sensitivity and attachment

interventions
Meta-analysis is one of the most useful tools to reach evidence-based conclusions
about best intervention practices. With a meta-analytic approach, data from mul-
tiple studies can be synthesised and quanti¿ed, and solid conclusions can be drawn
about essential features of effective attachment-based interventions, such as the
duration or the focus of the intervention.
In a series of meta-analyses, we examined 70 published intervention studies
with 88 interventions directed at either sensitivity or attachment or both (see Bak-
ermans-Kranenburg et al. 2003, 2008a). All intervention studies reported observed
parental sensitivity or children’s attachment security, or both, as outcome mea-
sures. The intervention studies were not restricted to a speci¿c population. Some
samples consisted of low-risk families with typically developing infants, but stud-
ies with clinical and at-risk populations were included as well.
Parental sensitivity
Eighty-one studies (including 7,636 families) presented intervention effects on
parental sensitivity; and the combined effect size (d, the standardised difference
between the means of the intervention and control groups) was a moderately strong
effect of 0.44 (p < .001). To estimate the combined effect size in the set of studies
with the most adequate designs, randomised controlled trials were selected. In this
set of 51 studies (including 6,282 participants), interventions were also signi¿-
cantly effective in enhancing parental sensitivity (d = 0.33).
The interventions appeared to be equally effective in at-risk or multiple risk
samples (including, for example, families with low socio-economic status (SES)
or adolescent mothers) and in low-risk families. The only difference was that
interventions with clinically referred families were signi¿cantly more effective
(d = 0.46) than interventions with other groups (d = 0.31) (Bakermans-Kranen-
burg et al. 2003).
Interventions with a relatively narrow focus, aiming at enhancing parental sen-
sitivity through an interaction-focused approach, were found to be signi¿cantly
more effective (d = 0.45) than broader interventions (such as interventions focus-
ing on mental representations of attachment or on social support) (d = 0.27).
Interventions with video feedback were more effective than interventions with-
out this method. Interventions with fewer than ¿ve sessions were as effective as
interventions with ¿ve to 16 sessions. Surprisingly, however, interventions with
more than 16 sessions were less effective than interventions with a smaller number
of sessions (‘Less is More’; see Bakermans-Kranenburg et al. 2003). Short-term,
interaction-focused interventions with video feedback thus appear most effective
in improving sensitive parenting.
Attachment security
Twenty-nine intervention studies (involving 1,503 families) aimed at promoting
children’s attachment security (Bakermans-Kranenburg et al. 2003). The com-
bined effect size for attachment security was modest but signi¿cant (d = 0.19).
Twenty-three studies (including 1,255 families) presented randomised controlled
trials resulting in a similar effect size (d = 0.20). The characteristics of the samples,
such as low SES, clinical referrals, or the presence of multiple risk factors, did not
result in differences in effect sizes between the studies. Attachment interventions
were thus equally effective in low-risk and high-risk families and in clinical and
nonclinical families.
Interventions focusing on parental sensitivity were signi¿cantly more effective
in fostering secure attachment than interventions targeting other aspects such as
representational interventions or social support. In fact, only sensitivity-focused
interventions showed a signi¿cant combined effect size on attachment (d = 0.39).
Most importantly, those interventions that were most effective in enhancing
parental sensitivity (d > 0.40) were also most effective in enhancing children’s
attachment security (d = 0.45; Bakermans-Kranenburg et al. 2003).
Attachment theory and empirical research (see the meta-analysis of De Wolff &
Van IJzendoorn 1997) already had predicted and con¿rmed the correlational asso-
ciation between sensitive parenting and children’s attachment security. From the
meta-analytical ¿ndings on attachment-based interventions (Bakermans-Kranen-

burg et al. 2003) we can extend the ¿ndings from correlational to causal relations
and conclude that sensitive parenting is, indeed, the key to (changes in) attachment
security in children. In fact, the meta-analytic study of randomised experiments
in this ¿eld is the most conclusive evidence for a causal relation between parental
sensitivity and infant attachment security to date.
Disorganised attachment
In another meta-analysis, we examined 15 attachment-based intervention studies
(including 842 families) that reported on children’s insecure-disorganised attach-
ment as an outcome measure (see Bakermans-Kranenburg et al. 2005, 2008a).
The combined effect size of these studies was not signi¿cant, d = 0.05. However,
the ¿ve interventions focusing on parental sensitivity only were most effective;
they were signi¿cantly more effective in reducing attachment disorganisation (d =
0.26) than other interventions not focusing on sensitive parenting (d = –0.08). This
¿nding is intriguing as disorganised attachment has been associated with frighten-
ing and atypical parenting (see above) instead of parental sensitivity which is the
focus of attachment-based interventions studied in the meta-analysis.
Concluding, our meta-analyses showed that interventions can signi¿cantly
enhance parental sensitivity and children’s attachment security, but attachment
security to a lesser extent than sensitivity (the same conclusion was reached in
a previous meta-analysis including a much smaller number of studies; see Van
IJzendoorn et al. 1995). Most importantly, our ¿ndings showed that speci¿c char-
acteristics distinguished more effective interventions from less effective inter-
ventions. In particular, brief interventions with a focus on sensitive parenting
behaviour appeared to be most successful in decreasing parents’ insensitivity as
well as children’s attachment insecurity and disorganisation.
The Leiden parenting programmes: VIPP and

VIPP-SD
Supporting sensitive parenting

Based on insights from attachment theory and building on the knowledge from our
meta-analytic studies, we developed an intervention aiming at promoting sensitive
parenting and positive parent–child interactions: Video-feedback Intervention to
promote Positive Parenting (VIPP). Essential outcomes of the meta-analyses of
attachment-based interventions (Bakermans-Kranenburg et al. 2003) were inte-
grated in the VIPP model: as a result we designed a short-term, home-based inter-
vention directed at sensitive parenting behaviour by utilising video feedback, and
we tested the VIPP in a series of randomised controlled trials.
Parental sensitivity, as the key to positive parent–child interactions and rela-
tionships, was translated and integrated in the intervention approach, structure and
themes of the VIPP. The main objective of the VIPP is to promote the parent’s
sensitivity by showing and reinforcing moments of sensitive parenting of the par-
ent herself in video fragments. The structure of the VIPP intervention closely fol-
lows the components of Ainsworth’s concept of sensitivity by paying attention in
the ¿rst and second home visit to teaching parents how to accurately perceive and
interpret their child’s signals, and in the third and fourth session by reinforcing
and promoting parents’ efforts to respond to their child’s signals in prompt and
adequate ways. The themes of the home visits are adapted to this structure so that
learning and practising observational skills are paramount in the ¿rst two inter-
vention visits (e.g. by ‘speaking for the child’, see below) while highlighting and
encouraging sensitive reactions are the main focus of the third and fourth sessions
(e.g. reinforcing ‘sensitivity chains’, see below). In cases where there are more
booster sessions, all themes are combined and repeated.
Development of VIPP
A ¿rst attempt to enhance parental sensitivity through an attachment-based video-
taped model of sensitive parenting, featuring strangers, appeared to be ineffective
(Lambermon & Van IJzendoorn 1989). A problem with videotaped model behav-
iour is that parents might not identify with the speci¿c model of a parent–child
dyad on the videotape. Parents apparently need a mirror of their own daily inter-
actions with their child to change their behaviour. Based on attachment theory
(Ainsworth et al. 1978; Bowlby 1982), a ¿rst version of our video-feedback
intervention programme was developed in a study of families with early-adopted
children (Juffer 1993). The intervention, consisting of three home sessions imple-
mented in the child’s ¿rst year of life, appeared to be successful in promoting
maternal sensitivity, secure infant–mother attachment, and the prevention of dis-
organised attachment (Juffer et al. 2005, 2008a). On the basis of these outcomes a
nationwide and government subsidised adoption aftercare service was started and,
since the year 2000, Dutch parents can ask for this service for each newly adopted
child, including special-needs or older-placed children and sibling placements.
The ¿rst version of this video-feedback intervention was extended to other types
of families and then also to toddlers and preschoolers into the current VIPP (Juffer
et al. 2008b, 2009), consisting of four to six sessions, organised into structured
stages according to a detailed protocol. Another extension of the VIPP programme
was developed and tested a few years later, with an additional component aimed
at enhancing adequate discipline (VIPP-SD: VIPP with an additional focus on
Sensitive Discipline; Juffer et al. 2008b; Mesman et al. 2008; Van Zeijl et al.
2006). The VIPP has been adapted for use with clinical groups (e.g. Stein et al.
2006), group care, and for fathers (see below).
The Leiden Centre for Child and Family Studies offers regular training courses
on how to use VIPP and VIPP-SD in practice (www.leidenattachmentresearch-
program.eu/vipp).
How to use attachment-based interventions
Illustrations from the VIPP programmes

How can attachment-based interventions be used in practice? What kind of themes
and techniques are included and how are the parents involved in the intervention?
We present illustrations and examples from the VIPP programmes in which par-
ents are offered short-term, interaction-focused interventions aimed at enhancing
sensitive parenting (VIPP) and adequate discipline (VIPP-SD). The programmes
are standardised and individualised, meaning that the interveners work from a
standard protocol (Juffer et al. 2008c) but attune the guidelines to the individ-
ual parent–child dyad. The VIPP programmes use videotaped interactions of the
parent and child involved and video feedback: interveners watch and review the
videotape together with the parent. The VIPP programmes are home-based and
short-term: the interventions are implemented in the home in a modest number of
sessions (usually six). Building a supporting relationship between the intervener
and the parent (Bowlby 1988) is a crucial element of the intervention.
In the VIPP programmes, parent and child are videotaped during daily situa-
tions at their home (for example, playing together, bathing, mealtime) during brief
episodes of 10 to 30 minutes. Parents are encouraged to react to their children the
way they normally do. In the period between the home visit and the intervention
session, the intervener reviews the videotape and prepares comments on the par-
ent–child interaction as shown on the videotape. The intervener writes down these
comments, directed by the guidelines of the protocol and screens the videotape for
suitable fragments to connect the information in the guidelines to the video frag-
ments, and this script serves as a guide for the video feedback in the intervention
session. This script can be discussed in a review session with peer interveners or
supervisors.
As an illustration, when the theme of exploration versus attachment behaviour
(see Table 5.1) is to be discussed in the next intervention visit, the intervener
searches for relevant fragments. Thus fragments of the child making eye contact or
seeking physical proximity are used to illustrate the child’s attachment behaviour,
whereas fragments of the child’s play behaviour are used to illustrate explora-
tion. In the intervention the intervener connects the fragments to general messages
described in the protocol. For example, while showing attachment and exploration
fragments, the intervener explains that these behaviours ask for differential paren-
tal reactions: children’s attachment signals should be met with prompt, adequate
reactions, whereas parents should adopt a different role during children’s play and
share the child’s activities without being intrusive or interfering. The intervener
may also comment that play behaviour is important for children because they
learn a lot from manipulating toys. At the same time, playing together provides
children with an extra dimension compared to playing alone: their overtures are
responded to, making them feel understood, and moments of joy can be shared
(the intervener may say: ‘A toy does not smile back, you do!’).
Table 5.1 Sensitivity themes used in VIPP and additional sensitive discipline
themes used in VIPP-SD
Session Sensitivity Sensitive discipline
1. Exploration versus attachment Inductive discipline and distraction
behaviour (A)
2. ‘Speaking for the child’ (A) Positive reinforcement
3. Sensitivity chain (B) Sensitive time-out
4. Sharing emotions (B) Empathy for the child
5. Booster session (A and B) Booster session
6. Booster session (A and B) Booster session
Note: (A) refers to the first part of Ainsworth et al.’s (1978) concept of sensitivity: accu-
rately perceiving and interpreting the child’s signals; (B) refers to the second part of Ain-
worth’s concept of sensitivity: prompt and adequate reactions to the child’s emotional and
behavioural signals. In the booster sessions all themes are combined.
During the next visit the videotape is shown to the parent, and the intervener
reviews the videotape with her, discussing the selected fragments on the basis of
the comments and script prepared before the session. Positive interaction moments
shown on the videotape are always emphasised. Focusing on positive interactions
serves the goal of showing the mother that she is able to act as a sensitive, compe-
tent parent: she should feel empowered by positive feedback rather than incom-
petent due to negative feedback. To focus the parent’s attention on the positive
moments, the videotape is stilled and the parent is shown a picture of a successful
interaction or a happy child. By repeating positive fragments, reinforcing mes-
sages are enlarged and emphasised while negative moments are counterbalanced.
In case of insensitive parental behaviour, the parent is encouraged to use more
sensitive behaviours, preferably behaviours she displayed at other moments on the
videotape, so that she is her own model of competent parenting. These ‘corrective
messages’ are, however, postponed to the third or later intervention sessions (see
below).
Video feedback provides the opportunity to focus on the child’s videotaped
behaviour, thereby stimulating the parent’s reÀective functioning, his or her
observational skills and understanding of the child. It also enables positive rein-
forcement of the parent’s moments of sensitive behaviour shown on the videotape.
Video feedback thus enables the intervener to focus on both parts of Ainsworth’s
concept of sensitivity: accurately perceiving and interpreting child signals and
adequately responding to them (Ainsworth et al. 1978).
VIPP
VIPP consists of four themes (see Table 5.1) that are elaborated successively dur-
ing four home visits: (1) Exploration versus attachment behaviour: showing the
difference between the child’s contact-seeking behaviour and play, and explaining
the differential responses needed from the parent, (2) ‘Speaking for the child’:
promoting the accurate perception of children’s (subtle) signals by verbalising
their facial expressions and non-verbal cues shown on the videotape, (3) Sensi-
tivity chain: explaining the relevance of prompt and adequate responding to the
child’s signals (‘chain’: child signal–parental response–reaction of the child), and
(4) Sharing emotions: showing and encouraging parents’ affective attunement to
the positive and negative emotions of their child.
The themes are ordered in a way that the ¿rst two intervention sessions focus
on child behaviour only (e.g. by actively ‘speaking for the child’; Carter et al.
1991). The next two intervention sessions are also directed at parental behaviour,
for example by discussing parental behaviour in a ‘sensitivity chain’. This speci¿c
order is part of the VIPP protocol: addressing parental behaviour is postponed
until the parent and the intervener have had more time to build a working rela-
tionship. Another advantage is that a primary focus on the child’s perspective is
already guaranteed in the ¿rst sessions.
Additional ‘booster’ visits (intervention sessions 5 and 6) are used in which
all sensitivity themes of the ¿rst four intervention sessions are repeated and
connected to new video fragments. Giving the parent written information (e.g.
brochures) is optional.
VIPP-SD
VIPP-SD is based on an integration of attachment theory (Ainsworth et al. 1978;
Bowlby 1982) and coercion theory (Patterson 1982). Coercion theory describes
how ineffective parental discipline results in increasingly dif¿cult and challenging
child behaviour. VIPP-SD can be characterised as an interaction-oriented inter-
vention using video feedback to promote parental sensitivity as well as adequate
and sensitive discipline strategies (Mesman et al. 2008).
The VIPP-SD programme consists of four speci¿c sensitive discipline themes
(see Table 5.1) that are elaborated during the intervention sessions in addition
to the sensitivity themes: (1) Inductive discipline and distraction: recommending
explanation and distraction as non-coercive responses to dif¿cult child behav-
iour or potentially conÀict-evoking situations, (2) Positive reinforcement: praising
the child for positive behaviour and ignoring negative attention-seeking, (3) The
use of a ‘Sensitive time-out’, to sensitively de-escalate temper tantrums, and (4)
Empathy for the child: consistent discipline and limit setting should be combined
with showing understanding of the intentions and feelings of the child.
For example, in the ¿rst intervention session the parent is encouraged to distract
the child in occurences of challenging behaviour and direct the child’s attention to
objects or situations that are allowed, thus creating opportunities for positive behav-
iours. At the same time, the parent is encouraged to use induction, that is, provid-
ing reasons and explanations for a prohibition or parental intervention (Hoffman
2000), thus helping the child to (gradually) understand the consequences of his or
her own behaviour and learning to empathise with other people’s perspectives.
As with VIPP, in additional ‘booster’ visits all sensitive discipline themes of the
¿rst four intervention sessions are repeated.
Through illustrations and examples we have described how VIPP and VIPP-SD
can be used in practice. However, before the implementation of an intervention
programme in clinical practice and social work, the evidence-base of the pro-
gramme should be indisputable. What do we know about the effectiveness of the
VIPP programmes?
Evaluating the VIPP programmes
Effectiveness of VIPP
VIPP has been tested in various countries in a number of studies with at-risk par-
ents or children (see Figure 5.1). In all studies, VIPP, or adaptations of the pro-
gramme, proved to be effective in enhancing sensitive parenting. In most of these
studies so-called dummy interventions, for example telephone calls, were given to
the control participants to keep in contact with all parents and to prevent attrition
(Juffer et al. 2008d). In one of the studies both the control group and the interven-
tion group received a cognitive behaviour module to help the parents with their
clinical problems. The intervention consisted of a cognitive behaviour module
Cohen's d
0,9
0,8
0,7
0,6
0,5
0,4
0,3
0,2
0,1
0
Meta-analysis Mothers of Insecure Eating- Mothers of Insensitive Home-based
adopted mothers disordered externalising mothers child care
children mothers children
Figure 5.1 Effectiveness of VIPP/VIPP-SD on sensitive parenting in six samples of

parents (caregivers) and children (solid line; total N = 627), compared
to the effectiveness on parental sensitivity in randomised controlled
trials in the 2003 meta-analysis of attachment-based interventions
(dotted line; N = 6,282; Bakermans-Kranenburg et al. 2003)
aimed at helping the mother with her eating problem for both groups and an addi-
tional adapted VIPP programme aimed at promoting sensitive parenting for the
intervention group only (Stein et al. 2006).
In a randomised controlled trial with Dutch low-SES mothers classi¿ed as inse-
cure with the Adult Attachment Interview (Hesse 2008; Main et al. 2003), VIPP
implemented in four home visits during the baby’s ¿rst year of life resulted in a
signi¿cant increase in maternal sensitivity of the intervention group compared to
the control group (Klein Velderman et al. 2006a). In a follow-up study of the same
sample, it appeared that, compared to the control group, VIPP had signi¿cantly
protected the children from developing externalising and total behaviour problems
in the clinical range at preschool age (Klein Velderman et al. 2006b).
Stein and colleagues (2006; Woolley et al. 2008) tested a short-term, slightly
adapted version of the VIPP in a randomised controlled trial with mothers with
eating disorders and their babies in the United Kingdom and found a signi¿cant
improvement in maternal mealtime interaction with the infant, including mother’s
appropriate verbal and non-verbal responses to infant cues (components of sensi-
tive parenting behaviour).
In Lithuania, mothers screened on insensitive parenting behaviours signi¿-
cantly gained in sensitivity after receiving VIPP compared to a control group of
insensitive mothers in a randomised controlled trial (Kalinauskiene et al. 2009).
Mothers of adopted children who had received a ¿rst version of the VIPP (see
before) also outperformed their control counterparts in sensitivity (Juffer et al.
2005, 2008a). In another randomised controlled trial, mothers of 1-year-old, 2-
year-old, and 3-year-old toddlers screened for high levels of externalising problem
behaviour showed signi¿cantly more sensitive discipline after the VIPP-SD inter-
vention implemented in six home visits compared to their control counterparts
(Mesman et al. 2008; Van Zeijl et al. 2006).
Further, a randomised controlled trial in home-based child care showed that
with some minor modi¿cations the family-based VIPP with six intervention ses-
sions could be successfully applied in a group setting (VIPP-CC: VIPP-Child
Care; Groeneveld et al. 2011). Global child care quality improved in the interven-
tion group compared to the control group and, after the intervention, caregivers in
the intervention group reported more positive attitudes toward sensitive caregiv-
ing than caregivers in the control group (Groeneveld et al. 2011).
In conclusion, VIPP appeared to be effective with respect to sensitive parent-
ing (see Figure 5.1) and the effect sizes were in the same range or even higher
than the combined effect size for parental sensitivity found in the meta-analysis
of attachment-based intervention studies (Bakermans-Kranenburg et al. 2003).
We computed the effectiveness of the VIPP programmes conducted so far with a
meta-analysis of the pertinent VIPP intervention studies shown in Figure 5.1 and
the combined effect size amounted to a signi¿cant medium effect for promoting
sensitive parenting, d = 0.48, including 627 participants in six studies.
A de¿nite conclusion about the effectiveness of VIPP for enhancing attachment
security cannot be drawn yet. Children’s attachment security was not reported in
the studies on mothers with eating disorders, children with externalising prob-
lems, and home-based child care. Mixed outcomes were found in other VIPP stud-
ies, with signi¿cant, positive outcomes in an adoption sample, and no signi¿cant
effect in the study on insensitive mothers. Interestingly however, although in the
VIPP intervention study of insecure mothers no overall intervention effect on
attachment security could be traced, we found that the outcomes varied for chil-
dren differing in temperamental reactivity: some children gained more from the
intervention than others.
VIPP and differential susceptibility

Early-childhood interventions might not always be effective for all families and
children (see also Scott & O’Connor 2012), implying that our VIPP intervention
might not be equally effective for all children involved. Children may be differen-
tially susceptible to environmental inÀuences and changes (Bakermans-Kranen-
burg & Van IJzendoorn 2007; Belsky 1997; Belsky et al. 2007; Ellis et al. 2011;
Van IJzendoorn & Bakermans-Kranenburg 2012a).
According to the evolutionary-based differential susceptibility hypothesis, chil-
dren vary in their susceptibility to parental rearing, for better – when receiving
sensitive care, or improved sensitive care after a successful intervention – and for
worse – when receiving less optimal care. Previous studies have indicated that
highly reactive children may be the more susceptible children (e.g. Belsky et al.
1998). Against this background, the differential effectiveness of our VIPP interven-
tion was tested in children with high versus average to low negative reactivity.
We found that the mothers of highly reactive infants were more susceptible to
the inÀuence of the intervention and gained more in sensitivity, and that highly
reactive infants, in turn, were more susceptible to (changes in) their mothers’ sen-
sitivity. In the group of highly reactive intervention infants, attachment security
and change in pre- to post-test maternal sensitivity were signi¿cantly correlated,
r = .64, p < .05. In the less reactive intervention group the correlation was r = .11,
ns. The difference in correlations was signi¿cant (p = .03; Klein Velderman et al.
2006a). The experimentally induced change in maternal sensitivity appeared to
impact more strongly on attachment security in the highly reactive infant group.
Thus, the outcomes con¿rmed the prediction that highly reactive children are
more susceptible to experimentally induced environmental change than less reac-
tive infants. Parents of highly reactive infants may therefore be the most reward-
ing targets of intervention efforts.
Our ¿ndings also revealed intervention effects at a neurobiological level: in our
sample with 1- to 3-year-old children screened for relatively high levels of exter-
nalising behaviour the VIPP-SD programme proved to be effective in decreas-
ing daily cortisol production in children with the DRD4 7-repeat allele (a variant
of the dopamine receptor gene that is associated with motivational and reward
mechanisms and ADHD in children), but not in children without the DRD4 7-
repeat allele.
These ¿ndings indicate that children are differentially susceptible to interven-

tion effects dependent on the presence of the DRD4 7-repeat allele (Bakermans-
Kranenburg et al. 2008b). Moreover, VIPP-SD proved to be effective in decreasing
externalising behaviour in the children with the DRD4 7-repeat allele. Zooming
in on parents who showed the largest increase in the use of positive discipline as
a result of the intervention, the decrease in externalising behaviour was strongest
in children with the DRD4 7-repeat allele, showing that they were indeed the
most susceptible to the change in their caregiving environment (Bakermans-
Kranenburg et al. 2008c).
This ¿rst experimental test of (measured) gene by (observed) environment
interaction in human development indicates that children might be differentially
susceptible to intervention efforts depending on genetic differences.
In summary, we documented the evidence-base of the VIPP programme as an
effective intervention for enhancing sensitive parenting and presented promising
outcomes regarding children’s differential susceptibility to intervention effects
based on their temperamental or genetic characteristics.
Against the background of the meta-analytical evidence on attachment-based
interventions presented above, the VIPP programmes were developed to include
intervention elements that were most effective in the meta-analyses. VIPP and
VIPP-SD are brief programmes, con¿rming the ‘Less is More’ feature of effective
interventions. VIPP and VIPP-SD both address sensitive parenting, converging
with the meta-analytical outcome that effective interventions focus on parental
sensitivity.
Before continuing with our conclusions and practical implications, we elabo-
rate on two intervention programmes that also included effective elements from
the meta-analyses of attachment-based interventions.
Examples of recent attachment-based interventions

Here we highlight two examples of recent, effective attachment-based interven-
tions tested in randomised controlled trials, and compare their characteristics to
the meta-analytic ¿ndings described above.
It is not our intention to give a complete overview of all current attachment-
based interventions here (other examples of such interventions are the Circle of
Security intervention (Hoffman et al. 2006), and the Infant–Parent Psychotherapy
and Psycho-educational Parenting Intervention (Cicchetti et al. 2006, 2011).
ABC Intervention
Mary Dozier and colleagues (Bernard et al. 2012; Dozier et al. 2006, 2008; Lewis-
Morrarty et al. 2012) designed an intervention for parents of young children in
foster care and for parents identi¿ed by child protective services as being at high
risk of maltreating their children: the Attachment and Biobehavioural Catch-up
(ABC) programme.
ABC was developed to decrease frightening behaviour and encourage sensitive,

nurturing care in (foster) parents and to enhance children’s relationship formation
and their ability to regulate neurobiological aspects of their behaviour (Bernard
et al. 2012; Dozier et al. 2008). ABC appeared to be effective in helping foster
infants regulate their neurobiological functioning, as measured after the interven-
tion with cortisol diurnal levels at the post-test (Dozier et al. 2008). Also, in a
preschool follow-up assessment the intervention foster children outperformed the
control foster children in cognitive Àexibility and theory of mind skills (Lewis-
Morrarty et al. 2012).
In their study on parents at high risk of maltreating their offspring, children in
the ABC intervention showed signi¿cantly lower rates of disorganised attachment
(32%) and higher rates of secure attachment (52%) compared to the control chil-
dren (57% and 33%, respectively) (Bernard et al. 2012).
How do the characteristics of this effective intervention compare to the ¿ndings
from the meta-analyses of attachment-based interventions? As stated by Bernard
et al. (2012), the home-based ABC intervention was designed to be relatively brief,
completed in 10 sessions, converging with the meta-analytical outcome of ‘Less
is More’ (see above; Bakermans-Kranenburg et al. 2003). The ABC intervention
was manualised with each session having a speci¿c focus, an important inter-
vention characteristic for promoting treatment adherence (see also Bakermans-
Kranenburg et al. 2005). Further, the intervention focus of the ABC was on chang-
ing sensitive parenting behaviours rather than mental representations of parents,
converging with the meta-analytical ¿nding that sensitivity-focused interventions
with a focus on interactions appeared to be more effective than other approaches
(Bakermans-Kranenburg et al. 2003).
Attachment-based intervention for maltreated children

Building on the principles from the VIPP programmes, Ellen Moss and colleagues
(Moss et al. 2011; Tarabulsy et al. 2008) designed an attachment-based home-
visiting intervention for maltreating families. The intervention was aimed at
enhancing mothers’ sensitivity to their child’s emotional and behavioural signals,
in order to promote the child’s attachment security (Moss et al. 2011). Outcomes
showed that this short-term intervention (8 weeks) was effective in enhancing
parental sensitivity, improving children’s attachment security and reducing attach-
ment disorganisation (Moss et al. 2011).
Like the VIPP and the ABC intervention, this intervention adopted crucial
intervention elements identi¿ed by the meta-analyses of attachment-based inter-
ventions (Bakermans-Kranenburg et al. 2003), and it was inspired by the VIPP
programme. This intervention for maltreating families was brief, that is, eight
home visits, and the main focus of the intervention was on parental sensitivity,
for example by encouraging the parent to follow the child’s lead. The interven-
tion sessions with video feedback were structured in a ¿xed order, including a
sequence of videotaping interactive behaviour and a sequence of video feedback
during which the intervener played back and discussed a video fragment of the
parent–child interaction. The interveners followed speci¿c guidelines from a man-
ual. To ensure treatment integrity, interveners were supervised on a weekly basis
(Moss et al. 2011).
In summary, two recent intervention models incorporated essential elements
that distinguished effective from non-effective interventions as found in our
meta-analyses on attachment-based interventions. Converging with the VIPP pro-
grammes, both interventions con¿rmed that brief interventions with a focus on
sensitive parenting can be successful and effective in changing parenting behav-
iour and parent–child relationships.
Conclusions and practical implications

Our series of meta-analyses of attachment-based intervention studies (Bakermans-
Kranenburg et al. 2003) showed that short-term, interaction-oriented interventions
that focus on parental sensitivity are most effective. Converging with this meta-
analytical evidence, recent effective intervention studies (Bernard et al. 2012;
Moss et al. 2011) made use of brief interventions focusing on sensitive parenting
behaviour. Although longer interventions may be needed to address other aspects
of parental or family problems (e.g. parent’s mental representations or psychiat-
ric disorders, dif¿culties in multi-risk families), the gold standard for enhancing
parental sensitivity and positive parent–child relationships is to use a relatively
narrow focus on sensitive behaviour during brief interventions. This rather mod-
est feature of successful and effective attachment-based interventions implies that
such an intervention can be quite easily included in more comprehensive and lon-
ger treatments of parents and families. It should also be noted that although a brief
sensitive parenting intervention may successfully change a parent’s behaviour
toward the child and the parent–child interaction, it is not a panacea for all parental
or family problems. A useful framework is to combine a brief sensitivity interven-
tion with another treatment module. For example, in the study with mothers with
eating disorders a brief video-feedback intervention to address parent–child inter-
action during mealtime was combined with a guided cognitive behaviour self-help
module for eating disorders (Stein et al. 2006; Woolley et al. 2008).
Based on insights from attachment research and the meta-analytical outcome
that sensitive parenting is the key to positive parent–child relationships, we devel-
oped the Video-feedback Intervention to promote Positive Parenting (VIPP and
VIPP-SD: VIPP with an additional focus on Sensitive Discipline). In several
studies in various at-risk samples VIPP/VIPP-SD appeared to be an ef¿cient and
effective intervention for enhancing sensitive parenting, revealing a signi¿cant
medium combined effect size in six studies with more than 600 participants.
To date, there are several ongoing studies in which VIPP-SD is being tested
in new settings (e.g. centre-based child care) and with other at-risk and clinical
samples (e.g. parents of children with autism spectrum disorder; ethnic minority
families; parents with intellectual restrictions; children in foster care). The outcomes
of these studies will reveal whether VIPP-SD can be successfully applied in these
new settings and samples and might also inform us about the possibilities of gen-
eralising VIPP-SD to different types of families and child rearing arrangements.
Some questions and issues remain that need reÀection and discussion for the
future. Interventions such as the ABC intervention and VIPP-SD are usually
implemented in home visits. An issue that remains to be resolved is whether cen-
tre-based, group interventions (e.g. Hoffman et al. 2006; Niccols 2008) are as
effective as home-based, individualised programmes. Also, the role of fathers
in sensitive parenting interventions needs to be examined. In a ¿rst pilot study
with ¿ve nonclinical fathers and their infant, VIPP was used to improve early
father–infant interaction (Lawrence et al. 2013). After the intervention, the fathers
reported that the intervention helped them to improve the relationship with their
baby. Although larger studies are needed to show the effectiveness of VIPP in
(clinical) populations of fathers, this promising study demonstrated the feasibility
of the VIPP with fathers.
An innovative avenue of intervention research addresses the neurobiological
effects of interventions, testing whether attachment-based interventions are not
only effective at observed behavioural levels but also at neurobiological levels
and, for example, result in altered daily cortisol diurnal levels (e.g. Bakermans-
Kranenburg et al. 2008b; Dozier et al. 2008; Fisher et al. 2006).
Also, the role of oxytocin in parental sensitivity and sensitive parenting interven-
tions is an intriguing and still largely unexplored research topic. In human beings
oxytocin is associated with delivery and lactation, mood regulation, facial emo-
tion recognition, and trust (Van IJzendoorn & Bakermans-Kranenburg 2012b). An
important question is whether oxytocin inÀuences parenting behaviour, not only
in mothers but also in fathers. A recent study has shown that oxytocin is indeed
associated with differential aspects of parenting style in mothers and fathers: for
mothers affectionate physical contact with the child was associated with oxytocin
increases, whereas for fathers this was the case after stimulatory contact with the
child (Feldman et al. 2010). In a ¿rst double-blind, placebo-controlled, within-
subject experiment with intranasal oxytocin administration in a sample of fathers,
Naber, Van IJzendoorn, Deschamps, Van Engeland, and Bakermans-Kranenburg
(2010) demonstrated that fathers in the oxytocin condition were more stimulating
of their child’s exploration and less hostile than fathers in the placebo condition.
From this ¿rst experiment it can be derived that interventions to promote sensitive
parenting might pro¿t from adding intranasal oxytocin administration as an inter-
vention component, and it would be extremely relevant to test the differential and
possible cumulative intervention effects on parenting behaviour.
Hopefully, the knowledge from successful and effective attachment-based
interventions will be further translated and disseminated and reach practice, policy
and clinical work with parents and children. Convincing evidence from theory and
research, as well as helpful skills rigorously tested in numerous intervention stud-
ies, are now available to offer parents the support they need and promote sensitive
parenting and positive family relationships.
References
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment.
A psychological study of the Strange Situation. Hillsdale, NJ: Lawrence Erlbaum.
Bakermans-Kranenburg, M. J. & Van IJzendoorn, M. H. (2007). Research review: Genetic
vulnerability or differential susceptibility in child development: the case of attachment.
Journal of Child Psychology and Psychiatry, 48, 1160–1173.
Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., & Juffer, F. (2003). Less is more:
Meta-analysis of sensitivity and attachment interventions in early childhood. Psycho-
logical Bulletin, 129, 195–215.
Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., & Juffer, F. (2005). Disorgan-
ized infant attachment and preventive interventions: A review and meta-analysis. Infant
Mental Health Journal, 26, 191–216.
Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., & Juffer, F. (2008a). Less is more:
Meta-analytic arguments for the use of sensitivity-focused interventions. In F. Juffer,
M. J. Bakermans-Kranenburg, & M. H. van IJzendoorn (eds), Promoting positive parent-
ing: An attachment-based intervention (pp. 59–74). New York: Taylor & Francis.
Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., Mesman, J., Alink, L. R. A., &
Juffer, F. (2008b). Effects of an attachment-based intervention on daily cortisol moder-
ated by dopamine receptor D4: A randomized control trial on 1- to 3-year-olds screened
for externalizing behavior. Development and Psychopathology, 20, 805–820.
Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., Pijlman, F. T. A., Mesman, J., &
Juffer, F. (2008c). Differential susceptibility to intervention: Dopamine D4 Receptor
Polymorphism (DRD4 VNTR) moderates effects on toddlers’ externalizing behavior in
a randomized control trial. Developmental Psychology, 44, 293–300.
Beijersbergen, M. D., Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H.
(2012). Remaining or becoming secure: Parental sensitive support predicts attachment
continuity from infancy to adolescence in a longitudinal adoption study. Developmental
Psychology, 48(5), 1277–1282.
Belsky, J. (1997). Variation in susceptibility to environmental influence: An evolutionary
argument. Psychological Inquiry, 8, 182–186.
Belsky, J., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2007). For better and
for worse: Differential susceptibility to environmental influences. Current Directions in
Psychological Science, 16, 300–304.
Belsky, J., Hsieh, K., & Crnic, K. (1998). Mothering, fathering, and infant negativity as
antecedents of boys’ externalizing problems and inhibition at age 3: Differential suscep-
tibility to rearing influence? Development and Psychopathology, 10, 301–319.
Bernard, K., Dozier, M., Bick, J., Lewis-Morrarty, E., Lindhiem, O., & Carlson, E. (2012).
Enhancing attachment organization among maltreated children: Results of a randomized
clinical trial. Child Development, 83(2), 623–636.
Bowlby, J. (1982). Attachment and loss (Vol. 1). Attachment (2nd ed.). New York: Basic
Books.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. London:
Routledge.
Carter, S. L., Osofsky, J. D., & Hann, D. M. (1991). Speaking for the baby: A therapeutic
intervention with adolescent mothers and their infants. Infant Mental Health Journal,
12, 291–301.
Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., et al. (2006).
Report of the APSAC Task Force on attachment therapy, reactive attachment disorder,
and attachment problems. Child Maltreatment, 11, 76–89.
Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants
in maltreating families through preventive interventions. Development and Psychopa-
thology, 18(3), 623–649.
Cicchetti, D., Rogosch, F. A., Toth, S. L., & Sturge-Apple, M. L. (2011). Normalizing the
development of cortisol regulation in maltreated infants through preventive interven-
tions. Development and Psychopathology, 23(3), 789–800.
De Wolff, M. S. & Van IJzendoorn, M. H. (1997). Sensitivity and attachment: A meta-
analysis on parental antecedents of infant attachment. Child Development, 68, 571–591.
Dozier, M., Peloso, E., Lewis, E., Laurenceau, J. P., & Levine, S. (2008). Effects of an
attachment-based intervention on the cortisol production of infants and toddlers in foster
care. Development and Psychopathology, 20(3), 845–859.
Dozier, M., Peloso, E., Lindhiem, O., Gordon, M. K., Manni, M., Sepulveda, S., et al.
(2006). Developing evidence-based interventions for foster children: An example of
a randomized clinical trial with infants and toddlers. Journal of Social Issues, 62(4),
767–785.
Ellis, B. J., Boyce, W. T., Belsky, J., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M.
H. (2011). Differential susceptibility to the environment: An evolutionary-neurodevel-
opmental theory. Development and Psychopathology, 23(1), 7–28.
Fearon, R. P., Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., Lapsley, A. M.,
& Roisman, G. I. (2010). The significance of insecure attachment and disorganization
in the development of children’s externalizing behavior: A meta-analytic study. Child
Development, 81(2), 435–456.
Feldman, R., Gordon, I., Schneiderman, I., Weisman, O., & Zagoory-Sharon, O. (2010).
Natural variations in maternal and paternal care are associated with systematic changes
in oxytocin following parent-infant contact. Psychoneuroendocrinology, 35(8),
1133–1141.
Fisher, P., Gunnar, M., Dozier, M., Bruce, J., & Pears, K. (2006). Effects of therapeutic
interventions for foster children on behavioral problems, caregiver attachment, and stress
regulatory neural systems. Annals of the New York Academy of Sciences, 40, 1–11.
Groeneveld, M. G., Vermeer, H. J., Van IJzendoorn, M. H., & Linting, M. (2011). Enhanc-
ing home-based child care quality through video-feedback intervention: A randomized
controlled trial. Journal of Family Psychology, 25(1), 86–96.
Groh, A. M., Roisman, G. I., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., &
Fearon, R. P. (2012). The significance of insecure and disorganized attachment for
children’s internalizing symptoms: A meta-analytic study. Child Development, 83(2),
591–610.
Harlow, H. F. (1958). The nature of love. American Psychologist, 13, 673–685.
Hesse, E. (2008). The Adult Attachment Interview: Protocol, method of analysis, and
empirical studies. In J. Cassidy & P. R. Shaver (eds), Handbook of attachment: Theory,
research, and clinical applications (pp. 552–598). New York: The Guilford Press.
Hesse, E. & Main, M. (2006). Frightened, threatening, and dissociative (FR) parental
behavior as related to infant D attachment in low-risk samples: Description, discussion,
and interpretations. Development and Psychopathology, 18, 309–343.
Hoffman, K. T., Marvin, R. S., Cooper, G., & Powell, B. (2006). Changing toddlers’ and
preschoolers’ attachment classifications: The Circle of Security intervention. Journal of
Consulting and Clinical Psychology, 74, 1017–1026.
Hoffman, M. L. (2000). Empathy and moral development. Implications for caring and
justice. Cambridge, UK: Cambridge University Press.
Jaffari-Bimmel, N., Juffer, F., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J.,
& Mooijaart, A. (2006). Social development from infancy to adolescence: Longitudi-
nal and concurrent factors in an adoption sample. Developmental Psychology, 42(6),
1143–1153.
Juffer, F. (1993). Verbonden door adoptie. Een experimenteel onderzoek naar hechting en
competentie in gezinnen met een adoptiebaby. [Attached through adoption. An experi-
mental study of attachment and competence in families with adopted babies.] Amers-
foort, the Netherlands: Academische Uitgeverij.
Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2005). The importance
of parenting in the development of disorganized attachment: Evidence from a preventive
intervention study in adoptive families. Journal of Child Psychology and Psychiatry, 46,
263–274.
Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2008a). Support-
ing adoptive families with video-feedback intervention. In F. Juffer, M. J. Bakermans-
Kranenburg, & M. H. van IJzendoorn (eds), Promoting positive parenting: An attach-
ment-based intervention (pp. 139–153). New York: Taylor & Francis.
Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (eds) (2008b). Pro-
moting positive parenting: An attachment-based intervention. New York: Taylor &
Francis.
Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2008c). Manual
Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline
(VIPP-SD) (version 2.0). Leiden University: Centre for Child and Family Studies.
Juffer, F., Van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2008d). Attachment-
based interventions in early childhood: An overview. In F. Juffer, M. J. Bakermans-
Kranenburg, & M. H. van IJzendoorn (eds), Promoting positive parenting: An attach-
ment-based intervention (pp. 37–57). New York: Taylor & Francis.
Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2009). Attachment-
based interventions: Heading for evidenced-based ways to support families. Association
for Child and Adolescent Mental Health, ACAMH Occasional Papers No.29, Attach-
ment: Current Focus and Future Directions, 47–57.
Kalinauskiene, L., Cekuoliene, D., Van IJzendoorn, M. H., Bakermans-Kranenburg, M.
J., Juffer, F., & Kusakovskaja, I. (2009). Supporting insensitive mothers: The Vilnius
randomized control trial of video feedback intervention to promote maternal sensitivity
and infant attachment. Child Care, Health & Development, 35, 613–623.
Klein Velderman, M., Bakermans-Kranenburg, M. J., Juffer, F., & Van IJzendoorn, M. H.
(2006a). Effects of attachment-based interventions on maternal sensitivity and infant
attachment: Differential susceptibility of highly reactive infants. Journal of Family Psy-
chology, 20, 266–274.
Klein Velderman, M., Bakermans-Kranenburg, M. J., Juffer, F., Van IJzendoorn, M. H.,
Mangelsdorf, S. C., & Zevalkink, J. (2006b). Preventing preschool externalizing behav-
ior problems through video-feedback intervention in infancy. Infant Mental Health Jour-
nal, 27(5), 466–493.
Lambermon, M. W. E., & Van IJzendoorn, M. H. (1989). Influencing mother–infant inter-
action through videotaped or written instruction: Evaluation of a parent education pro-
gram. Early Childhood Research Quarterly, 4, 449–458.
Lawrence, P. J., Davies, B., & Ramchandani, P. G. (2013). Using video feedback to improve
early father–infant interaction: A pilot study. Clinical Child Psychology and Psychiatry,
18(1), 61–71.
Lewis-Morrarty, E., Dozier, M., Bernard, K., Terracciano, S. M., & Moore, S. V. (2012).
Cognitive flexibility and theory of mind outcomes among foster children: Preschool
follow-up results of a randomized clinical trial. Journal of Adolescent Health, 51(2),
S17-S22.
Madigan, S., Bakermans-Kranenburg, M. J., Van IJzendoorn, M. H., Moran, G., Pederson,
D. R., & Benoit, D. (2006). Unresolved states of mind, anomalous parental behavior, and
disorganized attachment: A review and meta-analysis of a transmission gap. Attachment
& Human Development, 8, 89–111.
Main, M., & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related to
infant disorganized attachment status: Is frightened and/or frightening parental behavior
the linking mechanism? In M. T. Greenberg, D. Cichetti, & E. Cummings (eds), Attach-
ment in the preschool years: Theory, research, and intervention (pp. 161–182). Chicago:
University of Chicago Press.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as disorganized/disori-
ented during the Ainsworth Strange Situation. In M. T. Greenberg, D. Cicchetti, & E. M.
Cummings (eds), Attachment in the preschool years. Theory, research, and intervention
(pp. 121–182). Chicago: The University of Chicago Press.
Main, M., Goldwyn, R., & Hesse, E. (2003). Adult Attachment Scoring and Classification
Systems. Unpublished manuscript, University of California at Berkeley.
Mesman, J., Stolk, M. N., Van Zeijl, J., Alink, L. R. A., Juffer, F., Bakermans-Kranenburg,
M. J., et al. (2008). Extending the video-feedback intervention to sensitive discipline:
The early prevention of antisocial behavior. In F. Juffer, M. J. Bakermans-Kranenburg,
& M. H. van IJzendoorn (eds), Promoting positive parenting: An attachment-based
intervention (pp. 171–191). New York: Taylor & Francis.
Moss, E., Dubois-Comtois, K., Cyr, C., Tarabulsy, G. M., St-Laurent, D., & Bernier, A.
(2011). Efficacy of a home-visiting intervention aimed at improving maternal sensitiv-
ity, child attachment, and behavioral outcomes for maltreated children: A randomized
control trial. Development and Psychopathology, 23(1), 195–210.
Naber, F., Van IJzendoorn, M. H., Deschamps, P., Van Engeland, H., & Bakermans-
Kranenburg, M. J. (2010). Intranasal oxytocin increases fathers’ observed respon-
siveness during play with their children: A double-blind within-subject experiment.
Psychoneuroendocrinology, 35(10), 1583–1586.
Niccols, A. (2008). ‘Right from the Start’: randomized trial comparing an attachment group
intervention to supportive home visiting. Journal of Child Psychology and Psychiatry,
49, 754–764.
Out, D., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2009). The role of
disconnected and extremely insensitive parenting in the development of disorganized
attachment: Validation of a new measure. Attachment & Human Development, 11(5),
419–443.
Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castilia.
Pignotti, M., & Mercer, J. (2007). Holding therapy and dyadic developmental psychother-
apy are not supported and acceptable social work interventions: A systematic research
synthesis revisited. Research on Social Work Practice, 17, 513–519.
Schuengel, C., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (1999). Fright-
ening maternal behavior linking unresolved loss and disorganized infant attachment.
Journal of Consulting and Clinical Psychology, 67(1), 54–63.
Scott, S., & O’Connor, T. G. (2012). An experimental test of differential susceptibil-

ity to parenting among emotionally-dysregulated children in a randomized controlled
trial for oppositional behavior. Journal of Child Psychology and Psychiatry, 53(11),
1184–1193.
Sroufe, L. A., Egeland, B., Carlson, E. A., & Collins, W. A. (2005). The development of
the person. The Minnesota study of risk and adaptation from birth to adulthood. New
York: Guilford Press.
Stein, A., Woolley, H., Senior, R., Hertzmann, L., Lovel, M., Lee, J., et al. (2006). Treat-
ing disturbances in the relationship between mothers with bulimic eating disorders and
their infants: A randomized, controlled trial of video feedback. The American Journal of
Psychiatry, 163, 899–906.
Tarabulsy, G. M., Pascuzzo, K., Moss, E., St-Laurent, D., Bernier, A., Cyr, C., & Dubois-
Comtois, K. (2008). Attachment-based intervention for maltreating families. American
Journal of Orthopsychiatry, 78(3), 322–332.
Thompson, R. A. (2008). Early attachment and later development: Familiar questions, new
answers. In J. Cassidy & P. R. Shaver (eds), Handbook of attachment: Theory, research,
and clinical applications (2nd ed.) (pp. 348–365). New York: The Guilford Press.
Van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2012a). Integrating temperament
and attachment: The differential susceptibility paradigm. In M. Zentner & R. L. Shiner
(eds), Handbook of temperament (pp. 403–424). New York: The Guilford Press.
Van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2012b). A sniff of trust: Meta-
analysis of the effects of intranasal oxytocin administration on face recognition, trust to
in-group, and trust to out-group. Psychoneuroendocrinology, 37(3), 438–443.
Van IJzendoorn, M. H., Juffer, F., & Duyvesteyn, M. G. C. (1995). Breaking the inter-
generational cycle of insecure attachment: A review of the effects of attachment-based
interventions on maternal sensitivity and infant security. Journal of Child Psychology
and Psychiatry, 36, 225–248.
Van IJzendoorn, M. H., Schuengel, C., & Bakermans-Kranenburg, M. J. (1999). Disor-
ganized attachment in early childhood: Meta-analysis of precursors, concomitants, and
sequelae. Development and Psychopathology, 11, 225–249.
Van Zeijl, J., Mesman, J., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Juffer,
F., Stolk, M. N., et al. (2006). Attachment-based intervention for enhancing sensitive
discipline in mothers of one- to three-year-old children at risk for externalizing behavior
problems. Journal of Consulting and Clinical Psychology, 74(6), 994–1005.
Waters, E., & Cummings, E. M. (2000). A secure base from which to explore close relation-
ships. Child Development, 71, 164–172.
Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-
onset conduct problems: Intervention outcomes for parent, child, and teacher training.
Journal of Clinical Child and Adolescent Psychology, 33(1), 105–124.
Webster-Stratton, C., Rinaldi, J., & Reid, J. M. (2011). Long-term outcomes of Incredible
Years parenting program: Predictors of adolescent adjustment. Child and Adolescent
Mental Health, 16(1), 38–46.
Woolley, H., Hertzmann, L., & Stein, A. (2008). Video-feedback intervention with
mothers with postnatal eating disorders and their infants. In F. Juffer, M. J. Bakermans-
Kranenburg, & M. H. van IJzendoorn (eds), Promoting positive parenting: An attachment-
based intervention (pp. 111–138). New York: Taylor & Francis.
Chapter 6
Attachment-focused
therapeutic interventions
Daniel Hughes
Introduction
This chapter considers therapeutic work for children and teenagers with moder-
ate to severe emotional or behavioural problems as well as work with the adults
responsible for their care.
Following the research and theory of A. Sroufe and colleagues (Sroufe et al.
2005) we are proposing that the wide range of symptoms reÀective of such moder-
ate to severe problems can be understood as reÀecting a lack of organisation – or
integration – of the child’s emotional, cognitive and behavioural functioning. The
success or failure of these developing organisational patterns are highly inÀu-
enced by the child’s attachment organisational patterns. To quote Sroufe et al.:
‘Central aspects of individual organization originate in the organization of early
primary relationships’ (Sroufe et al. 2005: 40). These children and teens are likely
to manifest very signi¿cant relational disorders, including de¿cits in emotional
regulation and reÀective functioning.
A diagnosis of Developmental Trauma Disorder, proposed by a consortium of
Child Trauma Centers (Cook et al. 2005), may well capture the depth and breadth
of these relational problems that are secondary to intra-familial, interpersonal,
trauma. However, this diagnosis was not accepted for inclusion in DSM-5. The
diagnosis most commonly used is Reactive Attachment Disorder (RAD).
However, given the uncertainty of diagnostic criteria for RAD (see David
Shemmings in Holmes & Farn¿eld 2014) this chapter focuses more on attach-
ment-focused interventions as they apply to a broad range of children and teens
with moderate to severe emotional/behavioural/relational problems, irrespective
of the particular diagnosis that they have been given.
The organised nature of attachment patterns can be seen as predictive of the
integration of one’s psychological functioning, including emotional regulation
and reÀective functioning, from childhood through adulthood. Sroufe et al. (2005)
say that attachment is the ‘dyadic regulation of emotion’. Fonagy et al. (2008)
indicate that attachment security predicts reÀective functioning and the related
ability to mentalise, that is being aware of one’s own mind and the mind of others
(see also Luyten & Fonagy in Holmes & Farn¿eld 2014).
Attachment-focused therapeutic interventions 105
A central characteristic of the adult classi¿ed as being autonomously attached

is being able to engage in a coherent discourse about one’s narrative with
respect to attachment (Hesse 2008). It is suggested here that attachment-focused
interventions that facilitate emotional regulation, reÀective functioning, and the
development of a coherent autobiographical narrative represent great promise for
engaging these children and teens successfully in a secure attachment relationship
with their therapist and parents or other primary caregivers.
Attachment-focused interventions
Current interventions for children and their caregivers that rely heavily on attach-
ment theory and research for their theoretical foundation are primarily focused on
providing interventions to the parents and, less directly, to the child (see Chapter
5 by Juffer and colleagues).
The well-respected Circle of Security Project (Hoffman et al. 2006) focuses
on the parent in group settings, ¿rst by increasing their ability to read the attach-
ment-related cues of their child and to respond in a sensitive manner. This is
followed by assisting the parents in exploring their own attachment history,
with the goal of assisting the parents in reÀecting on their history so that their
functioning progresses toward resolved and/or autonomous attachment styles.
Parent-Infant Psychotherapies – more recently expanded to include children to
the age of 5 – also focus heavily on the parents’ own attachment histories so
that they may attain attachment resolution and/or autonomous patterns (Lieber-
man et al. 2005). These psychotherapies may also include assisting the parent
in becoming engaged with her infant in reciprocal, engaged, attuned activities
that emphasise eye contact, infant-directed speech, within contingent, reciprocal
interactions.
Video Interaction Guidance (Kennedy et al. 2011) uses principles of attachment
and infant inter-subjectivity to provide parents with very clear video feedback
regarding their interactions with their child. All of these programmes highlight the
need to develop a strong relationship between the therapist and parent – with the
emphasis on empathy – in order to facilitate the attachment relationship between
the child and his parent.
Finally, there is an attachment-focused treatment in which the therapist engages
the child in play activities that are similar to those that occur between parent and
toddler, and then facilitates such play between the parent and their child of any
age. This method of treatment, known as Theraplay (Booth & Jernberg 2010),
stresses here-and-now, highly engaging, nonverbal, attuned interactions to facili-
tate the attachment relationship.
Attachment-focused goals that focus primarily on individual therapy with the
child emerged within both a psychodynamic framework and more general play
therapy modalities. These therapies have generally not been focused on the treat-
ment of children and teens with moderate to severe relational problems (but see
Chapter 2 by Music).
106 Daniel Hughes
One therapy that became known as ‘attachment therapy’ was originated in the
1980s by a psychiatrist, Foster Cline (1995), in Evergreen, Colorado. The children
being treated by Cline and colleagues were primarily foster or adopted children
who had manifested a history of abuse, neglect, and attachment losses including
early years in an orphanage. They manifested severe problems with dysregulation,
including aggression, impulsivity, and distractibility and were unwilling or unable
to rely on their caregivers for comfort, guidance, or support.
These children and teens were extremely oppositional and de¿ant and most
often refused to become engaged in therapy and were not responsive to either
nondirective play or dynamic therapy or cognitive-behavioural interventions. The
therapist stressed, both in therapy and in the recommendations given to parents,
the need for compliance with the directives of the adult as the foundation for
any therapeutic change. While the goal was to facilitate attachment security, the
interventions were not based on the understanding of how parents facilitate secure
attachments in daily life. Rather, ‘obedience training’, was the guiding principle,
not reciprocal attuned interactions. Also in treatment, the child was often pro-
voked toward expressions of rage toward the therapist and parent, in order to
facilitate ‘rage reduction’ during which the child’s rigid defences were reduced
and the child turned to the parent for comfort and support. This treatment modal-
ity was rightfully criticised by many mental health professionals and others and,
to my knowledge, has not been taught or recommended openly by therapists since
around the year 2000.
The development of Dyadic Developmental

Psychotherapy (DDP) and Attachment-Focused
Family Therapy (AFFT)
Throughout the 1980s this author had repeatedly failed to provide effective treat-
ment to children and youth who had experienced abuse, neglect, and multiple
losses. I had been trained in play therapy, cognitive-behavioural therapy, and fam-
ily systems therapy and found these traditional interventions to be quite ineffective
in assisting these children to both resolve past traumas and to develop new rela-
tional patterns. While living in foster and adoptive homes, these children were often
not able to enter into relationships with their caregivers that were characterised
by attachment security. They often had great dif¿culty regulating their emotional
states while, at the same time, showing little ability to be aware of, or communicate,
their inner lives. They tended to be very avoidant and controlling in therapy and
had little motivation to become engaged with the therapist whether the approach
was nondirective or directive, dynamic or cognitive, within individual or family
settings. At the same time they tended to be very resistant to behavioural manage-
ment approaches based on social learning theory within the home, in spite of moti-
vated and competent foster or adoptive parents. While resisting parental guidance
and discipline they also avoided parental efforts to provide them with comfort and
support in the face of their developmental challenges and vulnerabilities.
As the 1990s began this author saw these children as manifesting a variety of
psychological patterns that were consistent with attachment disorganisation and, to
a lesser extent, avoidant or ambivalent attachment patterns. I then began to develop
therapeutic interventions that were consistent with attachment theory and research.
I went to Colorado to study Dr Cline’s programme. I saw the value in taking a more
directive stance with children who were so avoidant and controlling, though I did
not believe that the provocative and intrusive quality of their interventions was
compatible with providing the child with a sense of psychological safety. I saw the
value in actively involving the foster and adoptive parents, not to confront the child,
but rather to convey safety, commitment, and support for the child when he was
asked to explore his trauma, terror, and shame. I saw the value in providing touch
and nurturing holding for the child, but not the mandated and provocative holding
practised by Dr Cline and colleagues. Initially I would hold the child when he was
in distress, as this seemed to be easier for him than being held by his caregiver.
I then realised that this was not as productive as taking a slower pace and facili-
tating the child’s readiness to initiate or be receptive to the comfort and closeness
of parental hugs and support. In going slower, I focused more on developing the
overall relational patterns between parent and child, rather than taking a more
narrow attachment perspective of providing safety. By 1998, touch – by parent
or therapist – to encourage a sense of safety, became a secondary intervention,
with the central therapeutic activity and goal being to facilitate and maintain a
therapeutic dialogue that was based on attuned, reciprocal, moment-to-moment,
nonverbal and verbal interactions. I was greatly guided by the theory and research
of Colwyn Trevarthen (2001) and Daniel Stern (1985).
Over the past 15 years, a consistent therapeutic model has emerged for chil-
dren with serious psychological problems secondary to trauma and attachment
problems. This became known as Dyadic Developmental Psychotherapy (DDP)
(Hughes 2004, 2006). As this treatment model became applied to general popu-
lations it was called Attachment-Focused Family Therapy (Hughes 2007, 2009,
2011). This chapter focuses only on DDP – the application of this treatment to
children and teens with moderate to severe emotional and behavioural problems
and those adults responsible for their care.
Characteristics of DDP
DDP involves developing and maintaining a reciprocal, dyadic, relationship where
both safety and exploration are valued, with safety preceding exploration and
being continuously re-established whenever exploration generates fear or shame.
The relational quality of safety and exploration are emphasised, with dysregulat-
ing emotions being co-regulated by the therapist (or the therapist and parent when
a child is in distress) and the experience of past and present events being co-
created into a coherent narrative. Thus, DDP adheres to ‘the wider view of attach-
ment’ which focuses on ‘psychological security’ and includes both ‘security of
attachment and security of exploration’ (Grossman et al. 2008: 873).
108 Daniel Hughes
Attachment theory has expanded from the understanding of the infant and his
inherent need for safety to the understanding of development over the entire life
span and the human being’s inherent need for a coherent autobiographical narra-
tive. In a similar manner, DDP focuses on the entire autobiographical narrative
where all experiences are valued, understood, explored, and accepted.
The therapeutic relationship develops within the context of the child’s entire
narrative, with the therapist and foster carer or adoptive parent adding their inter-
subjective presence to the child’s efforts to make sense of all of the events of his
life. From this ‘wide-angle’ focus, the child is likely to experience suf¿cient safety
to remain fully engaged in the immediate relationships while focusing more nar-
rowly on speci¿c traumatic events. The therapist and caregiver’s inter-subjective
presence enables the child to co-regulate the stressful emotions associated with
these events, while co-creating new meanings of the events. The therapist and
caregiver attend to the event and experience it with their reÀective functioning,
enabling the child to also be reÀective while experiencing the event again, and so
increase his mentalising abilities while integrating his experience of the event into
his narrative.
Inter-subjectivity
Inter-subjectivity refers to a primary source of learning about self, other, events
and objects of the world (Trevarthen 2001). The infant develops his ‘inner work-
ing model’ of self, other, and the larger world, primarily through joining his
attachment ¿gures in their experience of him and the world. As the attachment
¿gures experience and express nonverbally – in their eyes, face, voice, and bodily
gestures as they interact with him – their joy, delight, interest, and love, the infant
experiences himself as being joyful, delightful, interesting, and lovable. If the
attachment ¿gure conveys safety in the presence of an object – a dog or a stranger
– or an event – a loud noise or sudden movement – then the child is likely to
experience safety. As the attachment ¿gure begins to explore the meaning of that
object or event, the child explores it with him. For infants these inter-subjective
communications are nonverbal. Their nonverbal component remains central in
such communications within a safe relationship throughout life. When we inhibit
the nonverbal expression of the experience, the other is much less likely to expe-
rience our experience and so the inter-subjective component is reduced and/or
distorted.
Inter-subjectivity in therapy
Similarly, in therapy, as the therapist and caregiver convey safety – inter-sub-
jectively – while exploring a past traumatic event of the child, the child is likely
to be able to remain safe while attending to that event. Then as the therapist and
caregiver convey their experiential meanings of that event – inter-subjectively
– the child is likely to attend to that event, experiencing it again within the light
of the therapist and caregiver’s experience of it. It is the therapist and caregiver’s
nonverbal expressions – contingent with the child’s present experiences or his
memories of past events – that convey their inter-subjective experience of that
event within the child’s narrative. The therapist becomes an attachment ¿gure
alongside the caregiver.
When the therapist remains in an ambiguous, or neutral stance, the child is less
able to be inÀuenced by the therapist’s inter-subjective experience of both himself
and the events of his life. When children have had a lack of positive inter-sub-
jective experiences with attachment ¿gures associated with safety, then it seems
reasonable for the therapist to clearly express the positive impact that the child
is having on him in order to broaden his self-identity to include the capacity to
have a positive inÀuence on a caring person (Gelso 2011). The therapist’s inter-
subjective experience of the child’s past traumatic events will enable the child to
integrate these events into his narrative with new meanings, without the associated
states of emotional terror and shameful meanings that had been embedded into
those events by the perpetrator of the abuse. The therapist’s inter-subjective mean-
ing of the past event serves as a balance to the meaning given by the perpetrator
and enables the child to safely experience it anew.
This open and engaged therapeutic relational stance is the same stance char-
acteristic of secure attachment interactions as well as the most inÀuential inter-
subjective experiences of exploration and learning. It involves the ongoing
activation of the ventral vagal neurological circuit that has been explored in such
detail by Stephen Porges (2011).
According to Porges’ polyvagal theory and associated research ¿ndings, the
ventral vagal circuit is activated when the infant or child is feeling safe. It enables
the social engagement system in the brain to become active and to optimise the
young child’s social and emotional learning. Under threat, the ventral vagal sys-
tem becomes inactive and the dorsal vagal circuit is activated. The dorsal vagal
system is the defensive system that focuses on the protection of the self, not on
learning about the environment. Thus, the activation of the ventral vagal circuit
and social engagement system requires the sense of safety and enables safety to be
maintained (through the open and engaged stance of the attachment ¿gure), while
the child explores and learns about the world (either the world of the present or the
world represented in memories of the past), while integrating the inter-subjective
experiences of the attachment ¿gure.
In DDP this open and engaged inter-subjective therapeutic stance is facilitated
through the therapist maintaining an attitude that is characterised by playfulness,
acceptance, curiosity, and empathy (PACE). These relational features are evident
in the attuned interactions between parent and infant and so might be seen as highly
suitable for facilitating attachment security for neglected and abused children who
had insuf¿cient quality and quantity of such experiences during their infancy.
Playfulness conveys a light optimism and con¿dence in the dialogue and gen-
eral nonverbal interactions. It indicates an enjoyment and acceptance of the other
and his past and present experiences. Playfulness does not refer to telling jokes or
110 Daniel Hughes
distracting someone from painful experiences or memories. Rather, it represents

a light emotional closeness that shows acceptance, not evaluation, of the other
person.
Acceptance is a central means of activating the ventral vagal circuit and gen-
erating a sense of safety and closeness. The inner life of the other – any thoughts,
feelings, intentions, wishes, memories, perceptions, values, beliefs – is met with
acceptance, though certain behaviours will be evaluated and may elicit conse-
quences. Acceptance creates the sense of safety that is necessary to give expres-
sion to one’s inner life and to explore it openly and so understand it and integrate
it into the autobiographical narrative. For example, if a teenager who had been
sexually abused, behaves sexually toward a child, the behaviour is evaluated as
not being ‘acceptable’ and restrictions and supervision follows to make such
behaviour very dif¿cult or impossible to engage in. However, if the teenager
is to be able to openly explore it in therapy, he needs to feel safe in knowing
that the thoughts, feelings, wishes, and intentions that were associated with that
behaviour, are themselves accepted. The therapist will be helping the teenager
to focus on those features of his inner life in order to make sense of them with-
out judgement, understand their probable connection to his own history, and
develop new meanings of the behaviour. These new meanings greatly increase
the likelihood that those behaviours will be less likely to have a purpose in the
child’s life.
Curiosity involves an open stance of not-knowing about the inner life of the
other. It also conveys a fascination with, a desire to understand, without judge-
ment, whatever is in the mind and heart of the other person. Such open, non-
judgemental curiosity from the therapist conveys a sense of safety for the child
necessary for him to begin to explore and share his inner life. This is not a pas-
sive stance where the therapist waits for the child to give expression to his inner
life. Rather, the therapist takes an active, inter-subjective stance, openly wondering
about possible thoughts, feelings, wishes, memories, perceptions, intentions, all the
while not judging anything that is being explored. Over time, the child may well
increase his sense of curiosity toward himself, increasing his tolerance for ambiguity
and enabling the development of his reÀective functioning and mentalisation.
Children who have been abused and neglected have little curiosity about their
mind and often do not have the words necessary to think about or communicate
their experiences about the events of their past as well as their current experi-
ences (Cicchetti et al. 1995). Communicating with these children often elicits the
response of ‘I don’t know’. Very often this response is truthful. For that reason,
engaging in dialogue with these children about their experiences tends to be dif-
¿cult, if not impossible, unless the therapist is willing and able to take the lead
in assisting the child in ‘¿nding the words’ that describe his experiences. These
treatment interventions will be discussed shortly.
Empathy conveys a sense to the child that the therapist will be with him when
he addresses and explores painful, frightening, or shameful events from the past.
Empathy functions to facilitate attachment security, encouraging the child to rely on
his attachment ¿gures to face the dif¿cult moments of his life. With empathy, the
therapist is able to co-regulate intense negative emotions that may be associated with
past traumas. As these emotions remain regulated the child is then able to explore the
events, and co-create new meanings, joining with the experiences of the attachment
¿gures. The message of empathy is much like the message of attachment ¿gures who
generate security: ‘I will not abandon you when you need me the most.’
Affective-Reflective (A-R) Dialogue

Therapeutic conversation, known as Affective-ReÀective (A-R) Dialogue is char-
acterised by nonverbal affective expressions involving modulated, rhythmic, voice
prosody, clear facial expressions, gestures, movement, posture, rather than the
monotone of a lecture or rational discussion. Within this ‘story-telling’ conversa-
tional stance, the therapist openly reÀects with the child on his autobiographical
narrative, facilitating its increasing depth and coherence.
The therapist is responsible for maintaining the Àow and momentum and coher-
ence of the A-R Dialogue, uncovering, developing, co-creating the experience of
events. The therapist follows the child and parent’s lead in the evolution of the
dialogue and narrative, while leading the child or parent into areas that are being
avoided, and then following the client’s response to those leads. This reciprocal
nature is characteristic of all intimate relationships. It is neither a directive stance
nor a nondirective stance. Any initiative of the therapist has only one step. The
next step in the dialogue is the child’s and the child’s response which determines
the therapist’s following step. This communicates to the child that his response
has an impact on the therapist. It is a true reciprocal dialogue where the two indi-
viduals are having an inÀuence on each other. It is not a one-directional lecture.
DDP: a two-phased treatment
Phase One
The treatment of the child with moderate to severe emotional/behavioural prob-
lems secondary to intra-familial trauma and attachment disruptions and disorgani-
sation begins with the therapist meeting with the parents without the child. This
¿rst phase is necessary for a number of reasons:
• The parent needs to experience safety within her relationship with the thera-
pist if she is to provide safety for her child during the treatment session. The
parent needs to experience the therapist’s unconditional acceptance of her, if
she is going to remain open and engaged with the therapist who is addressing
the parent’s behaviours that the therapist thinks might be hurting the child’s
ability to form a secure attachment with the parent.
• The therapist needs to explore the parent’s attachment history to determine
if the parent’s attachment pattern is resolved and autonomous since these
112 Daniel Hughes
classi¿cations are related to the parent’s ability to facilitate attachment secu-

rity. If the parent manifests an unresolved pattern then it might be necessary
for the parent to engage in his own psychological treatment before beginning
joint sessions with his child.
• The therapist needs to explore the parent’s parenting history with this particu-
lar child in order to determine the nature of the past and present parent–child
relationship, including the nature of conÀict resolution and repair, communi-
cation, comfort and support, discipline, and shared activities.
• The therapist needs to determine the strength of the parent’s commitment to
the child in order to ensure that it is suf¿cient to manage the stress of the treat-
ment over a period of time that is necessary to effect change.
• The therapist needs to make the parent aware of the nature of the treatment
in order to ensure that the parent is open to the basic treatment premises and
interventions. In particular, the parent needs to understand the necessity of
co-regulating the child’s emotional states and co-creating the past and present
meanings of his symptoms.
• If the therapist is not successful in facilitating the parent’s psychological
safety in the session and believes that the child will not be safe in joint ses-
sions with the parent, the therapist may recommend that the parent pursues
treatment for themselves prior to and/or during the course of the joint sessions
with the child. A second therapist is likely to be necessary to provide such
treatment if it is of any duration.
When the therapist meets with the parent without the child, the therapeutic rela-
tionship contains the same features that will be present during the joint sessions.
A-R Dialogue, with inter-subjective sharing and PACE, generates psychological
safety for the parent and prepares them for maintaining a similar way of engage-
ment when their child is present.
Phase Two
Once the alliance with the parent is established and the parent and therapist agree
on the course of the treatment, they are ready to begin the joint sessions with
the child. Throughout the treatment, the therapist and parent continuously moni-
tor and ensure that the child is experiencing psychological safety as she explores
aspects of her past and present, including those that might generate negative emo-
tions such as anxiety and shame. This is done by communicating PACE (in this
instance, acceptance, curiosity, and empathy but not likely playfulness) whenever
the child may experience any distress of the discourse.
Empathy is the primary communication, helping the child to experience that the
parent is experiencing the child’s distress with him, accepting the events that may
precipitate the distress, and then exploring the factors that are eliciting the distress.
The therapist’s nonjudgemental curiosity helps the child to know that understand-
ing and expressing whatever thoughts and feelings are emerging is safe. The child
– and his inner life – are never judged. Therapy is about understanding the child’s
experience and making sense of it and its origins, not judging the child, ¿xing him,
nor giving him a lecture and consequence. Through such nonjudgemental under-
standing, the child is much more able to face his experience, understand it in a way
that reduces his sense of shame, and develop a sense of safety that his parents, too,
understand his experience and continue to love him and be committed to him.
The process of attachment-focused treatment attends continuously to assist-
ing the child in regulating any emotions that are emerging in the discourse. This
facilitates both the ability to explore and integrate traumatic and shame-inducing
events but also in learning to be more able to regulate intense emotional states.
Co-regulation of emotion is central – and must precede – the developing ability to
auto-regulate emotional states.
The therapist and parent do so through remaining regulated themselves if the
child begins to dysregulate. Their regulation enables the child to feel safe and con-
¿dent in his and their ability to manage any emerging emotional states. They also
co-regulate the child’s emotional state by matching the child’s affective, nonver-
bal expression of his emotional state without feeling the emotion themselves. Dan
Stern (1985) de¿nes this as ‘attunement’ and it is a central means by which parents
facilitate the development of their child’s ability to regulate their emerging emo-
tional states. Within attuned states, the therapist and parent match the rhythm and
intensity (as well as beat, duration, contour, and shape according to Stern) of the
child’s bodily expressions (voice, facial expressions, gestures and movements) of
his underlying emotion, showing that the emotions are understood (with empathy)
and are able to be managed.
It cannot simply be assumed that the therapist and caregiver will remain regu-
lated when the child experiences distress over the memory of traumatic events.
The therapist is continuously aware of the caregiver’s psychological state to ensure
that he or she is able to be emotionally strong for the child. Any doubt requires
that the therapist meet with the caregiver alone and address any areas of distress
that she or he is experiencing. The same holds true for the therapist. The therapist
must have ongoing supervision to ensure that the therapist is able to remain fully
engaged and regulated when the child is exploring past traumatic events.
The process of DDP also greatly assists the child in making sense of the over-
whelming traumatic and shame-inducing events of his life. The therapist’s non-
judgemental curiosity enables the child to begin to safely explore these events,
while being open to their underlying meanings. The therapist’s – and parent’s
– reÀective functioning enables the child to reÀect on these events as well. The
child begins to develop a sense of what he thinks about them, what they mean
in light of his history and symptoms, and what implications they have regarding
his future. The child experiences the therapist and parent’s experience of those
events and through this inter-subjective experience is able to develop – with their
active minds interwoven with his – new meanings of those events. The therapist
and parent’s inter-subjective experience serves as a balance to the perpetrator’s
experience of those events and so frees the child to begin to experience them
114 Daniel Hughes
anew, rather than assuming that the perpetrator’s experience represents objective
reality. As this happens again and again in treatment, the child is learning how to
reÀect himself and so develop his mentalising abilities which are so important for
his developing mental health.
As was mentioned earlier, the therapist needs to facilitate the child’s ability to
develop the words to describe and communicate his inner life. To ask the child to
use his words or giving him time to tell his story often ends in failure because the
child does not have the ability to associate words with the traumatic, confusing, or
shame-inducing interpersonal events of his past. His inner life was not often seen,
recognised or valued by his attachment ¿gures and he was not given an adult’s
mind to use to develop his own mind. In therapy the therapist can greatly facilitate
this process by – with the attitude of PACE – speaking for the child to the parent
or therapist or speaking about the child to the parent or another person (or even a
stuffed animal or puppet).
When the therapist speaks for the child he does so with the child’s permission
and with the acknowledgement that he is only guessing what a child might be
thinking or feeling and so the child is encouraged to correct the therapist whenever
the guess is seen as being ‘wrong’ by the child. The therapist never disagrees with
the child. The therapist also takes the child’s nonverbal response to his guesses as
valid, so that if the child demonstrates confusion nonverbally over the therapist’s
guess, the therapist then suggests that his guess might be wrong, while asking for
clarity regarding the child’s response. This process resembles ‘doubling’, a tech-
nique used in psychodrama (see Holmes 1992).
When speaking for the child, the therapist begins tentatively:
I wonder if you sometimes think: ‘I really don’t like having to think about
this stuff.’
or
I really have a hard time thinking about what my dad did. I sometimes think
that I’m being selfish when I get mad about it.
Or the therapist guesses what the child might want to say to the parent:
I wonder if you sometimes want to say to your mom: ‘Mom, sometimes when
you say “no” to me, I think that you say it because you really don’t care what
I want. That what I want is not important to you. And then I get really mad at
you. It even seems that you don’t like me! And then I don’t like you!’
When the therapist speaks about the child to the parent, the child – relieved from
the need to respond or even to listen – will often listen in a more open and engaged
way to what the therapist is saying. The child hears the therapist’s words with less
defensiveness and more open curiosity about what the therapist thinks. Often, the
child remembers what the therapist says much more fully and deeply, allowing
the therapist’s thoughts to inÀuence the development of his own. For example, the
therapist might say to the parent, in the child’s presence, rather than to the child:
When your son has a hard time when you are correcting him or when we dis-
cuss some of his challenges in therapy, I really can understand why. He starts
to have doubts, wondering if you really care for him, wondering if you are
so angry with what he did that you might give up on him, wondering if there
is any hope that the problem can work itself out. Your son really cares about
these things, even when he might just show his anger or says that it’s not
important to him. He tries, I know he does, even if it seems that he isn’t trying.
He has had a hard life and looking at these things is very hard. We need to be
patient, and understand why he might give us a hard time sometimes.
Such words, when expressed with the open and engaged voice prosody charac-
teristic of PACE – are often heard, felt, and integrated by the child in a way that
would not occur if the therapist spoke directly to the child.
In summary, the attachment-focused interventions proposed represent both
the process and content of treatment. DDP establishes a therapeutic relationship
between the therapist and both the parent and child where both are able to remain
open and engaged in their relationship with each other and the therapist in order
to broaden and deepen their relationship. At the same time, they explore their con-
Àicts and stress as well as the child’s shame and traumas in a manner that leads to
their co-regulation of associated emotions and co-creation of new meanings. The
therapist is an attachment ¿gure to both parent and child, while at the same time
being a midwife to facilitate the child’s attachment to his parents.
References
Booth, P. & Jernberg, A. (2010). Theraplay: Helping parents and children build better
relationships through attachment-focused play. San Francisco: John Wiley.
Cicchetti, D., Toth, S., & Lynch, M. (1995). Bowlby’s dream comes full circle: The appli-
cation of attachment theory to risk and psychopathology. Advances in Clinical Child
Psychology, 17, 1–75.
Cline, F. (1995). Conscienceless acts, societal mayhem: Uncontrollable, unreachable
youth in today’s desensitized world. Golden, CO: Love & Logic Press.
Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., et al. (2005).
Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390–398.
Fonagy, P., Gergely, G., & Target, M. (2008). Psychoanalytic constructs and attachment
theory and research. In J. Cassidy & P.R. Shaver (eds) Handbook of attachment (2nd
ed.). New York: Guilford Press, pp. 783–810.
Gelso, C.J. (2011). The real relationship in psychotherapy: The hidden foundation of
change. Washington, DC: American Psychological Association.
Grossmann, K., Grossmann, K.E., Kindler, H., & Zimmermann, P. (2008). A wider view
of attachment and exploration: The influence of mothers and fathers on the development
116 Daniel Hughes
of psychological security from infancy to young adulthood. In J. Cassidy & P.R. Shaver
(eds) Handbook of attachment (2nd ed.). New York: Guilford Press, pp. 857–879.
Hesse, E. (2008). The adult attachment interview: Protocol, method of analysis, and empiri-
cal studies. In J. Cassidy & P.R. Shaver (eds) Handbook of attachment (2nd ed.). New
York: Guilford Press, pp. 552–598.
Hoffman, K.T., Marvin, R.S., Cooper, G., & Powell, B. (2006). Changing toddlers’ and
preschoolers’attachment classifications: The Circle of Security intervention. Journal of
Consulting and Clinical Psychology, 74, 1017–1026.
Holmes, P. (1992) The inner world outside: Object relations theory and psychodrama.
London and New York: Tavistock/Routledge.
Holmes, P. & Farnfield, S. (eds) (2014). The Routledge handbook of attachment: Theory.
Hughes, D. (2004). An attachment-based treatment of maltreated children and young peo-
ple. Attachment & Human Development, 6, 263–278.
Hughes, D. (2006). Building the bonds of attachment (2nd ed.) Northvale, NJ: Jason
Aronson.
Hughes, D. (2007). Attachment-focused family therapy. New York: W. W. Norton.
Hughes, D. (2009). Attachment-focused parenting. New York: W. W. Norton.
Hughes, D. (2011). Attachment-focused family therapy workbook. New York: W. W.
Norton.
Kennedy, H., Landor, M., & Todd, L. (2011). Video Interaction Guidance: A relationship
based intervention to promote attunement, empathy, and well-being. London: Jessica
Kingsley.
Lieberman, A.F., Van Horn, P., & Ippen, C.G. (2005). Toward evidence-based treatment:
Child–Parent Psychotherapy with preschoolers exposed to marital violence. Journal of
the American Academy of Child and Adolescent Psychiatry, 44, 1241–1248.
Porges, S.W. (2011). The polyvagal theory: Neurophysiological foundations of emotions,
attachment, communication, self-regulation. New York: W. W. Norton.
Siegel, D.J. (2012). The developing mind: How relationships and the brain interact to
shape who we are (2nd ed.). New York: Guilford Press.
Sroufe, L.A., Egeland, B., Carlson, E., & Collins, W.A. (2005). The development of the
person. New York: Guilford Press.
Stern, D. (1985). The interpersonal world of the infant. New York: Basic Books.
Trevarthen, C. (2001). Intrinsic motives for companionship in understanding: Their origin,
development, and significance for infant mental health. Infant Mental Health Journal,
22, 95–131.
Chapter 7
Clinical implications of
attachment in immigrant
communities
Elaine Arnold
An understanding of the nature and dynamics of attachment informs rather than

defines intervention and clinical thinking.
(Slade 1999: 577)
Introduction
This chapter focuses on the clinical implications for treatment in individuals who
have experienced disruptions of their attachments in childhood or have suffered
other traumas and losses. Such problems are not uncommon in communities where
families have travelled abroad either as economic migrants or because of war and
strife in their home countries (see Avigad & Pooley 2002).
Jafar Kareem, the founder of Nafsiyat the Inter-Cultural Therapy Centre in
London, expressed the view that ‘the concept of loss of a very early love object
and subsequent maneuvers to cope with such loss constitute, according to some,
the basis for many later emotional traumas’ (Kareem 1992/2000: 34). Attachment
theory has always considered the processes of loss and trauma in individuals and
in communities. Indeed John Bowlby was commissioned by the World Health
Organization in 1949 to study and report on the needs of children left homeless
at the end of the Second World War in 1945. This gave him the opportunity to
research in the United Kingdom and in France, the Netherlands, Sweden, Switzer-
land and the United States of America. He studied the literature and interviewed
professionals who worked in child care and child guidance. Bowlby observed that
in these various cultural groups there was a high degree of agreement regarding
the principles underlying the mental health of the children and the practices that
safeguarded this.
His report for the World Health Organization ‘Maternal Care and Mental
Health’ (1952) was abridged and entitled Child Care and the Growth of Love
(1953) and made available to the general public. The book became a best seller
and was translated into ten different languages. According to Jeremy Holmes
(1993: 38) the change of title of the book was a signi¿cant shift since, rather
than con¿ning itself to the mental health of the child, it gave a universal
118 Elaine Arnold
message about mothers and children. Bowlby stated that ‘what is essential for
mental health, the infant and young child should experience a warm, intimate
and continuous relationship with his mother (or permanent mother-substitute)
in which both ¿nd satisfaction and enjoyment’ (Bowlby 1952: 11). It should be
noted that although Bowlby held strong views of the importance of the mother
caring for the young child he did not rule out the possibility of someone other
than mother caring for the child.
This chapter describes clinical work in which those involved have, for differ-
ent reasons, experienced a disruption or a failure of these ideal experiences for an
infant. Such experiences are of course all too common not only during national
crises such as occur in war, but also at other times, and so to this extent they are
not dependent on cultures. However, such experiences occur more frequently in
some communities than in others.
Issues of race and culture were considered in research into attachment when
Mary Ainsworth, one of John Bowlby’s most senior collaborators, undertook
some of her original studies on the Ganda tribe in Uganda (Ainsworth 1963). Race
and culture have been considered further in many other studies (see, for example,
reviews by Van IJzendoorn and Kroonenburg 1988 and Reebye et al. 1999).
On Ainsworth’s return to the United States of America, building on her obser-
vations in Uganda, she observed children aged 12 months to 20 months with their
mothers at home and subsequently in a university laboratory play room in Balti-
more. She stated: ‘The laboratory procedure was designed to capture the balance
of attachment and exploratory behaviour under conditions of increasing, though
moderate stress’ and then to observe the child’s behaviour on reunion (Ainsworth
et al. 1978). She called this procedure ‘the Strange Situation’ (SSP) and it remains
one of the standard assessments of attachment (discussed in Farn¿eld and Hol-
mes 2014), and is considered as ‘the cornerstone’ of the current understanding
of infant–mother attachment behaviours. Ainsworth observed that the attachment
relationships between mothers and children from the two different backgrounds
of race and culture were similar, and she recognised difference in some patterns of
attachment behaviour. For example, in the Ganda sample, when there was a secure
attachment between mothers and children before the separation, upon reunion the
children clapped their hands while the American children hugged and kissed their
mothers (Reebye et al. 1999).
Attachment, separation, and loss

These are the main titles of Bowlby’s three linked books on the subject of attach-
ment (Bowlby 1969, 1973, 1980).
Attachment
In Attachment and Loss Volume 1: Attachment, Bowlby described the emergence
of attachment behaviour in early childhood and stressed that if the principal
Attachment in immigrant communities 119
¿gure is absent, another in the hierarchy of the attachment relationships can be a

substitute (Bowlby 1969/1982: 321). While this process occurs in all cultures, the
smooth progress to the development of secure attachments may be more disrupted
in some communities than in others. He also asserted that
children tend unwittingly to identify with parents and therefore adopt when
they become parents, the same patterns of behaviour that they themselves
have experienced during their own childhood. Patterns of interaction are
transmitted more or less faithfully from one generation to the next.
(Bowlby 1969/1982: 323)
Separation
In Attachment and Loss Volume 2: Separation, Anxiety and Anger (1973) he pro-
posed the idea that children who are con¿dent of the consistent availability of the
attachment ¿gure will be less prone to chronic fear, and the converse for children
who are not con¿dent that the attachment ¿gure will be available. This con¿dence
is acquired slowly through childhood and adolescence so that the expectations
regarding the responsiveness of attachment ¿gures are reÀections of the actual
experiences the child has with their parents and tend to persist at the level of the
unconscious throughout life (Bowlby 1973: 235). These seem to be universal fea-
tures in human development.
Loss
In his third volume of the trilogy, Attachment and Loss Volume 3: Sadness and
Depression (1980), Bowlby stated that he believed that the cause of unhappiness,
psychiatric illnesses and delinquency could be attributed to loss and that in work-
ing clinically with individuals, this was often missed. He expressed the view that
‘the loss of a loved person is one of the most intensely painful experiences any
human can suffer’ (Bowlby 1980: 7), and advocated that the individual needs help
to mourn the loss.
Too often this is unrecognised when individuals, whether of the indigenous
population or migrants, asylum seekers or refugees, who have been traumatised,
are assessed by therapists. An individual may be labelled as uncooperative when
he/she is unable to respond to the interviewer but, because of fear, they might be
more accurately described as ‘frozen’. The behaviour of such individuals might
be classi¿ed in a fourth category of insecure attachment, disorganized/disoriented
(Main and Solomon 1986), consequent upon his/her early experiences of having
been subjected to abuse – physical, emotional, sexual – or when the mother or
primary carer themselves showed frightened or fearful behaviour when the child
signalled the desire for nurture and comfort. According to George, Kaplan and
Main (1985/1996) if an Adult Attachment Interview (AAI) is conducted with
120 Elaine Arnold
these carers, they often recall separation, loss or traumatic violence in their child-
hood which has remained with them and is still unprocessed so it continues to have
an impact on their lives and on their capacity to parent.
Pressures on the care of children in urban

communities
In most cultures the care and protection of the young is undertaken by the mother
or mother-substitute, with or without the support of fathers, and with other mem-
bers of the extended family, or friends of the family; but speci¿c practices dif-
fer among peoples with different cultural norms. Regardless of the practices the
aim is to protect and safeguard the health and survival of members of the family.
Strong and supportive families within communities where individuals feel a sense
of belonging are conducive to good mental health.
In some urban areas in England, up to 80 per cent of the population come from
communities in which previous generations have suffered displacement from
their familiar environments to which they had been attached. This is particularly
true of migrants who came to Britain and who settled in the areas where employ-
ment was to be found. According to Marris: ‘the calculations of economic devel-
opment seldom take account of the psychological cost of this vast displacement.
And these costs will come to haunt us as alienation, rage, humiliation, violence
– all the ways that frustrated attachment seeks compensation and revenge’ (Mar-
ris 2008: 30).
The counsellor/therapist working in Greater London, which contains only one
eighth of the British population but of which nearly half are from minority groups
(Owen 2002–3), will ¿nd a population with very diverse cultures, some members
of which will have suffered personal and social upheaval.
Marci Green (2008) observes that most research on attachment is on the individ-
ual’s experiences of attachment separation and loss and admonishes us to widen
our vision to the public domain. She argues that ‘attachment experiences matter
for both the health of individuals and the quality of the human community within
and across generations’ (Green 2008: xv).
I will now describe some of my clinical work structured around Bowlby’s three
book titles: Attachment, Separation, and Loss.
Attachment
An inner London mothers’ group

One neighbourhood community centre in a London Borough, committed to pro-
viding excellent service for families, engaged in outreach work, and encouraged
young mothers to use the facilities provided at the centre and organised various
courses for them. It is in this context that I was invited to work with a group of
six mothers.
There were five mothers, four from ethnic minority groups – Jamaica,
Ghana, India, Greece – and one English. They were in the age group
25–30 and of lower socioeconomic backgrounds. Their children were
aged from one year to just over two.
I introduced them to attachment theory as part of a course on Parents’
and Young Children’s Relationships. The trainees viewed video tapes
of the Strange Situation procedure compiled by Bowlby’s son, Richard
Bowlby, and listened to the explanations of the classifications of the
attachment patterns. We then discussed the children’s reactions to being
left. The mothers were unanimous in their disagreement with the classifi-
cation of the SSP rated as secure. Their views were that the child’s crying
and trying to follow mother (protest) and not settling with the stranger
indicated that the child was ‘too tied’ to mother. They argued that since
most mothers needed to go out to work and to leave their children with
carers, either at home or in the nursery, children needed to learn to be
independent. The children who did not protest when mothers left were
considered to be more accepting even though they appeared ‘sad’.
It seemed that the trainees thought that children of that age were
capable of assessing their mothers’ needs and were on good behaviour
in order to please them.
We discussed the concept of mother being ‘a secure base’ to which
the child could return when stressed and the trainees were asked to
observe the reunions more closely. They acknowledged that the chil-
dren’s behaviour in seeking comfort from the mother or not acknowl-
edging mother on reunion, and mother responding to the child’s dis-
comfort, gave them some insight about how mother and child reacted
to each other before they were separated. If the child was used to being
comforted by mother when in distress, she went to her and mother
was able to calm her, while the child who was uncertain of mother’s
reaction did not seek comfort from a mother who did not attempt to
give any. This had been missed on the first viewing of the procedure.
The trainees expressed the view that the mother of the child who
did not cry or try to follow her when she left the room, and who
sat looking dejected, and whose pattern of attachment was classified
as ‘insecure’, needed to be more ‘active’ in engaging the child who
seemed unsure of whether to seek comfort and was unable to resume
her play. The mothers recalled how they felt when they left their chil-
dren in the nursery, and how their children responded to being left and
appreciated that the nursery allowed them to stay with the children
until they were settled and engaged in play.
122 Elaine Arnold
At the end of the course, the mothers had gained an understand-

ing of the concepts of attachment and of the Strange Situation and
were more accepting of the classifications in the video. This allowed
them to reflect on their own early experiences and conclude that they
realised how early childhood experiences remained in one’s mind into
adulthood, and how present feelings and behaviour were influenced by
these experiences.
Some of those who had experienced their primary carers as ‘mat-
ter of fact’ (that is, ‘dismissive’), and not demonstrative with hugs and
kisses, described this pattern of behaviour as common within families
of their countries of origin so that it could be considered as cultural.
Others attributed this to the fact that mothers who worked were tired
and did not have much time to devote to ‘cuddling’, but their behav-
iour could not always be interpreted in terms that their children were
not loved. Those from the Caribbean recalled that mothers and oth-
ers in the extended family paid great attention to grooming children,
especially with plaiting and braiding the hair and massaging the skin
with oil and telling the children how pretty they looked. Nevertheless,
it was considered necessary that the children learnt from an early age
to be independent of others. They were not encouraged to show their
emotions if hurt or sad by crying. This was particularly stressed with
boys.
This discussion prompted the mothers to reflect on the attachment
behaviour patterns of their mothers and their own behaviour towards
their children, and they realised that they were repeating the pattern
set by their mothers/carers and began to understand what was meant
by intergenerational transmission of attachment patterns.
The mothers felt themselves enabled to respond to the emotional
needs of their children more effectively and, after learning the devel-
opmental stages of the child, said they would be able to observe these
in their child/children as they matured and would be able to respond
to them appropriately. The concept of mother as a secure base for
the young child was accepted and the mothers agreed that they were
helped in beginning to understand how important it was to communi-
cate with their children, to tell them goodbye when they left and reas-
sure them that they would return, and so begin to meet the emotional
needs of their children more effectively.
The staff commented that the mothers seemed calmer and spoke
to the children more than previously, and the children settled to play
more quickly when they arrived at the centre.
Five of the women in the above group had been left by their parents as young
children in their countries of origin and were from different cultural backgrounds.
They had been cared for by grandmothers from whom they did not want to be
separated to come to Britain to join parents who had preceded them. The reunions
with mothers were painful, and sometimes they met siblings whom they thought
were loved and preferred by their mothers/parents. These life events had markedly
impacted on their attachment styles and thus on the care of their children.
Separation
The impact of early separation is not a new phenomenon but may have been more
marked in Britain as during the last few decades it has become more multiracial
and multicultural. Following the destruction of the country and the loss of many
people during the Second World War (1939–45) there was an inÀux of migrants
from the Caribbean, at the invitation of the government, to assist in rebuilding
‘the mother country’. Others came from the Asian and African continents and
former British colonies, often following political upheaval or civil wars in those
countries. More recently, with the establishment of the European Union which
allows free movement of people from the various European member states, there
has been an increase of migrants, who have added to the demographic change in
British society, with families of three and four generations.
Some of the original migrants, including many from the Caribbean, settled for
longer than they had planned, mainly due to a lack of economic success in this
country. They then sent for their children whom they had left with extended fami-
lies in their countries of origin. However, they often became parents to children
born in this country. This had implications for attachments within the families.
The reunited children had not been helped to grieve and mourn the loss of their
carers and country left behind and felt marginal to their new families after having
been at the centre of the extended family now so far away and with no hope of
seeing them again. Their perceptions of the close relationship between their moth-
ers and the younger children who had not been separated for long periods of time,
were that they were preferred and loved and they were not. The children born in
England who had not been prepared for the newcomer felt that their territory had
been invaded by a stranger. When the younger children had been prepared for
their older siblings’ arrival they were more able to accept the reunited children
(Robertson 1977, now Arnold).
It is not uncommon for those children, who felt no sense of belonging in their
new families when they became adults, to be unable to express their anger and the
distress experienced in their early childhood. Frequently their emotional distress
manifests itself in physical symptoms. Attachment theory provides a theoretical
basis for understanding their dif¿culties and argues for its inclusion in the training
of all professionals involved in the helping professions.
Some parents who left young children in the care of extended family members
for long periods of time before being reunited with them, have had disappointing
124 Elaine Arnold
reunions as they were virtual strangers and unable to communicate with each
other. Mothers were surprised to ¿nd that the children had become attached to
their carers in their country of origin, the loss of whom they mourned silently. The
birth parents and their children were unable to establish relationships with each
other. The reunited children suffered the discontinuities of all that was familiar to
them and while some have adapted to living in the new environment, there is little
doubt that history has left its own psychological impact on individuals and the
communities which have developed within the host country (Arnold 2012).
Many of the younger members of the migrant groups who were born in Britain
and reared by parents to whom they are attached have adapted to the cultural
norms of the host country. Even when parents and grandparents maintain links
with their homelands some of these children consider that they would feel like
strangers if they visited their homeland and consider themselves British (conver-
sations with young people, 2012) but do not have a sense of belonging, especially
when they suffer racial discrimination from the various sections of British society,
school, church, employers, the police, the justice system. Nevertheless, some of
these individuals have put down roots and formed stable relations, families and
work patterns.
The following case study demonstrates the long-lasting nature of the traumatic
effects of broken attachments through separation.
Tina – separated from and then deserted by her mother

Tina, a 45-year-old woman of Afro-Caribbean origin was referred for
counselling. Her doctor described her as being depressed, but she was
unwilling to take anti-depressants for fear of becoming dependent on
them. She spoke of being over worked and tired; she was a single par-
ent and the father of her 15-year-old son, Ben, was inconsistent with
any financial help and had stopped visiting.
Ben had expressed anger towards her for his father’s absence and
she was very hurt by his accusations. Tina described herself as being a
strict parent as she did not want him to ‘go astray’. Ben’s relationship
with his father was a close one and she realised that the loss of him
was painful for Ben.
When Tina was six years old, the youngest of eight children of
various ages, her mother, two aunts and a friend of the family had
migrated and left their children to be cared for by her grandmother.
Tina recalled that she always felt left out and said of her grandmother,
‘She tried to care for us but there was not enough love to go around.’
When she joined her mother in England they were strangers to each
other and did not develop a relationship. When her mother returned
to the Caribbean they had no opportunity to talk about the past. Tina
had hoped that she would have been married and experienced a loving
family and was very disappointed that this did not happen and was very
anxious for the future.
Tina’s history, although not unique to her African-Caribbean culture, was one
shared by many of her peers. A secure therapeutic environment enabled Tina to
disclose her long repressed feelings and accept a recommendation that Ben too
needed to discuss his painful feelings of loss and his anger and that he be seen by
the child psychotherapist. In this instance, the counsellor’s knowledge of Tina’s
background and an understanding of the effects of broken attachments, separation
and loss assisted in the development of the therapeutic work.
There are a number of families of all cultures who are experiencing dif¿culties
in parenting and may come to the attention of helping professionals, who think
that it would be bene¿cial for mothers to be assessed in order to appraise their
parenting skills and their attachment to their children or that their children are
struggling with issues of attachment. Working inter-culturally does not only mean
that the professional and the client come from different races, but also that for the
client ‘any kind of difference in culture is reÀected in their attitudes and concepts
of life, in their manifestations of distress and in their personal ideas about what
might be done or can be done’ (Kareem 1992/2000: 34).
Loss
There are some young people who live on the margins of society, unloved and
unable to love and are often angry. They may have experienced insensitive parent-
ing for a number of reasons such as acute poverty, poor housing, neglect because
of their mother’s physical or mental ill health or substance abuse and lack of
paternal support in the family: ‘after all when you are going through problems of
adjusting to a society which in many ways and forms is rejecting you, it doesn’t
really help if your father for whatever reason, decides to leave the family’ (Phillips
2006: 147). They may also have histories of emotional, physical, sexual abuse,
and several changes of care arrangements, with inconsistent careers in their early
lives, or have spent long periods in children’s homes or various institutions man-
aged by the state or voluntary agencies. Many will have suffered signi¿cant losses
in their lives. They have not developed a secure attachment to their primary carers
and they are detached and unable to build relationships.
At some time in their lives they may be referred for psychotherapeutic help,
through contact with other agencies. Since these young people have not had their
basic needs met it is important that the therapist is fully aware of their attachment
126 Elaine Arnold
history and, according to Pearce (2009), that they are given reassurance by under-
standing their needs without the therapist trying to be too emotionally close or too
distant. Maintaining consistency in the range of affect expressed and behaviour
reassures the young person and gives a sense of attunement which has been miss-
ing in their early lives.
There are also numbers of asylum seekers and refugees who were forced to Àee
from war-torn countries and who have suffered persecution, abuse and threats of
death. They have experienced broken attachments, separation from and loss of
family and friends and have been traumatised by the events that caused them to
leave the security of their own homes, and have been disappointed at not ¿nding
Britain to be the safe haven that they had imagined it to be. They might not be
aware of whether parents or relatives have survived in the countries from which
they Àed. Depending on their early experiences and their level of resilience, some
have been able to adapt to the new environment and cope reasonably well. Some
have come from countries where therapy is not practised and the concept of telling
their problems to a stranger is not acceptable to them. However, there are instances
when doctors or other professionals recommend therapeutic help with the services
of a counsellor or therapist of the client’s own ethnic and cultural background, who
speaks the language and who possesses knowledge of attachment theory. Where
this is not possible, carefully and well-trained interpreters need to be employed.
The acceptance of grief and the need for mourning loss are not only applicable
when there is the death of a loved one; there are others among this population
who will have suffered the discontinuities of their minority cultures. There will
be issues of dislocation and trauma often resulting from unwanted separation and
living among strange people and strange environments. There are also those who
deal with ambiguous loss where the person who is ‘lost’ is not dead and is thought
of and being grieved for. This may occur with children in foster care or who have
been adopted, and those whose parents are divorced, or in prison or in long-term
hospital care.
Older children who are adopted and who experience dif¿culty in settling may
be having dif¿culty in resolving ambiguous loss and their adoptive parents need
to be helped to appreciate the grief which the children suffer. The need to be
encouraged to summon up ‘the willingness to connect with children about their
adoption, instead of denying the difference of entering a family through adoption
rather than through birth, is an essential part of helping them grieve this important
loss and make sense of their circumstances’ (Hall and Steinberg 2000/2013: 179).
These authors state that sometimes adoptive parents are reluctant to address their
children’s questions, usually because of their fear of pain, anger, blame and their
own loss. Working therapeutically with adoptive parents’ knowledge of attach-
ment, loss, separation, anger and anxiety is invaluable in order to help them to
process their feelings and enable them to empathise with their children.
There are also situations where the ‘lost’ person may be physically present but
psychologically absent (Boss 2006), for example where a couple share the same
house but maintain no relationship.
Somatised distress: a case study
Julia was a 21-year-old woman of African origin who was referred for
an assessment when her GP was unable to find anything wrong. She had
complained of frequent stomach pains and had been given leave from
attending college as she found it impossible to sit up in the class. Julia
was very anxious about missing time from college as she was eager to
do well, urged on by her parents who set great store on education.
Julia spoke softly and said she hoped that she could be helped in order
to return to college as soon as possible.
This was her first year at college and she had not yet made any
friends and found the lecturers intimidating and she was not able to
concentrate as much as she would like. On returning home she helped
with preparation of meals; the younger siblings, a sister aged 12 and
brother 14, did not help. She volunteered that they were born in this
country and their upbringing was different from hers. Julia was asked to
tell her story. She had been reared in an African country by her grand-
mother whom she loved and regarded as mother. Her father left home
first for the UK followed by her mother soon after. Her childhood was
a happy one with other children in the extended family. She did well
at school and when her parents decided that she should join the family
here, she was very reluctant to leave home and all of her family and
friends. What was arresting in her narrative was Julia’s description of
her reaction to her mother’s presence. ‘When she enters the room, I
freeze. I am so afraid of her.’
Julia’s emotional pain was focused on her physical symptoms. According to

Wallin (2007: 130) ‘the impacts of acute trauma as well as disorganized attach-
ment are frequently somatic’. This implies that it is observed in individuals in any
culture. A knowledge of her attachment issues allowed her therapy to focus on her
insecurity and fear of authority ¿gures on whom she seemed to project the feel-
ings she held towards her frightening mother, with whom there was an insecure
disorganised attachment.
Attachment theory and issues of race and culture

Slade (1999) issues a warning that although attachment theory can assist clini-
cians in understanding the dynamics of the therapeutic relationship, changing
their views and responses to their clients, all aspects of human experience are not
de¿ned by understanding attachment organisation. It is particularly important to
128 Elaine Arnold
bear this in mind when assessing migrants, asylum seekers, refugees and all those
persons who have been displaced and who are of different ethnic groups. How safe
is the environment in which they live, and how unsettling are some of the policies
to which they are expected to conform?
Jeremy Holmes (1994), in his discussion of attachment theory and its theoreti-
cal base for counselling, states that the therapeutic process could be considered
as being based on the movement of the client from insecure to secure attachment.
Attachment theory should not be seen as yet one more form of psychotherapy, but
rather as de¿ning features that are relevant to therapy generally. Certain key ele-
ments shared by all therapies include a relationship with the client, which provides
a secure base from which to explore the problem. The task of the therapist is both
to encourage appropriate emotional responses to past trauma, and to encourage
discussion and ventilation about losses.
These aspects of the therapeutic process are not culturally based. The pain and
the anguish need to be experienced if the client is to feel safe enough to form new
attachments. According to Holmes the central context emerging from attachment
theory is that of narrative, and the individual’s core state is a condensed form of
his/her primary relationship which gives the individual ‘a sense of ownership of
their past and their life’ (Holmes 1993: 150).
However, there are also the social and historic factors that impinge upon the
individual which need to be taken into account. There are some professionals who,
when working with clients from black and other minority groups, are anxious about
being called ‘racist’ if they probe into their clients’ cultural beliefs and practices.
These anxieties can hamper workers in making accurate assessments of the needs
of their clients. Training in intercultural therapy would assist workers to maintain a
balance between, on the one hand, awareness of shared and universal human char-
acteristics and, on the other, not neglecting cultural variability by treating every-
one ‘the same’ or attributing the client’s problems to a cultural peculiarity.
Jafar Kareem founded the intercultural therapy centre in north London, where
therapeutic help was offered to adults and families, mainly from black and minor-
ity groups. Some of them needed to be spoken to in their own language and by a
therapist of a similar background with whom they felt secure and able to build a
relationship. Kareem was explicit in stating that:
for intercultural therapy it is necessary to understand how patients first expe-

rience and perceive their illness or problem, in effect to allow them authentic-
ity as a person. It is therefore useful to involve patients themselves from the
outset to let them explain and define how they see their own problem whether
in terms of bodily disease or emotional distress.
(Kareem 1992/2000: 34)
Many of the clients were immigrants or children of immigrants and their experi-
ences of broken attachments and the issues stemming from this were explicitly
recognised.
Within any one community there are usually different interpretations of the cul-
ture and, therefore, it is always important to discover the individual family’s cul-
tural pattern of behaviour. Sharpe (1997: 266), commenting on the mental health
and socialisation in the Caribbean, expressed the view that the mental health issues
attributed to attachment, separation and loss, ‘are central to much of the psycho-
pathology that may be associated with the speci¿cs of Caribbean family socializa-
tion’. Fletchman Smith (2000: 79), working with clients of Caribbean origins in
London, stated that, generally, children seem to suffer particularly badly when
problems occur in families from ‘an extended network background, described as
headed by women, and in which women take sole charge of caring for the chil-
dren, sometimes including the children of several generations’. In these instances
there undoubtedly will be issues of attachment for the children and for the women
who are parenting them and they could bene¿t from therapeutic help if their needs
are recognised by professionals with the knowledge of attachment disorders.
Conclusions
The understanding and knowledge of attachment theory and sensitivity to the
client’s verbal and nonverbal communication, as in all forms of counselling or
therapy, helps to build trust in establishing a working relationship. It is also neces-
sary to consider how the client’s ethnic background and the attachment behaviour
patterns of parents from that background have inÀuenced his or her behaviour.
Some of the elements of the task of the therapists as suggested by Bowlby
(1988) are:
• the provision of a secure base from which the client would be able to explore
past painful experiences;
• helping the client to consider how she engaged in relationships with signi¿-
cant attachment ¿gures and what the client’s expectations and behaviours
were;
• encouragement of the client to examine the relationship with the therapist/so-
cial worker and the way that she is thought of as an attachment ¿gure;
• helping the client to think about childhood and adolescent experiences, par-
ticularly in relation to parents’ inÀuence on the present. This task is often
painful and it may be hard to express feelings or ideas about parents which
previously seemed unthinkable;
• helping the client to understand that images of self and of others which might
have been derived from life experiences or from parents might not be appro-
priate for the present nor the future.
The nonverbal communication of the client is extremely important in work-

ing with those who are sometimes so overwhelmed by their experiences they are
unable to ¿nd the adequate words, and also when the language is not their mother
tongue. The quality of the nonverbal communications will, in time, inÀuence the
130 Elaine Arnold
attachment relationship and help the development of trust and security which will
help the client to recognise dif¿cult feelings and to begin to process them. Within
every individual there is the potential for change and this can be possible when
positive and meaningful interventions are made by those in the helping profes-
sions who are sensitive, empathic and patient.
References
Ainsworth, M. D. S. (1963) ‘The development of infant–mother interaction among the
Ganda’, in B. M. Foss (ed.) Determinants of Infant Behaviour, Vol. II, pp. 67–112, Lon-
don: Methuen.
Ainsworth, M. D. S., Blehar, M. C., Waters, E. and Wall, S. (1978) Patterns of Attach-
ment: A psychological study of the Strange Situation, Hillsdale, NJ: Laurence Erlbaum
Associates.
Arnold, E. (2012) Working with Families of African Caribbean Origins: Understanding
issues around immigration and attachment, London and New York: Jessica Kingsley
Publishers.
Avigad, J. and Pooley, J. (2002) ‘Strangers in foreign lands’, in B. Mason and A. Sawyer
(eds) Exploring the Unsaid Creativity, Risks, and Dilemmas in Working Cross-Cultur-
ally, London: Karnac Books.
Boss, P. (1999) Ambiguous Loss: Learning to live with unresolved grief, Cambridge, MA:
Harvard University Press.
Boss, P. (2006) Loss, Trauma, and Resilience: Therapeutic work with ambiguous loss, New
York: W.W. Norton and Company.
Bowlby, J. (1952) Maternal Care and Mental Health, Geneva: World Health
Organization.
Bowlby, J. (1953) Child Care and the Growth of Love, London: Penguin.
Bowlby, J. (1969/1982) Attachment and Loss; Vol. 1 Attachment, London: Hogarth Press.
Bowlby, J. (1973) Attachment and Loss; Vol. 2 Separation: Anxiety and Anger, London:
Hogarth Press.
Bowlby, J. (1980) Attachment and Loss; Vol. 3 Loss: Sadness and Depression, London:
Hogarth Press/Penguin.
Bowlby, J. (1988) A Secure Base: Clinical applications of attachment theory, London:
Routledge Kegan Paul.
Farnfield, S. and Holmes, P. (eds) (2014) The Routledge Handbook of Attachment: Assess-
Fletchman Smith, B. (2000) Mental Slavery: Psychoanalytical studies of Caribbean peo-
ple, London: Rebus Press.
Green, M. (2008) Risking Human Security: Attachment and public life, London: Karnac
Books.
George, C., Kaplan, N. and Main, M. (1985/1996) Adult Attachment Interview, unpub-
lished manuscript, University of California at Berkeley.
Hall, B. and Steinberg, G. (2000/2013) Inside Transracial Adoption, London and Philadel-
phia: Jessica Kingsley Publishers.
Holmes, J. (1993) John Bowlby and Attachment Theory, London: Routledge.
Holmes, J. (1994) ‘Attachment Theory: A secure theoretical base for counselling’,
Psychodynamic Counselling, 1(1): 65–78.
Holmes, J. (2000) ‘Narrative in psychiatry and psychotherapy: The evidence’, Medical

Humanities, 26: 92–96.
Kareem, J. (1992/2000) ‘The Nafsiyat Intercultural Therapy Centre’, in J. Kareem and R.
Littlewood (eds) Intercultural Therapy, Oxford: Blackwell Scientific Publications.
Main, M. and Solomon, J. (1986) ‘Discovery of a new insecure-disorganized/disoriented
attachment pattern’, in M. Yogman and T. B. Brazelton (eds), Affective Development in
Infancy, pp. 95–124, Norwood, NJ: Ablex.
Main, M., Kaplan, N. and Cassidy, J. (1985) ‘Security in childhood and adulthood: A move
to the level of representation’, in I. Bretherton and E. Waters (eds) Growing Points of
Attachment Theory, Monographs of the Society for Researching Child Development 50
(1–2), Serial No. 209.
Marris, P. (2008) ‘Attachment and loss of community’, in M. Green (ed.) Risking Human
Security: Attachment and public life, London: Karnac Books.
Owen, D. (2002–3) ‘Profile of Black and Minority ethnic groups in the UK’, The Univer-
sity of Warwick.
Pearce, C. (2009) A Short Introduction to Attachment and Attachment Disorder, London
and Philadelphia: Jessica Kingsley Publishers.
Phillips, M. (2006) The Name You Once Gave Me, London: HarperCollins Publishers.
Reebye, P. N., Ross, S. E., Jamieson, K. and Clark, J. M. (1999) Research report: A
literature review of child–parent/caregiver attachment theory and cross-cultural
practices influencing attachment. Available online at www.attachmentacrosscultures.
org/research/.
Robertson, E. (1977) ‘Out of sight, not out of mind’, in British Association of Social Work-
ers (ed.), Studies in Intercultural Social Work (pp. 26–35), Birmingham: British Asso-
ciation of Social Workers Publications.
Sharpe, J. (1997) ‘Mental health issues and family socialization in the Caribbean’, in J. L.
Roopnarine and J. Brown (eds), Caribbean Families: Diversity among ethnic groups,
Norwood, CT: Ablex Publishing and London: Jai Press.
Slade, A. (1999) ‘Attachment theory and research: Implications for the theory and practice
of individual psychotherapy with adults’ in J. Cassidy and P. R. Shaver (eds) Handbook
of Attachment Theory, Research, and Clinical Applications, pp. 575–594, New York and
London: The Guilford Press.
Van IJzendoorn, M. H. and Kroonenburg, P. M. (1988) ‘Cross cultural patterns of attach-
ment: A meta-analysis of the Strange Situation’, Child Development, 59: 147–156.
Wallin, D. J. (2007) Attachment in Psychotherapy, New York and London: The Guilford
Press.
Chapter 8
Attachment
A British lawyer’s perspective
Mary Ann Harris
Introduction
This perspective, from a British child care lawyer’s point of view, is written at
a time of immense change taking place in a bid by the government to reform
the family justice system through reducing delay, and consequently cost, in care
proceedings.
The courts have traditionally used senior professionals to act as expert wit-
nesses to assist them in understanding often complex issues in a case in the family
courts. In the current climate of change, the use and appointment of experts will
be affected, in that any expert put forward in public law (care) or private law
(contact and residence) proceedings, will be closely scrutinised by the court and
subject to a test of ‘necessity’ for the purpose of concluding the proceedings. In
the past the test was whether the expert was ‘reasonably required’ to assist the
court in concluding the proceedings. In the revised Public Law Outline (PLO)
– the government’s guidance for case management of child care proceedings, the
emphasis is on local authorities formulating a detailed case plan prior to issue of
proceedings.
In reality this is nothing new, except that more is now expected of them.
They will have to produce more succinct and relevant paperwork by way of
social workers’ statements and any appropriate assessments. From the outset
of proceedings, they should be in a position to set out their case for the court,
saying what case work, therapy or assessments they have done with the family
and detailing what still needs to be done to make ¿nal decisions for any relevant
children.
It is also envisaged that the court proceedings will conclude within 26 weeks.
In effect, local authority teams will need to have carried out some of the work
that in the past has been done by senior independent experts. These changes have
been a long time coming and are, in reality, the latest in various waves of reforms
since The Children Act 1989 ¿rst became law. They are government led, and are
supported by the President of the Family Division, Sir James Munby (the senior
family judge in England and Wales).
Attachment: a British lawyer’s perspective 133
The view from the President’s chambers

In Sir James’ ¿rst two statements published in 2013 about reform, entitled ‘View
from the President’s Chambers’, he outlines the needs for change and the steps to
be taken.
Sir James’s first view

He states: ‘The family justice system is undergoing the most radical reforms in a
lifetime’. Sir James outlines three strands of reform:
1 a new single Family Court (to incorporate all levels of the court possibly sit-
ting under the same roof and subject to a unified system of administration);
2 the implementation of the Children and Families Bill 2013–2014;
3 the goal of improving transparency in the family courts.
He states, ‘I do not accept that either of those reforms will prejudice the quality of
justice or the interests of those who appear before us’.
There are those who express concern about the implications of such reforms
and, indeed, to what extent they are achievable. A joint parliamentary brie¿ng in
May 2013 by the College of Social Work and the Family Rights Group regarding
the 26-week deadline for the conclusion of care proceedings from their implemen-
tation warn that ‘[t]here is a genuine risk that the proposed 26 weeks could result
in too much focus on procedure and not enough on the welfare of the child’. They
suggest there should be an amendment to the Children and Families Bill to provide
for an extension of the 26-week time limit where, in the judgement of the profes-
sionals involved, the case calls for it.
That begs the question who are the professionals making these decisions?
Sir James’ second view

In his second view, Sir James states that he hopes the revisions in both law and
procedure effect a change in the status of social workers ‘as trusted professionals
playing the central role in care proceedings which too often of late has been over-
shadowed by our unnecessary use of and reliance upon other experts’.
In a statement published in Local Government Lawyer on 9 May 2013, by the
Children and Family Court Advisory and Support Service (Cafcass), set up to
safeguard and promote welfare of children in family court proceedings, they note
there has been a 70 per cent increase in new care applications since the tragically
notable case of ‘Baby P’ in London in 2008/2009. The Baby P case concerned
the death of a baby aged 17 months at the time. The case shocked the community
when the details were released at the conclusion of the criminal trial as Baby P was
found to have suffered more than 50 injuries during an eight-month period, during
which time social services and other agencies had been involved with the family.
134 Mary Ann Harris
Tragically this was not the ¿rst case where a child suffered harm or death while
social services were monitoring the family.
In a time of increasing number of care proceedings coupled with a climate of
reforming policies to reduce cost and delay, it is dif¿cult to predict with any preci-
sion how these changes will affect the use of experts, in particular, assessments of
attachment (which in the past have usually been undertaken by such senior profes-
sionals) and the outcomes for children in court proceedings.
The appointment of expert witnesses

The change in the test regarding appointment of experts (the standard having been
altered from ‘reasonably required’ to ‘necessary’) will make it more dif¿cult for
lawyers to seek the appointment of professionals with speci¿c specialist expertise
to assist them in preparing cases for court.
The view of many solicitors is that it is an exceptional case (i.e. one which
is very straightforward) which can and should conclude within 26 weeks. Even
in those cases that are fairly clear cut as to harm caused to the child, ¿nding the
answers as to what is in the child’s best interests in the future can still be a chal-
lenging and lengthy process.
The process of assessment

There are various stages of the court process in public law children proceed-
ings which can be summarised as the pre-proceedings, fact-¿nding and welfare
stages.
Pre-proceedings
In the pre-proceedings stage (unless there are emergency proceedings necessary
to protect a child) the local authority will carry out a core assessment and other
assessments required to decide whether court proceedings are necessary to protect
the child. This sometimes includes assessments by medical or other profession-
als, however usually these pre-proceedings assessments are undertaken by social
workers.
Such preliminary input is extremely important and, as stated by Sir James:
Work done by local authority in the period pre-proceedings – front loading

– is vital for two quite different reasons. Often it can divert a case along
a route which avoids the needs for proceedings. When that is not possible,
and proceedings have to be commenced, work done beforehand will pay rich
dividends later on.
I would agree wholeheartedly with this point. However, it will be essential for
there to be transparency in the work/assessments carried out by the local author-
ity, and for the relevant parents/family members to be fully involved with their
own legal support and advice. If much of the assessment of the family has been
completed before court proceedings are initiated, challenging those early assess-
ments will be dif¿cult, particularly with the changes regarding the appointment of
independent experts.
It might, in the future, become incumbent on local authorities to seek expert
assistance at the pre-proceedings stage to strengthen their case. These changes
in the legal process will also demand much better training and supervision of
social workers to support them in meeting the tasks ahead. There is no doubt that
social workers already carry a heavy burden, are often over-worked and expected
to manage very dif¿cult complex situations. Increasingly, in this country, many
social workers are relatively young and inexperienced and, in my experience, there
are enormous variations in the quality of social work practice, from excellent to
very poor, which impacts directly on outcomes for children.
The children ignored and a lawyer’s question – a case

example
One of my cases in the last five years involved a young mother who had
been assessed by an adult psychologist prior to the proceedings as hav-
ing significant learning disability. The assessment was excellent, setting
out recommendations to professionals working with this mother about
how to talk to her and explain issues. This lady’s child who was under
the age of ten at the time, was removed from her care early on in the
case. It was alleged she failed to protect her from harm, and she failed
to take seriously the local authority’s concerns.
I spent many an hour with her trying to explain to her what ‘emo-
tional abuse’ meant, and why social services were taking court action,
in the hope of improving her ability to work with them. Somewhat
shockingly to me, it was many months into the case when I fully real-
ised she just could not understand the basic concepts. It also became
clear that social services did not follow the psychologist’s recommen-
dations about working with the mother. I recall the moment when the
mother asked me what an ‘emotion’ was. The combination of poor
social work practice and the mother’s inability to work with social
services resulted in the child remaining in foster care.
There was an independent assessment by a specialist learning dis-
ability team, which focused on the mother’s shortcomings, in my view,
rather than the child’s needs. There was little focus on long-term con-
tact issues, although a contact order was made with a full care order,
136 Mary Ann Harris
but there had been no independent assessment of the child’s needs and
her attachment with the mother.
Three years after the conclusion of the court proceedings, the child
had moved through three different foster placements, her behaviour
deteriorated, and she was receiving therapy. Her mother remained
involved through regular supervised contact, and tried her best to
understand what was expected of her. The case lasted two years in
court and, on the face of it, this should have been a straightforward
case, but the complexities were not in assessing the ‘harm’ caused, but
rather in deciding what would be in this child’s best interests in the
future. I have little doubt the mother is still involved in this child’s life,
doing her inadequate best for her.
Could the outcome have been better?

In my opinion this family was not well served by the system. There was little
doubt the child suffered signi¿cant harm while living with the mother, but the
harm was as a result of the mother’s ignorance, and she herself had little support.
Could there have been a better outcome for the child if more work was done with
the family, looking at the dynamics including the mother’s and child’s attachment
styles? Maybe, but if this case were to occur today, I do not think the outcome
would be different, as it would be even more unlikely that a court would agree an
expert assessment on attachment would be necessary to conclude the case. The
question really is whether that serves the child’s best interests or the short-term
interests of saving time and costs.
The lawyers become involved

It is during the pre-proceedings process that a lawyer ¿rst becomes involved,
having been consulted by a parent or family member about social services’
involvement in their family. It is at this stage when the parent either receives
a ‘pre-proceedings letter’ from social services stating their intention to issue
court proceedings, or they are considering the issues as to whether there are
genuine child protection concerns. At this stage the local authority is largely in
control.
If the family receives a pre-proceedings letter, the parent together with a lawyer
are invited to a meeting to try to agree a way forward without the need for court
intervention. If agreement is reached, and the parents acknowledge the concerns
and comply with the agreement, court proceedings can be avoided. Social services
would have produced a list of concerns and expectations for the parents to work
with. In my view this process, which was only introduced in the last few years,
can be very helpful as it crystallises what needs to be done to avoid court proceed-
ings being issued. The issue of attachment is not usually a point of discussion at
this stage, as social services are focused on whether they can work with the family
and, if necessary, whether there is suf¿cient evidence to intervene and instigate
court proceedings.
In my experience social services’ assessments rarely question the parents’
capacity to meet the needs for a secure base, an essential step to protect the chil-
dren’s emotional development (see Holmes and Farn¿eld 2014).
Lawyer and client – is this an attachment-based relationship?

The lawyer’s task at this early stage is not only to analyse the information and
advise the parent, but also to develop a trusting relationship with the parent so that
the lawyer can explain what social services are saying, and the consequences of
the parent’s response. This process can be understood as the development of an
attachment-based relationship in which, to a degree, the lawyer becomes a ‘secure
base’ for their client at the time of their possibly great distress and emotional
need. It may be easier for lawyers to develop such relationships with parents as
their responsibility is to their client alone and not to the child, local authority or
the state.
In a similar vein, it is important for the lawyer to work with social services in a
constructive although often challenging way.
However, if a relationship of trust cannot be forged with the parent, and the
parent remains argumentative and unaccepting of social services’ concerns, it is
almost impossible to run the parents’ case successfully (unless of course social
services’ assessment of the risk of harm is Àawed).
Although many lawyers manage this process intuitively, this is an area in which
lawyers might bene¿t from a better understanding of the attachment process and
its relevance to their relationships with their clients. In the typical neglect or
abuse case, it is crucial for the parent to trust the lawyer’s analysis and advice,
and believe that if they cooperate with social services they might get their child
back.
The fact-finding and welfare stages – the battle for the

appointment of expert witnesses
I have dealt with many cases which have resolved at the pre-proceedings stage.
However, much also depends on the willingness of social services to share infor-
mation regarding the family, and their willingness to work with the parents. If
the pre-proceedings, negotiation, route is not successful then the dynamics of the
situation change and court proceedings will be issued.
Under the new revised Care Proceedings Protocol, with a 26-week deadline to
conclude cases from the start, it is anticipated that lawyers will be kept in the loop
138 Mary Ann Harris
as to what evidence social services have and local authorities will have to state
their care plan for the child and suggestions for expert assessment clearly and
early on. Lawyers for parents will have to be quick off the mark to give careful
thought as to how they will challenge the local authority case, and what experts
they wish to put forward.
In the past, lawyers have argued the need of an expert witness to assist the court
with complex psychiatric and psychological issues. However, increasingly, the
issues required to be dealt with by expert assessment will have to be more clearly
de¿ned. Lawyers will need more assistance in their efforts to persuade a judge
that the appointment of an expert is ‘necessary’ for the welfare of the children to
be adequately protected. As a consequence lawyers will need to be well informed
about issues such as attachment, both from a theoretical but also a practical assess-
ment perspective. It will be helpful for individual experts to set out general state-
ments of their expertise and usefulness or relevance to different issues in care
proceedings.
Mothers and babies

It is common knowledge that if the child is a newborn baby and the local authority
want to separate the mother and baby, a court will be loathe to allow separation
except as a last resort. In some cases, social services will argue they have enough
information about the parent, but in many cases the court will consider whether
there should be a further assessment, often in a residential unit, which allows the
case to progress without separating parent and baby.
A residential assessment might only inform the court about the parent’s
basic abilities to parent. However, some residential units are multi-disciplinary,
including a psychologist or psychiatrist to assess dynamics in the family. Ide-
ally any such assessment should use evidence-based tools to look at the parent’s
attachment and the dynamics of their relationship (see Farn¿eld and Holmes
2014).
If the parent successfully completes the residential assessment and the local
authority has not brought the case back to court to remove the child, then the plan
is likely to be gradual rehabilitation of the child and parent in the community. The
main issue at the end of the proceedings will be under what type of court order
should social services need to share parental responsibility with the parent. If, on
the other hand, the residential assessment throws up more concern, it is likely the
local authority will bring the matter back to court with a view to separation of the
child and parent.
At this point the issue of separation and its impact not only on the child but also
on the parent’s ability to ¿ght the case is important. Although, as the law stands,
if a child is removed at an interim stage, that fact is not supposed to prejudice the
parent’s case to seek the child’s return, the reality is that, in practical terms, it is
far more dif¿cult to get a child back from foster care than if the child were never
separated from the parent.
How can an assessment of attachment assist?

An assessment of attachment could be very useful at this interim stage, to inform
the court about the parent’s ability to become a ‘secure base for the child’. In
light of the move towards reducing the length of care cases, it is likely lawyers
representing parents or children will need to be considering the instruction of an
expert to assess attachment at a very early stage in the proceedings. Such assess-
ments should include an Adult Attachment Interview (AAI) with the parent and a
mother–infant assessment, such as the CARE-Index with mother and baby. Issues
of attachment should also be considered in wider terms of a child’s extended fam-
ily. The issues of assessment and the protocols that can be used are considered
in The Routledge Handbook of Attachment: Assessment (Farn¿eld and Holmes
2014).
There is no doubt professionals and parents will have to not only think of expert
assessments, but also give early consideration to other family members who might
be able to care for the children to avoid their being removed from their family
home. In my view it is important for any assessments of extended family members
to be looked at inclusively, rather than exclusively, in other words, to look at the
family holistically and systemically rather than from a ‘them and us’ scenario (see
Dallos, in Farn¿eld and Holmes 2014).
Court proceedings
In relation to the process of court proceedings, it is fair to say they are considered
in two stages: the ¿rst stage is fact-¿nding and agreeing the issues regarding the
threshold criteria (has the child suffered, or are they at risk of suffering, signi¿cant
harm), and the second stage, or welfare stage, considers what ¿nal orders should
be made and decides where the child should live and with whom he should have
contact. In many cases, these two stages evolve together, although before the case
can proceed at all, a court must be satis¿ed that the grounds for intervention in
family life are met, i.e. the interim threshold is met.
The legal test for threshold is set out in ss 31 and 38 of The Children Act 1989,
the interim test being based on reasonable grounds that the child is at risk of signif-
icant harm caused by the parent, whereas the test for a ¿nal care order must show
that the child has suffered signi¿cant harm, or will in the future if not removed.
These tests are far more complicated and take up much of the court’s time. In my
experience there are not many cases where threshold is not met, and the court then
goes on to decide what is in the child’s best interests in the future.
Interestingly, and perhaps uniquely in this country, much of the time spent at
court revolves around discussions outside of court, where lawyers thrash out the
issues and agree the way forward in a case. It is only the issues on which the par-
ties cannot agree that are argued and determined by the court. There are differing
views about the bene¿t of lengthy discussions outside of court. There is no doubt
it saves court time, and can avoid unnecessary conÀict, but it can sometimes result
140 Mary Ann Harris
in the parents of the child being left out of the loop – as the discussions are usually
conducted by lawyers only.
The use and abuse of expert witnesses

Judith Mason, Professor of Socio-legal Studies, School of Law, Bristol University,
in an article entitled ‘The use of experts in child care proceedings in England and
Wales: bene¿ts, costs and controls’ (2010), analysed data from two studies in par-
ticularly looking at why there were so many experts instructed in care proceedings.
She argues that the focus of care proceedings is more on what will happen in the
future rather than what has happened. In other words, whether threshold is met is
not the main focus of care proceedings, but what is the best outcome for this child.
She also points out that, based on her research, many of the issues in care pro-
ceedings, including issues of assessment, ‘were largely negotiated by the parties’
lawyers, not determined by the court’. I would agree with her analysis that, in
many cases, the negotiations outside of court will often result in an ‘agreed’ list
of directions to be presented to the court for its approval. Of course, there are the
hearings where issues cannot be agreed or negotiated, and have to be scheduled
for a contested hearing before the court, whether that issue is the appointment of
an expert, or other issue.
However, a full and adequate assessment process requires both time and exper-
tise. In this jurisdiction, a court has to be persuaded that the instruction of an
expert is ‘necessary’ rather than ‘reasonably required’, and recent court decisions
show that the bar for ‘necessary’ is set very high.
Further, in recent years the Ministry of Justice, which at the end of the day pays
a proportion of an expert’s fee, has set prescribed rates of pay at increasingly low
levels. Some experts will work at these rates, however there is concern that many
professionals will not, resulting in a loss of the necessary expertise required to
ensure that the needs of children in care proceedings are best met.
The lawyer’s dilemmas and confusions in public law

Lawyers will need to think carefully about the particular expert to be instructed,
but also about the questions to be addressed. Generally speaking, it is common
practice for such letters of instruction to be agreed by the parties outside of court,
and there are precedents for standard letters and questions for each type of expert
which are well known and used in care proceedings.
If the lawyer is acting for a parent, it can be more dif¿cult to frame the ques-
tions, and it is important to ask about support and therapy for the parent. If, on
the other hand, the lawyer is acting for the child, one’s goal is always to have in
mind what is best for the child, and therefore usually the more information/expert
assessment, the better.
In many cases, where I have represented children, the Children’s Guardian (the
social worker appointed by the court to represent the children’s welfare in the
court proceedings) may raise attachment or behavioural issues and will express
the view that an expert on attachment is necessary. Such an opinion might be
based on behavioural issues the Guardian has observed or read about in social
services documentation, and which the Guardian considers an expert is necessary
to assess.
It is probable that such an assessment would provide the court with a more
detailed and sophisticated opinion than can currently be provided by most social
workers; one which should assist in analysing and identifying the needs of the
child in the immediate and long term. This assessment would also assist in con-
sidering what type of therapy would be helpful for the child and, possibly, the
parent.
I think attachment assessments are particularly helpful in allowing for a deeper
understanding of the members of the family and thus looking at the bigger picture.
This allows the identi¿cation of the types of support from which parent and child
might bene¿t, whether the child is to remain at home, or, if the child is to remain in
care, looking at continuing contact, and whether a particular therapy will help the
child overcome or address any insecurity in his or her attachment style.
As I understand it the early attachment style of the child will continue through-
out adulthood, unless altered by loss, trauma or abuse, and if it is an insecure
attachment, that will continue throughout adulthood, having an impact on per-
sonality, behaviour and relationship patterns. But the issues and processes are
complex.
A case example
Why did David continue to wish to see his abusive father?
About 10 years ago I represented a teenage boy who was separated

from his family at the age of 15 years – he had been sexually abused
by his father from a very young age, but had not told anyone. The
mother had left the home when the child was very young, so the father
was the main care giver. The child went to the police to report the
abuse at the age of 15, and social services became involved. The father
was arrested, convicted of sexual offences against the child, and sent
to prison for several years. The issues in the care proceedings were
narrow. The father admitted the abuse and was ruled out as a carer.
The mother was assessed after it was decided she did not know of the
abuse, and the child eventually went to live with his mother. What I
thought was interesting, was that the child insisted he wanted to visit
his father in prison and stay in contact with him. This was against social
services’ and the Children’s Guardian’s advice.
142 Mary Ann Harris
What does that say about this child’s attachment with each of his parents, a
mother who effectively abandoned him as a young child, and a father who sexu-
ally abused him from a young age? The child’s contact with the father would
undoubtedly be supervised, but what would happen when he became an adult?
Was the child’s attachment with his mother irretrievably broken down, or could
that be improved? I do not know, but in my mind it poses interesting questions
about an assessment of each individual’s attachment and how that might have
assisted in understanding this child’s relationship with his parents. Could it have
provided a better understanding of this child’s long-term needs? Might it have
suggested how the attachment to the mother could have been improved, or helped
to resolve in some way the issues with the father?
Such apparently paradoxical behaviour in children is not uncommon. I have
been involved in many cases over the years where a child has been abused or
neglected and who is then separated from their family and placed in foster care,
and as they get older, the child seeks out advice to be reunited with their family.
These long-term issues for children in care, and their relationships, if any, with
their families are not well served in care proceedings, perhaps necessarily, and
can be sadly minimised by social services in the planning for the child on leaving
care.
The short- and long-term views of remaining in care – the

role of attachment assessments
In my view, assessments in care proceedings tend to focus on short-term issues,
even when considering what is in the child’s best interests long term.
There can be a lack of consideration given to outcomes in the longer term in
court cases, although perhaps it depends on what is meant by long term. When
I ¿rst became involved as a lawyer in care proceedings, there seemed to have
been more argument about balance of harm issues, balancing the harm suffered
at the hands of the parent with the harm likely to be suffered in care. Of course,
the court’s monitoring role is extremely limited in time, and once the care plan
has been approved by the court, and the case ¿nished, neither the court nor the
Children’s Guardian are involved in that child’s life, unless someone brings the
matter back to court. I have seen so many children and young people in long-term
foster care who desperately seek out being reunited with their families, knowing
the abuse or harm suffered but still choosing their families as soon as they are old
enough to realise they can do this.
These older children in care have fewer options and are heavily reliant on
good social work practice and being listened to. There are so few avenues for
these young people to change their lives, so many run away, only to be found and
returned to the foster placement. Some will seek legal advice, often in despera-
tion having failed to make the social worker listen and getting nowhere with their
Independent Reviewing Of¿cer (IRO) who has been allocated to them by social
services. Such cases, in my view, are desperately sad, as these are children who
have already suffered abuse or neglect, have been separated from their families,
and who then suffer poor care or treatment in the care system, and whose voice is
not listened to. In one such case I dealt with, it took four months to even get con-
¿rmation from the local authority that the child was in their care (which triggered
my ability to obtain legal aid to represent the child) and it then took another few
months to get speci¿c responses to questions about the child’s living arrangements
in care and ascertain the local authority’s views on contact with the parents.
You might think the solution would have been simply to make an application
to the court to discharge the care order. The reality is that information gathering
to assess the merit of the case, and then obtaining legal aid, are the hoops through
which one has to jump before making such an application. Social services would
have to assess the family fully, including their attachment patterns, before simply
releasing the young person back home and this all takes time. This may be an area
where expert guidance as to attachment would be helpful, particularly to inform
any work that might need to be done within the family, including support and
therapy.
Julie aged 13
In one case where I acted for a 13-year-old girl who was subject to a
care order and placed in long-term care (along with her siblings), the
court refused the parents’ application to discharge the care order as
it determined that the parents’ situation had not significantly changed
since the original care proceedings. The child desperately wanted to
return to her parents’ care. She was represented by me through a
Children’s Guardian. At the final hearing, the Guardian did not sup-
port the child returning to her parents’ care, and the court decided the
child was not competent to represent herself (i.e. without a Guardian).
Although the court took into account the child’s wishes and feelings
it decided there was no merit in the parents’ application. The child,
therefore, remained in the foster placement. Subsequently, the child
ran away, on several occasions, each time to be returned to the fos-
ter placement. Eventually, what changed was a change of position by
social services. Through negotiations with the leaving care team it was
agreed the child could return to her parents’ care with a support pack-
age, and while remaining under a care order.
This was an unusual outcome, but the other option was that this
young person would probably have continued to run away, exposing
herself to harm and possibly leading to the local authority applying for
a secure accommodation order.
144 Mary Ann Harris
The point I wish to make in this regard is that the practicalities or reality of
whether or not a care plan will work in the long term are extremely important, and
the monitoring of children in long-term care, although subject to precise proce-
dures and regular review, would bene¿t in my view from the inclusion of a truly
independent monitoring system. The role of the IRO needs to be rede¿ned so that
they are independent of social services’ pressures as to how well they perform
their functions.
Lawyer’s dilemmas in private law

In public law proceedings, the court’s focus is on child protection and determin-
ing what is in a child’s best interests. In contrast, in private law proceedings the
emphasis is on conciliation, mediation and trying to achieve a compromise in the
child’s best interests. Thus in private law, child protection issues, although rele-
vant, are not the forefront consideration. These cases are about competing parents
who disagree about some issue or issues regarding their child’s upbringing.
When I ¿rst started practising in this area of law, I recall a robust judge who
would take the opportunity at the ¿rst conciliation hearing to shout at all parties
in the courtroom, including the parents, appearing quite threatening and unpleas-
ant, telling them that if they did not sort out their differences about their children,
they would have to accept him making the decision for them. In many cases this
worked, at least temporarily, and the parents would walk away from court having
reached some sort of compromise. I am not suggesting this is the solution to most
cases, but I think it highlights the essential difference in public law and private
law cases.
Of course, if there are child protection issues in a private law case, for example
domestic violence or other abuse, and where there has been social services
involvement with the family, the court will ask social services to carry out an
assessment and consider if there is a need for them to intervene by way of public
law proceedings.
Cafcass (the Children and Family Court Advisory and Support Service which
looks after the interests of children in family proceedings) would also be involved
at the onset of proceedings. It is not usual to have psychiatric or psychological
assessments of children in private law proceedings as a general rule. However, if
the issues are complex and demand the need for an expert, particularly if the child
is made a party and is separately represented, this will be considered by the court.
I think it likely in the current climate of change, in private law proceedings, the use
of experts will become more scarce and the use of compromise more prevalent.
There are also further restrictions on obtaining legal aid, public funding, for a
parent to be represented in private law cases, and it is anticipated this will result
in more litigants in person. If there are child protection concerns, or domestic vio-
lence, legal aid will be available, and the case will follow a different process, with
a fact-¿nding hearing before consideration of the issues in dispute. There is no
doubt some private law cases can be as complex as their public law counterparts,
and that the use of attachment assessments in particular could play an important
role in examining the nature of the child’s attachment to each parent, and the long-
term consequences for that child.
A lawyer’s confusion
In my experience there can be considerable confusion about the importance, and
implications of, attachment assessments as different psychologists and psychia-
trists seem to analyse the issues differently. Indeed they may even be using the
term ‘attachment’ differently and might not be in agreement that the processes
they are observing and describing are indeed attachment at all. This can lead to
considerable confusion in the minds of lawyers and judges. These issues are dis-
cussed in The Routledge Handbook of Attachment: Theory (Holmes and Farn¿eld
2014). It is important that assessors use terminology that is consistent and clear.
The way ahead

It is a daunting task to endeavour to ensure that all children who are subject to
court proceedings are not only protected from harm, but also that their basic human
rights including the right to family life are protected. Social work practice needs
to be on top form to ensure good cooperative working practice with families, and
in those cases where court intervention is necessary, appropriate expert evidence
will continue to be available to assist the courts in making long-term decisions in
children’s best interests.
ReÀecting on the dif¿culties that lie ahead, with reforms designed to reduce
delay and cost, it would be helpful to put in place safeguards to ensure a more
transparent process pre-proceedings, where the costs of the expert professionals
involved are borne by the local authority. This would necessitate a shift in atti-
tude of all professionals involved to include training of those professionals (the
former ‘experts’) working with local authority teams and more extensive supervi-
sion and training of social workers, and for all those involved to actually work
together, otherwise pre-proceedings assessments will continue to be challenged
subsequently in the court proceedings.
Some local authorities do better than others in regard to their attitude and prac-
tices towards working with families. I have come across differing approaches
working with a number of different local authorities. As a lawyer, I suspect I do
not fully understand the implications of attachment and separation issues, how-
ever, I have seen such assessments signi¿cantly assist the court in making the right
decisions for children.
These are such dif¿cult and complex issues which will continue to bene¿t from
the input of an expert focused on the child’s needs and, in particular, his or her
attachment needs.
146 Mary Ann Harris
References
Farnfield, S. and Holmes, P. (eds) (2014) The Routledge Handbook of Attachment: Assess-
Holmes, P. and Farnfield, S. (eds) (2014) The Routledge Handbook of Attachment: Theory,
Mason, J. (2010) The use of experts in child care proceedings in England and Wales: ben-
efits, costs and controls, Annual Legal Research Network Conference 2010.
Munby, J. (2013) View from the President’s chamber: the process of reform, Family Law,
May 2013.
Chapter 9
The applications of
attachment theory in the
field of adoption and fostering
Jeanne Kaniuk
Introduction
Attachment theory has a special place in adoption and fostering as it provides a
conceptual framework for the practitioner who is grappling with major decisions
about the future of vulnerable children. It offers a scaffolding for thinking about
the children’s experiences, the impact of these experiences on the children’s inter-
nal expectations of parental ¿gures and information as to how best to support both
the children and the substitute parents who are charged with their care.
The signi¿cance of an infant’s attachment to her primary caretaker (usually
mother) was ¿rst recognised by John Bowlby, who understood that attachment
was a basic biological drive, as signi¿cant for the infant’s survival as nourish-
ment, and that separation from the mother was potentially catastrophic, especially
if there was not a substitute carer available (preferably one already familiar to the
infant) who could provide responsive care, accepting the infant’s distress (Bowlby
1988).
Later work by Mary Ainsworth enabled the development of a system for clas-
sifying the types of attachment of infants to their mothers based on the care she
provided, particularly her responsiveness to their communications, both positive
and negative (Ainsworth et al. 1978). When these attachments to the primary
caregiver are disrupted, particularly if there are repeated disruptions accompa-
nied by the absence of an available and sensitive substitute caregiver, there may
be far reaching consequences for the infant’s later emotional, psychological,
cognitive and social development. Alternatively, if the infant’s primary care-
giver is neglectful or abusive rather than a reliable source of protection, the
parent who should be the source of protection and security is experienced as
threatening and the infant will have no strategy for keeping safe (Main & Solo-
mon 1986).
The consequences of attachment trauma are far reaching for the children who
are fostered or adopted. Many of these children have huge dif¿culties trusting the
adults with whom they are placed and, rather than expecting them to be essentially
nurturing and attentive, anticipate hostility and neglect. Children who have been
abused will have these experiences ‘hard wired’ into their nervous system, as it
148 Jeanne Kaniuk
is essential for survival to learn from dangerous situations and to be alert to avoid
them in future. Thus these children are often slow to develop trusting attachments
to their new parents even, or particularly, when they offer benign caregiving that
runs counter to their previous experience (Steele et al. 2007).
The child’s negative expectations require enormous reserves of hopefulness
and perseverance on the part of the adopters or other long-term carers, as well
as the professionals who are charged with the responsibility for planning for the
children’s future care. It is an understandably complex task, which is open to mis-
interpretation and requires careful assessment to ensure that communications from
the children to their new parents are understood, and that the parents who might
be struggling to care for children are not misjudged when they express frustration
and possibly despair. There is often a tendency to seek someone to blame when
plans for vulnerable children prove dif¿cult to realise, and the adopters might be
the ones who are seen to be failing when their attempts to nurture the children
placed with them are rejected. In turn, the adopters might be tempted to give up
and reject the children.
The context for contemporary adoption and

fostering
Children in foster care need stable placements where they can experience attach-
ments to carers who are attuned to their dif¿culties. Some of these children are in
short-term care and may return home, or be placed with members of their extended
family or be adopted. Others are in long-term care. Of 67,050 children in England
who were looked after on 31 March 2012, 50,260 were in foster placements. This
is a Àuctuating population, with very different leaving care pathways. In 2011–12,
27,350 children left care but 28,220 started to be looked after. Of those who left
care 10,160 returned home, 2,620 became subject to Residence or Special Guard-
ianship Orders, 3,720 moved to independent living and 3,450 were adopted (DfE
2012).
There are no ¿gures relating to the number of children in long-term foster care
whether designated as such or by default, but they might be in excess of 20,000.
These are children for whom adoption is not an option for a variety of reasons
such as: the child’s age (age at placement is the most signi¿cant factor with regard
to whether children are likely to be placed for adoption); the nature of the child’s
psycho-social dif¿culties; the child’s status as an asylum seeker. In the last case
the child might be emotionally attached to parents and others in the home country,
who are prevented from offering care because of social strife in that country.
This represents a major challenge for local authorities charged with their care,
and for the social work staff to ¿nd appropriate placements for these children, who
will have suffered similar trauma as the general population of children who need
adoption, but might be older or more emotionally damaged.
By de¿nition, adoption practitioners are concerned with children who have
suffered separation and whose attachments to their birth parents are insecure or
Attachment theory in adoption and fostering 149
disorganised. It is sadly not uncommon for them to experience changes in place-

ment leading to further disruptions of attachment while in care.
If a child comes into care at birth and is made the subject of care proceedings,
ideally she should be in a stable foster placement where the foster carer will tem-
porarily become the child’s primary attachment ¿gure until her future is decided
by the courts. Inevitably this means that the child will suffer a broken attachment
and will have to make a new attachment with her adoptive parents or re-establish
a primary attachment with her parent/s. Some children suffer several changes of
foster carer and thus broken attachments before being permanently placed, which
makes the process of building an attachment even more dif¿cult for the child.
The population of children who require adoption in the UK generally come
from backgrounds of multiple disadvantage with parents who might be substance
abusers, have mental health problems, suffer from domestic violence, and/or
where the children might be abused or neglected or both. These children have
often experienced adversity pre-birth (26 of 41 infants studied by Ward et al.
(2006) were born with neonatal abstinence syndrome). In addition they may have
genetic vulnerabilities.
Within the care system there is a risk of multiple placements or of repeated and
unsuccessful attempts to return the child home, and many children experience
protracted delays during the court proceedings to determine whether they are to
return to the care of parents or extended family members or to be adopted. All
these factors compound the likelihood of damage to the infant or growing child’s
capacity to build attachments.
In the UK the number of children who are relinquished by their parent/s for
adoption and adopted at less than 12 months has dropped dramatically. In 2011/12,
there were just 70 adoptions of children under 12 months of age out of a total of
3,450 adoptions. The average age was 3 years 8 months. Thus the vast majority
of adoptions in the UK involve children who are older at placement and may have
experienced considerable early trauma. The current UK government has intro-
duced an Adoption Reform Programme which aims to reduce the length of court
proceedings in care cases to 26 weeks and to ensure that children who cannot
return home are adopted at younger ages to maximise their opportunity for devel-
oping secure attachments (Children and Families Act 2014: section 14).
In the USA there is also a tradition of placing children from the care system,
who have experienced deprivation and trauma, into adoptive families. The manda-
tory imposition of an adoption plan in the USA has resulted in over 50,000 adop-
tions a year but over 100,000 children wait for an adoptive home. Many of these
children are over the age of ¿ve, including a signi¿cant number of adolescents.
A different model of adoption involves inter-country adoptions where some of
the issues are similar, but where there are also signi¿cant differences with regard
to greater uncertainty about the child’s background, why she needs to be adopted
and her birth parents’ circumstances. There is usually a less full and reliable medi-
cal history. Step-parent adoption is also possible. This chapter does not address
either step-parent or inter-country adoption.
150 Jeanne Kaniuk
The task of professionals involved in placement

planning
The theoretical framework provided by attachment theory can provide scaffolding
for the social worker engaged in the following tasks:
• understanding the needs of children: how the child’s experience of care and
of broken attachments and placement moves has inÀuenced her expectations
of parental ¿gures which informs the search for adopters or a foster family;
• providing a supportive relationship to the child which is marked by the reli-
able and ongoing involvement of a familiar adult who takes responsibility for
talking to the child in an age-appropriate way about the plans for the child,
preparing the child for any moves, and ensuring that the child has a record of
the signi¿cant people and events in her life (life story work);
• assessing potential adopters or foster parents;
• matching the strengths of adopters with the needs of children;
• foster placements may be made in an emergency, and there may be little choice
of family, but insofar as possible, matching the foster family’s strengths with
the child’s needs, and providing support to the foster family;
• supporting both children and new parents as well as the foster family through
the period of introductions; i.e. the move from a temporary placement to the
permanent placement – whether foster care or adoption;
• supporting families post placement, including advising the new parents/
carers on behaviour management likely to reduce the child’s defensive behav-
iour, and to allow attachments to develop;
• therapeutic interventions or referral for more specialist support, for example
from child and adolescent mental health services.
This chapter cannot consider all these tasks and will concentrate on:
• assessing attachment in children;

• understanding the child’s needs;
• supporting the child;
• assessing adopters and foster carers;
• supporting adopters, carers and children.
Assessing attachment in children

Professionals working with children needing substitute family care can be greatly
assisted by a formal assessment of the child’s attachment status. There are a
number of such valid and reliable assessment tools. These are discussed in the
Routledge Handbook of Attachment: Assessment (Farn¿eld & Holmes 2014). This
chapter discusses those tools on which work familiar to the author is based.
The Strange Situation procedure (Ainsworth et al. 1978) is not used very often
in adoption and so has been omitted.
Story stems
Older children’s attachments have been assessed using narrative story

stems, and Jill Hodges, a consultant child and adolescent child psycho-
therapist has developed a set of story stems for use with children who
have suffered abuse and neglect. Narrative stems are a useful tool for
exploring children’s internalised expectations of parental figures as
opposed to other assessments which measure external aspects of the
child’s functioning. This approach can be used with children who are
verbal – approximately aged three or four to nine years. The story
stems draw on children’s unconscious expectations of parental figures
– their Internal Working Models (IWMs) – by inviting the children to
supply the ending to 13 story stems which all pose a dilemma of some
sort in terms of the outcome. However, they do not ask direct ques-
tions about the child’s own experience and are therefore less threat-
ening. The child’s responses are not taken literally as a concrete repre-
sentation of the child’s actual experience, but as indicating the quality
of that experience. The worker illustrates the story with toy figures
representing a family or toy animals, depending on the story, and the
child’s completions are videoed, so that the assessment of the story
stems can use both verbal and non-verbal cues. For example, there is a
story about a child (boy or girl depending on the sex of the child being
assessed), who knocks over a glass of juice at the tea table. The chil-
dren’s story completions may range from mother mopping up the juice
and simply saying to be a bit more careful next time, to bizarre events
and extreme punishments. Some children who feel anxious about the
scenarios, which do all pose a dilemma, are unable to complete a story
and disengage (refuse to complete the story).
Story stems have been used in a longitudinal research study explor-
ing the way attachments develop between older children (aged 4–8
years at placement) and their adopters. All of the children had come
from backgrounds of adversity and were assessed soon after place-
ment, after one year and again after two years (Hodges et al. 2003).
The research demonstrated that all the children developed significantly
more secure themes within their narratives over time; for example,
an increase in parents helping children and being aware of the chil-
dren’s needs. However, all the children also retained a significant level
of insecure themes; for example, representing parents as rejecting
and aggressive. These findings suggest that past experiences are not
152 Jeanne Kaniuk
simply wiped out by later, good experiences of attuned care. The

adopters’ task is one of actively disconfirming children’s negative IWMs
of attachment by provision of attentive care, and the daily lived experi-
ence with adults who are attentive and responsive builds up a compet-
ing set of expectations (IWMs) in the child’s mind which, over time, it
is hoped will become increasingly strong and gradually outweigh the
negative expectations. Nevertheless these children will remain vulner-
able, especially at times of change and transition, and their parents will
need to remain vigilant and supportive.
Some clinicians within children’s mental health teams use story stems as a diag-
nostic tool which can also be used to provide detailed, focused advice on parenting
strategies to a parent. This is discussed below.
Understanding children’s needs

Children who are in the care system depend on a team of adults working together
who will mediate the external world and ensure that the child is protected from
danger. It is the foster carer’s responsibility to provide day-to-day care, physi-
cal nurture and also responsive, sensitive care. However, carers might be eager
to help a child catch up and meet their milestones and encourage the child to
learn and to become independent rather than attending to the de¿cits and gaps
in their early experience to give them a ¿rmer emotional foundation on which to
build.
The child’s social worker holds responsibility for ensuring that plans are made
for his permanent care, whether at home, with members of the extended family, or
via adoption. The social worker needs to work closely with the foster carer and the
child’s parents to ensure that plans are made and implemented thoughtfully and
without undue delay, and that all parties are supported through the process. The
social worker also has the responsibility of working with the child to ensure that
she understands the plans and has an opportunity to express her own views and to
be heard. This does not mean giving the child responsibility for adult decisions,
but treating children with respect and ensuring that they are not left in limbo. This
can only be achieved by a worker who takes time to get to know the child and
develop a relationship of trust.
Kenrick (2000) has written an account of psychotherapy with children who
have been subjected to repeated separations. She comments: ‘some of our most
vulnerable children already with unprocessed trauma, are subjected to further
trauma from repeated separations while in the care system. This often reactivates
early trauma and too often ensures the failure of the next placement.’ She goes on
to say that children who lack a benign internal representation of a parental ¿gure
to support them, as well as lacking a reliable caregiver in the external world,
‘may . . . develop defences of not thinking or of Àight to action against experi-
ences that it would be hard for anyone to comprehend’. Children who are unable
to think, or who take refuge in unthinking action are challenging to care for and
can be frightening to the adults, who need to be reminded that they are children
and that they are likely to be frightened themselves. It is often these children
who suffer repeated moves between foster families and breakdowns in adoption
placements.
The move to an adoptive family

It is important to recognise that when children in foster care have to move to an
adoptive placement, this will be experienced as another disruption, and is likely to
evoke resonances of earlier moves and a sense of insecurity. This will be true even
for a child who has had a relatively stable period of foster care, where he came to
feel safe. Such a child may be able, in the course of time, to use his experience of
a relationship with an attentive caregiver as the basis for taking the risk of build-
ing a new attachment, but the scars of repeated moves and broken attachments
are likely to have an ongoing impact. Adopters should be prepared to anticipate
that the child they hear about in the foster home is likely to behave differently
for a period, and will need support and reassurance to help them to settle and feel
safer. Alternatively there are children who have been in foster families where the
adults have made few demands on them, and in turn the children have responded
by ‘blending in’ without making demands as a strategy for remaining ‘safe’ in an
uncertain world. These children are often described as not presenting any manage-
ment issues in their foster home.
Given the traumatic backgrounds from which children who are removed from
their families via the courts generally come, it is unlikely that they are so well
adjusted that the fact that they do not present overt problems is an indication of
their positive mental health. It is more likely that many of these children are pre-
senting a ‘false self’ which will not be possible to maintain in an adoptive family
where the dynamics are very different, and the new parents are keen to build a
caring relationship. Children in such a situation are expected to relate to their new
parents in a way that demands skills in building relationships which they might
never have had the opportunity to develop. Children who have been abused will
frequently associate the intensity of intimate family relationships with danger, and
may respond in the unthinking ‘Àight to action’ described by Kenrick. It is impor-
tant to recognise what is happening, and not to assume that it is the lack of com-
mitment or warmth on the part of new parents that is responsible for the child’s
reaction. It is more likely to be that the child is re-experiencing fears and trauma
associated with the past, and will need the adults to remain calm, not to over-react
and panic, to convey that they can think about the child’s feelings and anxiety, and
that the child is safe in his new home.
154 Jeanne Kaniuk
The need for a coherent life story

Children who have suffered separations and moves often lack a coherent nar-
rative of the signi¿cant events of their life and reasons why they needed to be
adopted (or fostered). In order to process the feelings associated with the separa-
tions and the events which preceded their removal from home, the child will need
an explanation that is factual and age appropriate. Loxtercamp (2009) has worked
extensively with adopted children and writes about his experiences of working
with angry adopted children who display intense hostility towards their adopters.
He suggests that often social workers have attempted to protect the children from
knowing that their birth parents abused or neglected them, providing bland reas-
suring accounts of the reason for their adoption. These reassurances do not chime
with the child’s non-verbal memories of intense fear and distress which remain
unprocessed because they have not been understood and acknowledged. Since the
child has no understanding that the experiences that have left them dealing with
this distress are located in past relationships, they project their despair and rage on
the adopters, holding them responsible for their unhappiness. Loxtercamp makes a
strong plea for children to have an honest account of the reasons for their removal
from their birth family in order to allow them to process the residue of feelings
and inchoate memories.
Based on her experience as a post adoption worker, Joy Rees (2009) has devel-
oped an approach to Life Story Books (LSBs) which encourages the child’s
attachment to her adoptive parents, while giving an age-appropriate and truthful
account of the signi¿cant events of the past that can be developed and elaborated
as the child grows and is able to comprehend the complexity of past events. Rees
suggests that adopted children’s LSBs should not start with the child’s birth and an
account of her family of origin as has been traditional, but rather with her present
(adoptive) family, con¿rming that she belongs there and is loved. The story then
moves on to acknowledge that this has not always been her family, and gives an
account geared to her age and understanding which is nevertheless honest. Choos-
ing the words to convey a dif¿cult story which is clear and developmentally within
the child’s understanding and which the adopters feel comfortable in sharing and
discussing is important.
Rees stresses that it is not appropriate to give lengthy descriptions of the birth
parents’ own dif¿culties, which might leave the child feeling burdened with con-
cern. The process of unpicking the dif¿culties experienced by the previous gen-
eration is a task for a later developmental stage.
Supporting children
Children in adoptive or long-term foster placements are, by de¿nition, in an envi-
ronment which it is hoped will provide 24/7 reparative experience. This is the
most radical treatment option available. However, many of these children will also
require professional intervention at times. It is important to ensure that children
experience continuity of their social worker throughout the period of moving and
settling into their new family as she acts as a bridge between past and present and
supports them in processing the losses involved as well as the task of settling into
their new family.
Story stems can be used in a therapeutic way either before the child is placed
or once the child is in placement. A careful analysis of the themes that emerge
allow an individualised map of the issues which are particularly sensitive for that
child to be constructed, enabling the worker to assist the new parents to devise
strategies to discon¿rm that child’s negative expectations and to augment the
positives. For example, a child might have no expectation of parents who notice
when he is hurt. Such parents might be advised to maximise any opportunity to
show the child that they are indeed aware when the child has a fall or scrapes his
knee for example, and provide overt comfort. Another child might have expe-
rienced criticism and mockery of his efforts, and might prefer to destroy any
achievements such as drawings rather than risk ridicule. Such children might
need particular parenting strategies in order to approach below the child’s ‘radar’
for detecting and rejecting praise, and accustoming them to accepting that they
can be appreciated, thus gradually building their self-con¿dence. For example,
by ensuring that any small achievement is noticed and celebrated – not waiting
for major achievements, but thanking the child for coming to the table, or for
shutting the door when asked.
A number of child and adolescent mental health services (in the UK CAMHS)
employ clinicians who are trained to administer and evaluate story stems. If local
authorities are commissioning services from their local CAMHS for looked-after
and adopted children, they could specify such assessments as an important method
of understanding the challenges posed by some children, and of supporting their
parents.
Assessing adoptive parents

The training of child care social workers in the 1960s took cognisance of Bowl-
by’s teaching, which emphasised the importance of attachment and the impact
of separation on babies. In the 1970s the specialist training of child care, mental
health and welfare social workers was abandoned in favour of a generic model of
training and service provision, at the same time as attachment theory and a psy-
chodynamic model of practice were overtaken by an empowerment/rights-based
approach. Nevertheless the assessment of adopters and foster carers retained a
focus on what parents bring to their role from their own experience of having
been parented, along with an understanding that healthy psychological adjustment
requires that past losses (including the experience of infertility) have to be pro-
cessed if they are not to remain as ‘ghosts in the nursery’ affecting the ability to
build new attachments on a healthy emotional basis (Fraiberg et al. 1975; Steele
et al. 2008).
156 Jeanne Kaniuk
The Adult Attachment Interview

The development of the Adult Attachment Interview (AAI) by Mary Main,
enabling the classi¿cation of the attachment status of adults, provided a theoreti-
cal validation of what had been developed and retained as practice wisdom.
The AAI is a semi-structured interview in which the interviewer asks a series of
questions about the subject’s experience with his mother and father as a child, ¿ve
adjectives to describe the relationship with each of his parents (plus an example to
illustrate the adjective); to whom he would turn if upset or hurt; any experiences of
loss or separation, and also of abuse. Any later experiences of supportive relation-
ships are also explored. The respondent is also asked what he makes of those expe-
riences in retrospect, and whether/how they have shaped the person he is today.
The assessment of the adult’s attachment is made on the basis of the qual-
ity of the narrative, rather than on whether the history of childhood reÀects a
secure attachment, or experiences of loss and trauma; i.e. it is not what happened
but how the subject thinks about it now, in the present, that is important; the
respondent’s ability to assume the perspective of their parent and understand why
they acted as they did, and their ability to reÀect on the past in suf¿cient detail to
convey a sense of something real rather than bland generalisations. The qualities
upon which the classi¿cations are made include accounts which are either lack-
ing in any detail to con¿rm generalised statements, or alternatively, overly long,
involved and delivered with a sense that the issues are still live and unresolved
for the respondent.
Adults who are rated as ‘Autonomous’ give an account of their childhood
which is clear and balanced, reÀecting both positive and painful experiences, and
not idealising their parents, but acknowledging their weaknesses as well as their
strengths. The respondent is able to evidence his descriptions of his parents and
experiences by giving examples that are vivid and convey something real. Their
stories convey a sense that the subject is ‘psychologically minded’ – i.e. they can
see other people’s points of view, and in retrospect make allowances for their
parents’ shortcomings. They are truthful, and the detail provided is relevant to the
point being made. Adults whose interviews are classi¿ed as ‘autonomous’ might
have experienced a good quality of care from their parents so they would have
been assessed as ‘securely attached’ as children. Alternatively they might have
experienced considerable adversity which they have subsequently processed and
have consequently developed resilience so their interviews are classi¿ed as having
‘earned’ autonomous status. Resilience is the capacity to deal with adversity and
to persevere in the face of the dif¿culties and challenges that life might present.
It is based on having had good enough experiences of being cared for, having
learned to deal with and process loss and other dif¿cult experiences. It can also
be the result of later experiences of therapy or of a relationship within which the
person could con¿de about their past and have support in thinking about it and
making sense of it such that the person no longer feels responsible and is able to
make sense of why things happened as they did.
Adults who are rated as Insecure/Dismissing (minimising) have narratives that

tend to minimise the importance of relationships and the impact of separations or
losses. They might show dif¿culty in remembering relationships and may also ide-
alise their parents, despite some evidence of emotional dif¿culties in their child-
hood which are glossed over. They have dif¿culty in giving speci¿c examples to
verify their account of their childhood, and minimise the impact of their childhood
on their current functioning.
Adults who are classi¿ed as Insecure/Preoccupied (ambivalent) have narratives
that are long and confused. They give examples to illustrate their story, but they
tend to lack focus and to be lengthy and rambling. They might display high levels
of anger with their parents regarding incidents in the past. They might not convey
a clear impression of their childhood. There are references to childhood dif¿cul-
ties which still preoccupy them.
Adults who are rated as Disorganised or with Unresolved patterns of response
to past trauma or loss have narratives which refer to the past losses or traumas
in a way which conveys ongoing bereavement, guilt or irrational thinking about
these events. They may be similar to the dismissive adults described above, but
with this additional overlay. Adults who are in other ways rated as secure may
display this pattern in relation to recent bereavements or losses which are still
being mourned.
Steele and Steele (2005) followed up the transmission of patterns of attachment
from parents to their children in a study that measured AAIs of both parents dur-
ing pregnancy and followed up their children to middle childhood. There was a
signi¿cant correlation in attachment status, especially between mothers and their
children measured between the ages of 5–6 years and 11–12 years. A signi¿cant
correlation was also found between fathers’ AAI scores during pregnancy and
their children’s ability to make friends and manage conÀict with peers at age 10
years, perhaps indicating that in general the fathers’ inÀuence is more marked in
respect of relationships with the outer world.
Steele and Steele (2005) comment that
the AAI is a uniquely valid measure of competence in the parenting role, i.e.
pointing to the adult who will or will not be likely to meet the child’s needs
for care and love in the first year, and manage effectively most if not all later
parenting tasks appropriate to each developmental stage in the child’s life.
Kaniuk and colleagues studied the attachment pro¿les of adoptive parents and
the children they had adopted (Kaniuk et al. 2004). The majority of the children
showed signi¿cant increases in their secure attachment construct over the two
years. Those who did not were children who had adoptive mothers who had unre-
solved losses. In addition as long as children have one adoptive parent who has
autonomous attachment status, that child will make progress in developing more
positive expectations of parental ¿gures, more secure attachments and managing
better in the family and at school (Kaniuk et al. 2004). Having two parents with
158 Jeanne Kaniuk
autonomous status leads to better outcomes, but as long as one parent is able to
hold the child in mind and reÀect on their experience, rather than being preoccu-
pied with their own issues, the child is able to bene¿t.
Other researchers have developed different tools to assess adults’ attachment
status. Patricia Crittenden developed the Dynamic-Maturational Model of pat-
terns of attachment in adulthood. The Crittenden model has some signi¿cant dif-
ferences from Main’s AAI. These are discussed in Farn¿eld and Holmes (2014).
The AAI as a tool for assessing prospective adopters

Administering and scoring the AAI requires intensive training and there are a
limited number of trained professionals in the UK. A few adoption agencies have
brought the AAI in as either a standard aspect of their assessment, or to use in
cases where the standard assessment highlights concerns and a more in-depth
assessment is judged necessary. As far as is known, there is currently no study
of the outcomes of using the AAI in this way, nor of the costs of introducing this
as a standard aspect of assessments. There is also some evidence of a few agen-
cies who have attempted to use the AAI without having appropriately quali¿ed
personnel to undertake this work. This is plainly inappropriate. Nevertheless the
insights from the AAI and the longitudinal research referred to above do indicate
that the conceptual framework provided by the AAI has an important contribution
to make to the ¿eld. The thinking behind the AAI has been signi¿cant in con¿rm-
ing the importance of taking an account of the applicant’s childhood and relation-
ships with their parents (which is already a standard aspect of the assessment of
adopters). It also alerts the social worker to pay attention to losses suffered by the
applicant and to look for evidence that they have been resolved. The importance
of identifying applicants who can discuss both the positives and the negatives in
their childhood, and who give a balanced account of their lives which addresses
both the positives and the more challenging or painful experiences they have had;
people who demonstrate the capacity for reÀecting on relationships – the abil-
ity to see other people’s perspective and be empathetic – these are all important
qualities needed by a child who has suffered adversity, and who is likely to come
with expectations of parental ¿gures which are at odds with what is offered by the
prospective adopters. It is important to identify adopters with the capacity to be
reÀective rather than responding in a reactive and possibly angry way when the
child is rejecting or challenging.
It is important that social workers receive supervision where these qualities of
the prospective adopter can be considered. Building up experience of working
with adopters and using the framework provided by attachment theory and the
AAI, enables social workers to make better assessments, but will not replicate
the level of accuracy obtained from the AAI. Having said that, the longitudinal
research study where the adopters all completed an AAI before their child was
placed revealed that of the sample of 48 adoptive mothers, 70 per cent were rated
as having Autonomous attachment status, as opposed to 50 per cent in a com-
munity sample (i.e. people in a general population group) (Kaniuk et al. 2004).
Thus the assessment process had identi¿ed a signi¿cantly higher proportion of
these mothers as secure than would be in the general population. Only one of the
children had a placement which disrupted (broke down) over the ¿rst two years of
placement, although there was also a small group of children whose story stems
did not reÀect an increase in secure constructs over that period.
Given the very disadvantaged group of children and the severe levels of adver-
sity they had experienced prior to placement, this represents a huge improvement
in their emotional functioning and their life chances. As Rustin comments (Rustin
1999: 60): ‘Something new is always a possibility. Without this element of opti-
mism adoption could never have been invented as a solution to something that
has not worked. But the complexity of the task never fails to ¿ll me with wonder.’
It is suggested that part of the ‘magic ingredient’ which does enable the child to
have such a reparative experience lies in the transformative power of parental
devotion when it is freed from preoccupations arising from losses and unresolved
conÀicts and the adults are able to concentrate their energies on the child in a way
which values the individual child and respects his past as well as his present and
his future.
Recent theoretical developments have suggested that ReÀective Function (RF)
is the key factor which provides the mechanism whereby parents who have auton-
omous status (secure) inÀuence the attachment trajectory of their children. Ari-
etta Slade de¿nes RF thus: ‘ReÀective functioning refers to the capacity not only
to recognise mental states, but to link mental states to behaviour in meaningful
and accurate ways’ (Slade 2005). This concept clearly links to the ideas of ‘psy-
chological mindedness’ and the way adults describe previous losses, reÀecting
whether these have been processed and understood, or whether they are still in
some way ‘live’ and interfering with the individual’s ability to manage current
relationships.
Attachment Style Interview

The Attachment Style Interview (ASI) (Bifulco et al. 2008; Bifulco 2014) aims to
assess the strength of people’s current relationships and support network. It was
originally developed for research with depressed mothers. Training to use the ASI
is available in the UK, and a number of adoption agencies use it as part of their
assessment of prospective adopters. It does not attempt to ‘surprise the uncon-
scious’ in the way the AAI does, revealing the quality of people’s early relation-
ships in a way that they might not be consciously aware of themselves, but does
provide a framework for assessing current relationships in a consistent manner.
Assessing foster carers

Many of the same considerations apply to the assessment of foster carers as
described in the section regarding adopters, particularly where long-term fostering
160 Jeanne Kaniuk
is concerned. Carers need help to understand the children’s vulnerability and to

interpret behaviour that may be challenging or which might appear, on the surface,
to indicate that they do not require much individual attention. As described above,
the carers need to have the capacity to stand back and reÀect in order to understand
the child’s communications, and will need to discon¿rm the child’s expectations
which are likely to be of harsh or neglectful care. The carer will need support from
a worker who understands these complexities. This is at odds with the advice
foster carers are sometimes given, to remain emotionally distant in order not to
encourage the development of an attachment which might make it more painful
for the child to move. It is true that a child who is attached is likely to have more
dif¿culty separating from the carer, and moving to his new home; however, it is
more damaging to a child for the foster home to con¿rm his expectation that adults
do not hold him in mind and are not available to establish a relationship within
which the child can feel supported.
Both Dozier (2003) and Steele et al. (2008) have demonstrated that if children
are placed with carers who have secure attachments, they can recover from inse-
cure and disorganised attachments and develop more positive IWMs of parental
¿gures’ representations than if placed with carers who are themselves insecure or
suffering from unresolved loss.
Dozier (2003) has demonstrated that infants who have been neglected may be
unresponsive to attempts by their foster carers to provide nurture and care, and
might appear independent. The temptation of the carer is to respond to the child’s
cues that he does not need attention, by assuming that the child is, indeed, self-
suf¿cient, and to reduce the level of interaction and nurture offered. However,
if the foster carers are trained to over-ride the child’s signals of self-suf¿ciency
and to reach out to the child, providing sensitive care and reassurance, the chil-
dren respond to this and within a matter of two or three months their behaviour
becomes responsive to the level of care they receive. In other words, their expecta-
tions or IWMs of parental/caregiving ¿gures has been transformed.
Wakelyn (2011) describes the observation of a baby in foster care from birth
to 12 months when he was placed with adopters, having been relinquished by
his young parents at birth. The foster carer was repeatedly advised by the social
workers that the baby would move as soon as adopters had been identi¿ed, which
resulted in a sense of uncertainty and impermanence permeating the foster mother,
who was not able to make plans, for example to take the baby to visit her own
mother who lived at a distance.
It is evident in the account of the observation that the uncertainty affects the
carer deeply as she struggles to provide care while also worrying about the baby’s
future. The carer’s own sense of uncertainty also seems to impact on the baby’s
development. Even at such a young age, and within a stable foster placement the
anxieties that are an inevitable part of the experience of separated children and
their carers have an impact on the baby.
Dozier notes that repeated experiences of having to move children on to a new
placement having formed a bond with the child depletes the carers’ emotional
resources. She suggests that the more children a carer has moved on to a new
placement, the less sensitive to the needs of the next child the carer becomes (Doz-
ier 2003). If we want to enable carers to retain their capacity to relate to distressed
children and to reach out to them, it is important that the carers’ own needs are
recognised and they are not treated as a commodity on a conveyor belt. Carers
need support at the time a child moves, and to have their own feelings acknowl-
edged. They need a space in which to process the loss and to recover before the
next child is placed – even a week or two would offer them some respite. They
should continue to be paid a fostering retainer during this time. Failure to give
carers this kind of support is likely to result in ‘burn out’ with the result that either
they will resign after a certain number of placements, or they will become hard-
ened and less responsive to the needs of the individual child.
If a carer develops a bond with a particular child who needs to be adopted, and
offers to adopt that child, her offer should be carefully considered. In such a case
the carer’s motivation to adopt the child, in the knowledge of that child’s dif¿cul-
ties, provides a foundation for a positive outcome particularly if the child is also
attached and wants to remain in the placement, as the adopter will have chosen the
child on the basis of real knowledge about the issues that child presents, which is
usually not possible in adoptions by strangers. If we are truly child centred in our
decision making, the needs of that individual child to a secure family placement
will outweigh the organisation’s need to ensure a good supply of foster carers
available to care for children when needed.
Supporting adoptive parents and carers

Many children do respond to the daily lived experience of sensitive caregiving by
their new parents, and many do not require specialist professional input. However,
if children are not able to respond to the care of their new parents after a period of
months, a referral to CAMHS may be considered. Generally speaking it is impor-
tant for children and parents to have an opportunity to get to know each other and
for the parents to establish themselves in their new role before a referral is made.
Parents need to be treated with respect; professionals should appreciate that the
parents know the child and their concerns should be treated seriously. They should
be offered an opportunity to speak to the professional team without the children
present in the ¿rst instance – both so that they feel free to speak openly about
their concerns which they may be reluctant to voice in front of the children, but
also because as the parents, they need to feel some con¿dence in the professionals
before their children are involved. In some cases consultation to the parents is the
most helpful intervention. Other helpful approaches include story stem assess-
ments which can provide insights into the nature of the child’s internalised beliefs
about parental ¿gures. Where there is a child psychotherapist on the team, many
of these children will bene¿t from the opportunity to process some of their early,
pre-verbal experiences and to have somewhere other than their adoptive family to
deposit some of the rage and upset they have endured. Parenting skills courses or
162 Jeanne Kaniuk
support groups for adopters/foster carers may provide a forum for shared learning
and support for these parents.
Adopters report that the response they receive at clinics is not universally well
informed. Adopters are sometimes made to feel responsible for their children’s
dif¿culties, which makes it very dif¿cult for the adopter to develop a positive
working relationship with the therapist. It is important that professionals who offer
a service to families who care for children who have been looked after, understand
the powerful long-term sequelae of such early experiences, and manage to convey
to the adopters respect for what they manage. Adopters are often distressed and
conscious of their ‘failure’ as parents at the point of seeking help. It is, therefore,
important that the professionals convey awareness that the children’s dif¿culties
pre-dated their placement, even if their responses are sometimes unhelpful to the
child. It is dif¿cult for parents to maintain a positive stance in the face of consis-
tent rejection which some children who have been abused and neglected in the
past may present as their default position.
Parenting skills training groups which are tailored to the needs of adoptive or
foster parents provide them with insight into the reasons for their children’s dif¿-
cult behaviour within a supportive peer group which facilitates sharing and learn-
ing. Some programmes also provide a ‘toolkit’ of strategies to use to improve their
relationship with the child and enable them to manage the child’s challenging
behaviour without being drawn into a negative spiral.
There are a range of such groups available in the UK. Adoption UK which is
a self-help organisation for adoptive parents offers a course entitled ‘A Piece of
Cake’, which spends time exploring the reasons why children from backgrounds
where they have experienced trauma have behaviour dif¿culties before discussing
strategies to support them. The voluntary adoption agency After Adoption has
developed a package called ‘Safebase’ which also offers adopters a programme
of groups designed to support the development of more positive strategies and
interactions.
Dr Stephen Scott and his team at the Maudsley Hospital have developed a pro-
gramme for a support group for foster carers entitled ‘Fostering Changes’, which
draws on ‘The Incredible Years’ developed by Carolyn Webster Stratton in the
USA, initially for children with conduct disorders (not foster or adopted children).
Researchers from the Anna Freud Centre and Coram conducted a study over three
series of the Webster Stratton groups (Henderson & Sargent 2005), from which
they identi¿ed additional themes relevant to adopters, and the package has since
been modi¿ed in the light of this study. The package is highly rated by the partici-
pants, and an evaluation carried out established that the parents had an increase in
their con¿dence and ability to manage as parents to their children (Henderson &
Sargent 2005).
All the parenting skills groups mentioned above provide the adopters or foster
carers with the opportunity to share their experiences with a group of peers where
they feel understood and able to speak frankly about the dif¿culties they encoun-
ter. However, the parenting skills groups provide only one aspect of the support
needed by these families. Many of the children will require individual therapy,
and the parents might need access to consultation and advice from time to time.
Access to a multi-disciplinary team is valuable as these children often have a
multiplicity of needs and may require assessments by educational psychologists,
speech therapists, occupational therapists, child psychotherapists, neurologists,
and/or psychiatrists.
Conclusion
Adoption and foster care social workers are responsible for providing services to
some of the most vulnerable children in our society as well as supporting the adults
who make themselves and their homes available on a full-time, and in the case of
adopters, a permanent basis. The care these parents offer is the most potent source
of therapeutic experience available for these children. However, their role makes
huge demands on people who are not mental health professionals, but ordinary
folk who are child centred and motivated to help a child as well as wanting the
satisfactions of parenthood. They need to be persevering, patient and to have an
optimistic outlook, even though they will at times experience despondency and
despair. Indeed, one of the most signi¿cant qualities of adopters is that they should
withstand attacks (psychological but sometimes physical) and survive as paren-
tal ¿gures. Children who have been catastrophically let down by adults will test
them to destruction, and need to know that they can survive. Remarkably, a very
high proportion of these placements do endure (reliable statistics are not available,
although a research study by Julie Selwyn has been commissioned by the Depart-
ment of Education). However a report produced for the Prime Minister in 2000
(Prime Minister’s Review 2000) set the disruption rate at 20 per cent, which many
in the ¿eld believe is considerably higher than the true ¿gure. Nevertheless, even if
20 per cent disrupt, that means that 80 per cent endure, and a study by David Howe
(1996) gives cause to hope that some of the troubled children who leave their adop-
tive families in distress during adolescence, will have bene¿tted from living in their
adoptive family and will re-establish a cordial relationship in their twenties.
This high rate of positive outcomes is a testament to the powerful drive of chil-
dren to make an attachment when the opportunity presents, and when they are able
to be persuaded that their new parents are indeed benign and able to care for them.
It is also testament to the level of devotion which enables the parents to keep going
even when things might appear hopeless, thereby ¿nally convincing children who
have learned to expect rejection and discontinuity, that relationships can be differ-
ent. It is important not to impose arbitrary cut off points in evaluating the success
of adoptions. Adoption is a lifelong process, not an event, and as people grow up,
mature and age, they are capable of seeing things in a fresh light and making dif-
ferent choices. Although much about the attachments people make relates to the
trajectory they set out on early in life, individuals do remain capable of change in
response to changes in their circumstances and the other relationships they forge
as they mature.
164 Jeanne Kaniuk
Applying attachment theory to this complex ¿eld is not a straightforward pro-

cess, but the insights it provides gives the context within which professionals and
parents can make sense of the complex and contradictory messages they receive
from children, and indeed from the adults who care for them, who are themselves
inevitably affected by the children’s projections and sometimes extreme behav-
iour. The message is one of optimism, hope and respect for the human spirit.
References
Ainsworth, M. D. S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of Attachment,
Hillsdale, NJ: Erlbaum.
Bifulco, A. (2014). ‘The Attachment Style Interview’, in S. Farnfield & P. Holmes (eds) The
Routledge Handbook of Attachment: Assessment, London and New York: Routledge.
Bifulco, A., Jacobs, C., Bunn, A., Thomas, G., & Irving, K. (2008). ‘The Attachment Style
Interview (ASI): A support-based adult assessment tool for adoption and fostering prac-
tice’, Adoption and Fostering 32, 3, 33–45.
Bowlby, J. (1988). A Secure Base: Parent–child attachment and healthy human develop-
ment, New York: Basic Books, p. 146.
DfE (2012). ‘Children looked after by local authorities in England, including adoption’.
Statistical first release. Available online at www.education.gov.uk/rsgateway/DB/SFR/
s001084/index.shtml
Dozier, M. (2003). ‘Attachment-based treatment for vulnerable children’, Attachment &
Human Development 5, 3, 253–257.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). ‘Ghosts in the nursery: A psychoanalyti-
cal approach to the problems of impaired infant-mother relationships’, Journal of the
American Academy of Child Psychiatry 14, 387–421.
Henderson, K. & Sargent, N. (2005). ‘Developing the Incredible Years Webster–Strat-
ton parenting skills training programme for use with adoptive families’, Adoption &
Fostering 29, 4, 34–44.
Hodges, J., Steele, M., Hillman, S., Henderson, K., & Kaniuk, J. (2003). ‘Changes in attach-
ment representations over the first year of adoptive placement: Narratives of maltreated
children’, Clinical Child Psychology and Psychiatry 8, 3, 347–363.
Howe, D. (1996). ‘Adopters’ relationships with their adopted children form adolescence to
early adulthood’, Adoption & Fostering 20, 3, 35–43.
Kaniuk, J., Steele, M., & Hodges, J. (2004). ‘Report on a longitudinal research project:
Exploring the development of attachments between older, harder to place children
and their adopters over the first two years of placement’, Adoption & Fostering 28, 2,
61–67.
Kenrick, J. (2000). ‘“Be a kid”: The traumatic impact of separations on children who are
fostered and adopted’, Journal of Child Psychotherapy 26, 3, 393–412.
Loxtercamp, L. (2009). ‘Contact and truth: The unfolding predicament in adoption and
fostering’, CCPP 14, 3, 423–435.
Main, M. & Solomon, J. (1986). ‘Discovery of a new, insecure-disorganised/disorientated
attachment pattern’, in M. Yogerman & T. Braxelton (eds) Affective Development in
Infancy, Norwood, NJ: Ablex, pp. 95–124.
Prime Minister’s Review of Adoption, Permanence and Innovation Unit (2000) The Cabinet
Office, London.
Rees, J. (2009). Life Story Books: A family friendly approach, London: Jessica Kingsley.
Rustin, M. (1999). ‘Multiple families in mind’, Clinical Child Psychology and Psychiatry,
4, 51–62.
Slade, A. (2005). ‘Parental reflective functioning: An introduction’, Attachment & Human
Development 7, 3, 269–281.
Steele, H. & Steele, M. (2005). ‘Understanding and resolving emotional conflict: Findings
from the London Parent–Child Project’, in K. E. Grossman, K. Grossman & Waters, E.
(eds) Attachment from Infancy to Adulthood: The major longitudinal studies, New York:
Guilford Press, pp. 137–164.
Steele, M., Hodges, J., Kaniuk, J., D’Agostino, D., Blom, I., Hillman, S., & Henderson, K.
(2007). ‘Intervening with maltreated children and their adoptive families: Identifying
attachment-facilitative behaviours’, in D. Oppenheim & D. F. Goldsmith (eds) Attach-
ment Theory in Clinical Work with Children: Bridging the gap between research and
practice, New York: The Guilford Press, pp. 58–85.
Steele, M., Hodges, J., Steele, H., Hillman, S., & Asquith, K. (2008). ‘Forecasting out-
comes in previously maltreated children: The use of the AAI in a longitudinal adoption
study’, in H. Steele & M. Steele (eds) Clinical Applications of the Adult Attachment
Interview, New York: Guilford Press, pp. 427–451.
Wakelyn, J. (2011). ‘Therapeutic observation of an infant in foster care’, Journal of Child
Psychotherapy 26, 3, 393–412.
Ward, H., Munro, E., Gearden, C., & Nicholson, D. (2006). Outcomes for Looked After
Children: Life pathways and decision making for very young children in care or accom-
modation, London: Jessica Kingsley.
Chapter 10
Attachment and social work

David Howe
Introduction
Social workers get involved with people of all ages, from the young and vulner-
able to the old and dependent. They work with children and families, individuals
with mental health problems, and the disabled. They work with the troubled and
troublesome, the endangered and dangerous. Their work might involve duties of
care or control. And the more ambitious might grow excited by the possibilities of
treatment and cure as they seek to ape the evidence-based success of other people-
based professions including medicine and clinical psychology.
They are social workers in the sense that their concerns are with people who
either have problems with society or with whom society has problems. This being
the case, social workers ¿nd much of their work determined by welfare legisla-
tion and social policy. Although concise de¿nitions are dif¿cult, Wilson and col-
leagues characterise social work as:
a professional activity which takes place at the boundary of many different

spheres of society: private and public, the civil and judicial spheres, and the
personal and political arenas. However, it is above all about relationships. We
see at the heart of social work the provision of relationships to help people
(children, young people and adults) negotiate complex and painful transi-
tions and decisions in their lives . . . Our book, then, is based on the belief
relationships are at the heart of effective social work and that the essential and
distinctive characteristic of social work is its focus on the individual and the
social setting and context.
(Wilson et al. 2011: xiv, original emphasis)
So, although such broad de¿nitions mean that practitioners are required to know
something of social policy and the law, the many schools of psychology and their
applications, sociology, systems theory, philosophy and the political sciences, a
perennial interest has remained in social relationships and human development.
And to the extent that this has remained true, attachment and its theories have
retained a signi¿cant fan-base among many of the profession’s practitioners. Nev-
Attachment and social work 167
ertheless, because much of the content, manner and purpose of social work is
governed by the state and its agencies, practitioners tend to have a complex, often
constrained relationship with social science’s theories and their evidence-based
practices.
Origins of social work’s interest in attachment

James Robertson, a social worker, practised with John Bowlby during their time
together at the Tavistock Clinic. His close observations of young children’s highly
distressed reactions when they were separated from their parents, for example
when they went into hospital or foster care, offered early empirical support for
Bowlby’s immanent ideas on attachment (for example, Robertson 1953). In par-
ticular, Robertson’s recognition of the several stages of loss through which young
children progress upon separation from their parents (protest, despair and detach-
ment) not only provided an important contribution to early ideas about attachment
but also began to inÀuence people’s thinking on how best to mitigate the more
distressing effects of loss and separation when children were admitted to hospital
or went into foster care. Indeed, attachment’s earliest and most signi¿cant impact
on social work practice was in the placement of children in short- and long-term
foster care (also see Kaniuk, Chapter 9, this volume).
And for a couple of decades, until the early 1980s, that was almost the extent
of social work’s interest in attachment. Social work in the 1970s and 1980s was
under assault from two ideologically opposed groups. The group interested in
empirically robust and evidence-based approaches to social work wanted the pro-
fession to be more treatment-oriented which, at the time, meant practices based on
behaviour modi¿cation. Those supporting this approach were particularly dismis-
sive of any social work practice that had even a whiff of psychodynamic thinking
about it, including attachment theory.
The second band of would-be reformers were inspired by a range of radical polit-
ical theories including 1970s’ Marxism, feminism and early post-structuralism.
For them, attachment theory at best merely offered a plaster on the deep wounds of
inequality and injustice caused by the iniquities of capitalism, and at worse offered
a theory that subjugated women as well as blamed them for many of society’s
man-made ills. Social workers with attachment sympathies, therefore, tended to
lie low or simply tread water for a while, con¿ning their interests mainly to chil-
dren moving in and out of foster care.
Nevertheless, in spite of the ideological buffeting that social work suffered dur-
ing these times, most practitioners continued to value the theories and practices
associated with loss, grief and mourning, often unaware of attachment’s contribu-
tion to our understanding of these shared experiences.
However, gradually, throughout the 1980s, attachment-based thinking began
to ¿nd its way back into the profession’s practices. Again, it was foster care and
adoption work that acted as the stimulus. In particular, the shift in adoption prac-
tice from placing babies to placing older children forced workers to think about
168 David Howe
how early life experiences affected children’s psychosocial development and

behaviour. This coincided with signi¿cant developments in attachment theory and
research. Ainsworth’s work on caregiving, attachment patterns and personality
was particularly inÀuential (Ainsworth et al. 1978). And the recognition that child
abuse, neglect and trauma could have profound consequences for the developmen-
tal pathways taken by some children had major implications for adoption policy
and practice.
The early work of researchers such as Main and Solomon (1986), and Crit-
tenden and Ainsworth (1989), also began to transform social workers’ thinking
about the causes and consequences of child abuse and neglect. In particular, ideas
about the quality of caregiving, the making and breaking of affectional bonds,
and attachment in situations of abuse and neglect began to offer social workers
much more sophisticated understandings of the nature of dangerous and neglectful
parenting and their effect on children, their behaviour and development. As well
as the intuitive appeal of these ideas, their strong research underpinnings gave
attachment-informed practices increasing credibility in the world of child protec-
tion social work.
Thus, by the mid-1990s, attachment was ¿rmly back on social work’s agenda,
especially in the ¿elds of child protection, adoption and foster care.
We now follow the child protection story in more detail. This gives a particu-
larly good idea of how social workers, along with many other professional groups,
have understood (and sometimes misunderstood) and used (and sometimes mis-
used) some of attachment’s key concepts and categories.
Social work and child protection

In child protection and welfare work, the key concerns of social workers are chil-
dren’s developmental wellbeing and safety. In order to assess and make judge-
ments on these concerns, they have to assess the quality of parents’ caregiving,
the developmental prospects and condition of their children, whether or not the
children are safe, and whether or not the children should be removed, either per-
manently or temporarily. As attachment has many interesting things to say on all
these matters, by the mid-1990s the theory began to play an increasingly important
role in the way social workers assessed, judged, supported and worked with par-
ents and their children.
One of the ¿rst consequences of this interest was to determine whether a par-
ticular child in a particular family was securely attached or not. This was, and
continues to be assessed most typically by observing parent–child interactions
both in the home and, in cases where children are separated from their parents,
during contact visits.
Although very few social workers are trained to use any of the fully validated
instruments now available, such as the Strange Situation procedure or the CARE-
Index, they might make up for their lack of methodological rigour by undertaking
repeated observations, over time, in the home setting, under different conditions.
However, in order to assess and interpret the quality and character of these
parent–child interactions, social workers do need a full and proper understanding
of attachment and what it is. In particular, the part that parents play in acting as
safe havens and secure bases at times of need and distress is an especially help-
ful idea. When attachment is not properly understood, it is possible that some
secure children happily playing on their own in an independent fashion, having no
particular need of their attachment ¿gure at that time, might be mis-classi¿ed as
insecurely attached.
Perhaps more critically, some children who might be classi¿ed as ‘ambivalent’
in their attachment organisation using a reliable, validated measuring instrument,
who, when observed in the home setting, seem to be constantly engaged with the
parent, might wrongly be judged ‘secure’ inasmuch as they seem to show no fear
of their parent, indeed seem particularly anxious to remain close and energetically
engaged with their caregiver at all times. Here, proximity seeking in and of itself
is mistakenly perceived as an indication of security.
Furthermore, the rather low-grade value that secure versus insecure gives in
terms of making key decisions in a child’s life is not always appreciated. ‘Secure
good, insecure bad’ is too crude a division on which to base life-changing judge-
ments. Given that between 30 and 40 per cent of children in any normal population
might be classi¿ed insecure, we learn a little, but not a lot from the distinction.
The past as a guide to understanding the present

Of more value has been the research evidence that has looked at the relationship
histories of abusive, rejecting and neglectful parents and how these relate to their
caregiving. Social workers have had a long-standing interest in people’s social
histories. This, coupled with opportunities to collect detailed observational infor-
mation on parent–child, parent–partner and parent–professional interactions in the
home and other community settings, affords rich material on which to base sound
assessments on parenting capacities and children’s safety. Good assessments lead
to good problem formulations. Good problem formulations guide decision making
and intervention strategies.
Attachment theory has proved particularly useful in terms of helping social
workers make sense of complex, long-standing, often turbulent cases. It is all
too easy on a home visit to feel overwhelmed or intimidated by the behaviour of
highly dysfunctional parents and their families. Practitioner anxiety, of course,
does not lead to sound or safe practice. Attachment theory’s ability to see pattern
and logic in what otherwise might seem like random chaos helps reduce profes-
sional stress. Low anxiety increases emotional availability and helps sharpen the
worker’s intellectual bearings. If the social worker knows where she is and where
she’s going, it also helps clients feel less stressed and more con¿dent.
Attachment theory and research has recognised a variety of caregiving pat-
terns and styles, each one of which has its origins in the parents’ own attach-
ment and relationship history (George & Solomon 2008). The more information
170 David Howe
social workers can collect on parents’ past and present relationship experiences,
the more they can make sense of current caregiving environments.
The presence of unresolved states of mind in parents with respect to their own
attachment experiences of abuse, rejection and neglect provide powerful clues
about the way they are likely to respond to current stresses and strains, particu-
larly those associated with parenting their own children. When current stressors
evoke unresolved and painful memories of their own childhood experiences of
abandonment and abuse, parents employ the defensive and adaptive strategies that
helped them survive their own traumatic childhoods. Thus it is that when their
own children are in a state of need and distress that parents’ own attachment sys-
tems become activated. This triggers attachment behaviours with all their atten-
dant demands and feelings of threat and danger. The challenge and stress of their
children’s arousal and attachment behaviours then evokes unresolved and dis-
tressed states of mind in parents who, at the very moment their children need them
to be emotionally available, attuned, regulating and responsive, actually shift into
one of their own threatened states of mind and the defensive strategies that go with
it. Crudely, these might be characterised as ones of ¿ght, Àight or freeze. These,
in turn, might be loosely associated with various forms of avoidant or ambivalent
attachment behaviours including one or more of their many re¿nements, including
the use of compulsive and coercive strategies following Crittenden’s Dynamic-
Maturational Model (DMM) (Crittenden 2008 – also see Farn¿eld & Stokowy
2014), and controlling and punitive behaviours as explored in the ABC + D model
(Main & Cassidy 1988; also see Van Rosmalen et al. 2014; Shah & Strathearn
2014). In either case, the parent’s ability to perceive, process and respond to the
needs of their children is disturbed.
In Fonagy’s (2006) pithy phrase, parental mentalisation at these key moments
‘goes off-line’. The parents’ defensive responses in fact become ones of abuse
(¿ght), neglect (Àight), or abandonment (freeze) as they attempt to deal with their
own distressed and threatened state. Each one of these responses represents a dan-
ger to the child whose attachment behaviour triggered the feeling of threat and
distress in the ¿rst place. The child is then obliged to ¿nd his or her own adaptive
and defensive survival strategy with its own distortions and disturbances which,
unless recognised and treated, is likely to result in development following a sub-
optimal pathway.
In the ABC + D model (see Chapter 1 and various chapters in Holmes & Farn-
¿eld 2014) abused and neglected children experience their parents’ behaviour as
either frightened or frightening (Main & Hesse 1990; Lyons-Ruth et al. 1999).
Under these caregiving conditions, young children may ¿nd it dif¿cult to ¿nd
any behavioural strategy that helps reduce their feelings of arousal, fear and
distress. In the presence of an attachment ¿gure who frightens them, children
appear to experience the simultaneous activation of two incompatible behav-
ioural responses – fear (triggering an escape response) and attachment (recover
proximity with your attachment ¿gure). However, as the attachment ¿gure is
both the source of danger and is the ostensible provider of safety, children ¿nd
themselves in a behavioural dilemma. Their attachment systems remain highly

activated and their levels of arousal and distress quickly escalate. They suffer
‘fear with escape’ and ‘fright without solution’. Unable to ¿nd a behavioural
strategy that helps terminate their highly activated attachment system, their
attachment behaviours are classi¿ed as disorganised or disoriented. However,
under less stressful conditions, their attachment behaviours often possess more
organisation. They might, therefore, also be classi¿ed as either avoidant, ambiv-
alent or even secure (also see Farn¿eld & Holmes 2014 for a DMM’s alternative
interpretation of these behaviours).
Understandings and misunderstandings of attachment

classifications
The proper recognition and correct classi¿cation of an attachment as disorganised,
or indeed the recognition of any other attachment pattern, requires the use of the
correct measurements and codings along with the reliability training that goes
with them. Very few social workers are trained, or indeed likely to be trained in
the use of these measuring instruments. Care should therefore be taken before
any classi¿catory or diagnostic label is attached to a child or a parent. However,
labels such as ‘disorganised’ and ‘disordered’ do have an evocative ring to them
and there is a temptation to use them whenever a child, parent or family seem to
be leading lives that are chaotic, turbulent or violent. This is wrong and should be
avoided. It is particularly worrying when attachment labels and jargon are used
by the untrained to support radical decisions such as the removal of a child or
condemnation of a parent’s caregiving.
Here is Crittenden in similar vein:
Far too often, clinical opinion regarding attachment is relied upon, even in
court cases, where custody and placement in care are issues . . . Most of the
‘experts’ rendering the opinion have no formal training in attachment
(Crittenden 2008: 276)
When life-changing decisions will be based in part on the outcomes of the

assessment of attachment, fully qualified and authorized professionals should
code, classify and write up the results of the assessment, it being certain that
they are not the same individuals who carried out any of the assessments.
Even more hesitation is required when it is acknowledged that there are rela-
tively weak or unproven correlations between many of attachment’s major mea-
sures. It can be the case that a child or parent might even be classi¿ed as avoidant
on one measure and ambivalent on another. This lack of measurement consensus
must surely mean that professionals and courts alike should view attachment diag-
nostics with some considerable caution.
172 David Howe
The companion volume to this book, The Routledge Handbook of Attachment:

Assessment (Farn¿eld & Holmes 2014), considers these issues and describes the
various formal, evidence-based tools currently available to assess attachment.
Even if the classi¿cation of a particular child’s attachment did have validity, social
workers cannot, in the Humean sense, simply argue from an is to an ought. That is,
recognising that a child has a disorganised attachment say, or is using a compul-
sively compliant or coercive strategy, does not, in and of itself, determine statutorily
what should be done. Decisions about removal and custody involve social, legal and
moral issues as well as scienti¿c facts and opinion. In Stevenson’s (1974) immortal
words, social workers are inevitably brokers in shades of grey. So although knowl-
edge about attachment styles and types can be extremely useful, they should never
be the sole determinants of a decision, a recommendation or a course of action.
Social workers, therefore, should be cautious, even queasy about their use of
too much attachment jargon, particularly the more evocative terminologies such as
‘disorganised’ and ‘disordered’. It is lazy, immoral and dangerous to be over-reliant
on the use of single, contestable labels to make life-changing recommendations.
The profession’s strengths lie in knowing clients over time, in different settings,
and under different conditions. This knowledge provides powerful information. A
good understanding of attachment certainly helps social workers perceive, recog-
nise, collect, organise and make sense of complex information about troubled
lives but on its own it cannot be the whole story.
Attachment and relationship-based social work

However, it is possible, maybe even preferable, to think about attachment’s value
to social workers in a different way. There is a strong argument that social work
remains an essentially relationship-based practice (Wilson et al. 2011; Baim &
Morrison 2011). Yet, in most countries the profession has a large number of statu-
tory duties, some mandatory, some discretionary. It is required to deliver a wide
range of services. But most of these work best when the social worker establishes
a good working relationship with the client. ‘Good relationships, it seems, are a
universal therapeutic good’, argues Bentall (2009: 260), ‘and yet may turn out to
be the single most important ingredient of effective psychiatric care’. The good-
enough relationship is the medium in which most therapeutic change takes place.
Attachment theory provides social workers with a sophisticated, subtle and
nuanced understanding of human behaviour and social relationships, particularly
in situations where people ¿nd themselves feeling under stress. When clients feel
anxious, threatened and uncertain, their attachment systems become activated.
It is then that their internal working models and dispositional representations
(Crittenden 2008) guide their perceptions of, understandings of, and responses
to the people with whom they are in relationship. These people might include
partners, children and professionals, including social workers themselves. Clients
will employ in the present those established and familiar behavioural strategies
that have kept them safe and helped them survive in the past. There are longer
discussions on these topics in The Routledge Handbook of Attachment: Theory

(Holmes & Farn¿eld 2014).
Attachment theory, therefore, with its interest in people’s relationship histories,
adaptive strategies, defence mechanisms, and personality traits can be extremely
useful in helping workers make sense of why clients are doing what they do, and
saying what they say. Such understandings can help social workers make sense
and so keep their bearings in dif¿cult cases. And the more the worker can make
some kind of sense of what is going on and why, the less anxious she is likely to
be. In short, like all good caregivers, she can provide a relationship in which she
is experienced as both ‘stronger and wiser’ (Bowlby 1997).
In the lives of many social work clients, it is relatively unusual to ¿nd yourself
in relationship with someone who remains emotionally available for you under
conditions of stress, who is willing to try to understand you and where you are
coming from, and who is willing and able to communicate and connect with you.
To the extent that the social worker is able to create such a relationship, she is act-
ing as a transitional attachment ¿gure (Crittenden 2008: 292; also see Winnicott
1965). And one of the key things that sensitive, responsive attachment ¿gures do
is keep the other in mind.
The minds of babies form, both neurologically and psychologically, as they
relate with others who view and interact with them as ‘mental state’ beings, as
having a mind. Parents’ capacity to keep their children in mind facilitates chil-
dren’s general understanding of minds – their own and other people’s. Thus, we
learn to think of others in psychological terms because we were thought of in psy-
chological terms (Fonagy et al. 2002). Our ability to improve the skill of keeping
others in mind by feeling psychologically understood ourselves continues across
the lifespan. Workers who understand, acknowledge and communicate their cli-
ents’ thoughts and feelings help clients take on board and reÀect on their own and
other people’s mental states and the behaviours to which they give rise.
Social workers who are able to stay with and process the strong feelings of
clients offer containment. Worker–client relationships based on collaboration,
cooperation and containment help clients to self-regulate. Practitioners who are
not emotionally available leave clients with feelings that go unrecognised and
unprocessed (Bion 1962). Bower suggests that:
Bion’s theory of containment is immensely valuable in providing not only a

model of the development of the capacity to manage emotional states, but a
way of understanding how a thoughtful and emotionally receptive stance to
clients can have therapeutic value without anything fancy being done.
(Bower 2005: 11)
Mind-mindedness and mentalisation

Recent developments, many fashioned by developmental psychologists, have pro-
duced a variety of concepts similar to containment. Parents whose children are
174 David Howe
observed to be secure in their attachments typically relate with their babies in a

way that Meins terms mind-minded and Fonagy and colleagues call mentalisation
(Fonagy et al. 2002; Bateman & Fonagy 2006; see also Fonagy et al. in Holmes
& Farn¿eld 2014).
In a series of studies, Meins (1997, 1999) found that caregivers who are inter-
ested in what their children are thinking and feeling, and seek to share and enjoy
this understanding with their children, possess what she calls ‘mind-mindedness’.
Mind-minded parents are good at translating psychological experiences into an
active, coherent dialogue with their children. They help children attend to their
inner thoughts and feelings and how these affect mind and body. Such mind-
minded interactions facilitate emotional understanding, regulation and secure
attachments. Parents who focus on their children’s subjective experiences help
them understand their own and other people’s psychological states, and how these
are linked to actions and behaviour.
Many of the clients of social workers, particularly parents who maltreat their
children, suffered deprived and dif¿cult childhoods. Their own parents lacked
sensitivity and interest in their children’s growing minds, their thoughts and feel-
ings. They lacked mind-mindedness and, as a result, did their children a profound
developmental disservice increasing the risk of them growing up with impaired
social cognition, poor affect regulation, low empathy, limited emotional intelli-
gence, insecure attachments, behavioural problems and poor mental health (Howe
2005). Any one or more of these impairments is likely to increase the chance of an
individual becoming a social work client.
The concepts of ‘mentalisation’ and ‘reÀective function’ are similar to mind-
mindedness but take matters of psychological awareness a step further (Fonagy
et al. 2002). Mentalisation is the capacity to understand how one’s own and other
people’s mental states affect behaviour. It also involves an appreciation of how
‘my behaviour affects your thoughts and feelings, and how your behaviour affects
my thoughts and feelings’. The process includes the idea that ‘I also recognise that
as I am “mentalising” our interaction and modifying my behaviour accordingly,
you are probably doing exactly the same’.
In order to develop the capacity to mentalise, an individual must have been in a
relationship, particularly a parent–child relationship, in which the other was men-
talising. In other words, to understand, one must have been understood. People
who are able to recognise and reÀect on themselves and others as meaningful and
understandable become more competent social beings. Mentalisation correlates
with secure attachments, a coherent sense of self, resilience, good mental health,
and the ability to self-regulate.
Many clients of social workers, whether in mental health, child and family work,
or youth offending, have problems mentalising, making sense of, and reÀecting
on their own and other people’s psychological states. This results in miscued
responses, feelings of confusion and distress, emotional arousal, and problematic
behaviour in most signi¿cant relationships – with partners, children, professionals
and of¿cials. Never having been fully engaged as an independent, complex psy-
chological being themselves, they have problems relating to others as complex,

reÀective, psychological beings.
In the case of working with parents of maltreated children, Slade (2008: 220)
writes that ‘it is more often the case that mothers and fathers ¿nd it very dif¿cult to
enter their child’s experience as a means of understanding them’. Their children’s
needs and behaviour are therefore dif¿cult to read. This is stressful and can precip-
itate strong feelings of fear, anxiety and anger leading to abuse, neglect or both.
The inability to mentalise not only makes relationships inherently more puz-
zling and stressful, it can also trigger the defensive responses of ¿ght, Àight and
freeze which, if experienced in the parent–child relationship, can lead to feelings
of helplessness and hostility resulting in abuse or neglect. Similarly, if the parent’s
relationship with the worker is experienced as of¿cious and impersonal, stress and
the defences associated with it are likely to increase.
To help clients, including abusive and neglectful parents, feel less confusion
and stress as they interact with signi¿cant others, clients might be helped by being
in relationship with social workers who are able to hold their clients’ thoughts and
feelings in mind. In the case of working with abusive and neglectful parents, it also
helps if the worker can also hold children in mind for parents. In this way, other
people’s mental states and their links to behaviour, including the mental states of
children of maltreating parents, are re-presented back to clients. This is how Slade
describes her psychotherapeutic work with parents:
[W]hen I work with a parent, I am trying to create a context in which he or

she can slowly shift from a physical to a reflective or mentalizing stance. That
is, I hold the child in mind for the parent as a mentalizing being, as a person
whose feelings and behaviors are inextricably intertwined with theirs as a par-
ent. Most important, I see the child’s behaviour as meaningful. Hopefully the
parent will come to internalize this view of the child, which will in turn allow
them to hold this in mind for the child.
(Slade 2008: 220, original emphasis)
Creating an environment in which the parent can begin to hold the child in
mind depends upon our capacity to first – and perhaps for a very long time
– hold the parent in mind.
(Slade 2008: 222)
In relationship-based social work, practitioners relate with clients in the same

way that they want clients to relate with their children, partners, parents, pro-
fessionals, and other authority ¿gures, that is, develop a reÀective, mentalising
stance.
From a practice point of view, social workers ¿rst have to establish a working
or therapeutic alliance – a secure base from which clients can begin to explore
dif¿cult thoughts and feelings, hopes and fears. Exploring from the secure base
allows feelings and mental states to be linked to behaviour, whether the behaviour
176 David Howe
is that of the other or the client. Being held in mind by practitioners is a powerful
way of containing clients’ anxieties, fears, anger and sadness.
Practice, therefore, needs to re-focus. Rather than simply concentrate on what
has gone wrong, much more attention needs to be paid to the psychological pro-
cesses that get clients into distress and dif¿culty. In the case of parents who abuse
and neglect their children, it is necessary to tune into their world:
In order to understand parents’ intent, we will need to get ‘inside’ [their]

adaptive strategies. That is, understanding how they develop over childhood
(patterns, strategies, dispositional representations, distortions of cognition
and affect), we will need to think and feel like someone using their strategy
if we are to understand parents who harm their children. Once we can do
that, we may be able to join parents meaningfully and guide them safely to a
less dangerous reality. Without understanding them as they understand them-
selves, we may not be able to help.
The social workers aim is behavioural reorganisation and not symptom reduc-
tion. There is a need to be empathic, to see and understand how the world looks
and feels from the client’s point of view, and accurately convey that understand-
ing (Gross & Capuzzi 2007).
Assessments, supports and interventions

Attachment-based thinking is also useful in helping social workers understand
why and how they might be being perceived, interpreted and responded to by
clients when they meet and communicate.
For example, a client with a history of rejection and abuse might approach the
relationship warily and without trust, keeping themselves and their feelings at a
distance. Their attachment style is essentially avoidant and dismissing of attach-
ment-related cues. A hostile, intimidating attitude is the default mode for all new
relationships, especially those with professionals. If they are to remain emotion-
ally available, cognitively interested, and not react counter-aggressively or with
trepidation, social workers needs to know and understand these things. In order to
establish a secure base, social workers need to be consistent, contingent, congru-
ent, predictable, sensitive and open. Maintaining this degree of responsivity and
attunement means that social workers must be in regular receipt of good quality,
critically reÀective supervision.
It might also be the case that knowing that avoidant clients, for defensive rea-
sons, are uncomfortable with accessing their own and other people’s feelings,
the social worker might need to tread a ¿ne line between those communications
that appeal to cognition and those that appeal to emotion. Some recognition and
acknowledgement of feelings and how they affect body language, facial expres-
sions, and what is being said might be explored, but the worker has to proceed
with care. The idea is to help clients do what defensively they have learned not
to do in order to feel safe. The worker is helping them to think about feelings,
to recognise and reÀect on emotions, both in the self and others. This is just one
example of a very small step in helping avoidant personalities feel safe when feel-
ings are aroused. The more affect and cognition can be coupled, the more able
avoidant clients are to self-regulate.
In contrast, many clients show behaviours and relationship patterns that suggest
an ambivalent-preoccupied type of attachment organisation.
For example, Deanna has been a long-standing client of a social work

agency. She was the third of four children, each with a different father.
Deanna’s mother often said that she was on this planet to enjoy herself.
It seemed to Deanna that men were more important to her mother
than her children and that when her mother was in-between relation-
ships she would swing unpredictably between being angry, depressed
and vengeful. Although her mother would often tell her children that
they were the most precious things in her life, it was hard to square
this with her behaviour and life style. Deanna said she never really felt
loved.
The mother of three school-age children herself, Deanna is cur-
rently without a partner. She now says she has given up on men: ‘You
give them everything, they take everything, and they give you nothing
back.’ Home life is chaotic. There are weekly crises that typically end
up with Deanna visiting the social work office demanding that the chil-
dren be taken into care and fostered, or complaining that no one gives
a ‘shit’ about her and that she might as well be dead ‘and who would
look after the children then, eh?’ She regularly runs up debt, gets into
arguments with staff at the housing department and medical centre,
and cannot stop eating and then gets depressed about what a ‘fat cow’
she is and that no man will ‘fancy’ her. She watches a lot of day-time
TV and particularly enjoys the reality shows, believing that she learns
a lot about ‘human nature’ and ‘people’s real psychology’ from watch-
ing them.
But her most frequent gripe is the behaviour of the children. She
says they take no notice of her. She tries her best to be a good mum,
‘God knows I do’, but ‘they forever want this or that’ and they are
‘rude’ . . . and it all begins to feel out of hand. She sees herself as a good
person who would do anything for anybody, but no one appreciates
178 David Howe
her love and generosity, least of all her ‘ungrateful kids’. The latest
visit to the office saw Deanna in a highly distressed state. Before the
social worker has a chance to say anything, Deanna tearfully launches
into her current woes.
Deon [her son] has been sent home early from school for misbehav-
ing in the classroom, again. ‘He’s getting a real pain and I can’t cope
with him any more. Those teachers should be able to control him.
They’ve been trained, haven’t they, they get paid lots of money for
doing the job, don’t they? Why should I be expected to cope? What
help do I get? It’s not fair. I don’t get enough money to keep them
decent. The dogs cost me a fortune to feed, but at least they’re grate-
ful and I wouldn’t be without them. And do you know what’s happened
now? Roxy’s started her periods! That’s the last bloody thing I could
be doing with right now. It’ll be boys next, and one thing and another.
I definitely do not want to be dealing with that. I can’t cope, I really
can’t. What have I done to deserve all this? Nobody cares.’
The practice of a social worker guided by an attachment perspective takes note

of Deanna’s childhood history. The worker understands why so many other pro-
fessionals, including some of her own managers, feel frustrated and exasperated
with Deanna, that in spite of seemingly endless support, nothing changes, there is
no apparent progress. Several times the social worker has been advised to close
the case: ‘Deanna is getting too dependent; she must learn to cooperate and stand
on her own two feet.’ When the case has been closed, it has usually been only a
matter of a few weeks before Deanna crashes back into the of¿ce with a new crisis,
a fresh drama.
The social worker knows that Deanna has deep anxieties about her own worth
and lovability. She craves acceptance. But her anxious need to be loved and appre-
ciated makes her go too far in relationships. She ends up placing huge emotional
demands on others. It seems impossible ever to meet her needs. The outcome is
always the same. People feel emotionally exhausted, cross and give up on her. Yet
again she feels abandoned and frightened. The only way she can provoke recogni-
tion and response is to precipitate another crisis that cannot be ignored.
Patiently, the social worker knows that she must remain steady, available, pre-
dictable and reliable in all her dealings with Deanna. Calmness and structure have
become her watchwords. Over time, in what sometimes has been dubbed ‘man-
aged dependency’, the practitioner has become both a safe haven and a secure base
for Deanna. The social worker’s basic aim is to keep ‘the show on the road’ for
as long as it takes. It might even be appropriate to consider the occasional use of
brief, respite foster care for the children.
In cases like Deanna’s it might be many years before the client begins to pick
up and value some of the structure, logic and consequential thinking that the social
worker always provides when she is working with her. Historically, Deanna has
used anxious arousal and strong feelings as her guide to action. Thought and
reÀection have rarely entered the frame. However, feeling contained, acknowl-
edged and understood by the social worker has allowed Deanna to ¿nd herself
in a calm place, a safe haven. In the relationship with her social worker, she is
slowly beginning to learn to stop and think before she feels and reacts. Know-
ing that the social worker is going to be there at times of need is actually helping
Deanna to be less dependent and more con¿dent. The social worker is becoming a
secure base from which Deanna, with growing independence, can explore, learn,
anticipate and plan. It is generally a case of two steps forward, one step back, but
slowly, Deanna is relying less on feeling and more on thought. She is beginning
to mentalise and reÀect. As a result, the children feel less confused, less uncertain,
less anxious, and better behaved as their mother learns to tune into their thoughts
and feelings. She, too, begins to take on some of the attributes of a safe haven and
secure base.
To recap
It is unlikely that social workers en masse will ever be trained to use the many for-
mal instruments and measures that attachment researchers and specialist clinicians
use to assess and classify children and adults.
Nevertheless, a good working knowledge of attachment theory helps social
workers do a number of key things. It helps them make sense of, and keep their
bearings in dif¿cult cases. It encourages them to remain curious, fascinated and
engaged with other people and their lives.
To be the subject of genuine interest and to be on the receiving end of a
relationship in which the other is interested in you and wants to understand
you and what the world looks and feels like for you, is a rare experience for
most clients. It marks the beginning of a possible willingness to engage and
for a working alliance to be forged. The worker–client relationship itself then
becomes the major vehicle of support, change and progress. The worker acts
as a safe haven, a secure base, a mentalising other, a transitional attachment
¿gure. The relationship with the social worker becomes a place where clients
feel a degree of safety. It becomes a place where they can begin to access, make
sense of, and integrate their own thoughts and feelings, behaviours and reac-
tions, hopes and fears (Baim & Morrison 2011). It marks the beginning of an
improved ability to self-regulate. An attachment-informed social worker also
knows when thoughts about feeling (say with ambivalent/preoccupied clients)
or feelings about thoughts (say with avoidant/dismissing clients) might be intro-
duced and explored. All of this is entirely compatible with interventions that
might decrease stress, improve material resources, provide advice and guidance,
promote insights, modify behaviour and set targets.
180 David Howe
Attachment across the client groups

Child and family social workers traditionally have been the most regular and
enthusiastic users of attachment-informed thinking. Attachment’s presence has
been most robust in child protection, adoption and foster care work. Although
historically attachment’s presence has been based on experience, practice wis-
dom and personal conviction, in more recent years, attachment-informed practices
have been supported by a growing body of evidence-based research. For example,
there is growing interest in employing attachment-based thinking in a number of
preventive and early intervention services. Many of the positive parenting pro-
grammes and treatments designed to enhance the quality of early attachments
are beginning to attract practitioners who work in support and early intervention
teams and family centres (see Juffer and colleagues in Chapter 5, this volume).
Social workers who work with disabled children and their parents are also begin-
ning to see some value in taking an attachment-based perspective.
There is also a slow, but growing interest in attachment being shown by men-
tal health social workers. As attachment theory and research advance in helping
us understand some features associated with diagnoses such as Borderline Per-
sonality Disorder, Antisocial Personality Disorder, depression, anxiety disorders,
eating disorders, and problems of substance abuse, so mental health social work-
ers have begun to appreciate attachment’s relevance and value in the assessment,
treatment and support of patients with various mental illness (see Jeremy Holmes
in Chapter 3).
Attachment is increasingly taking a lifecourse perspective on personality devel-
opment and behaviour (Howe 2011). However, the growing literature in the ¿eld
of adult attachments, whether generated by developmental psychologists or social
psychologists, has yet to have a signi¿cant impact on social work thinking and
practice. Nevertheless, there is potential to adopt and adapt many of the clinical
practices being developed by attachment-based couple therapists (for example,
see Johnson & Whiffen 2005) and family therapists (see Chimera in Chapter 4).
Attachment theory and research can also be helpful in assessment work for courts
that deal with issues of children’s custody in divorce, separation and mediation
cases.
And ¿nally, attachment theory holds promise for social work with older people.
This is an interesting client group from an attachment perspective (for example,
see Magai 2008). As parents age and become more fragile, vulnerable and depen-
dent, their roles and relationships with their children and others change from that
of caregiver to careseeker. As Bowlby (1997: 207) observed, as peer relationships
gradually disappear, older people’s attachment behaviour is increasingly directed
towards the younger generation – their own children, nurses, doctors and social
care workers. Established attachment styles are still present and are likely to affect
the way an old person responds to their own increasing dependency as well as
their relationships with their adult children who may, or may not become willing
carers.
Attachment is rather good at understanding the moral and behavioural conse-

quences of the way we behave and have behaved in close relationships. As you
sow, so shall you reap, and what goes round comes round. This is particularly true
in the case of old age. Admittedly rather simplistic, there is some truth in the idea
that securely attached children are most likely and willing to take on the role of
caregiver for their parents. Elderly parents with avoidant, dismissing attachment
styles are not only more likely to want to remain independent for as long as pos-
sible, even beyond the time when it is no longer sensible, but are also more likely
to have adult children who are reluctant to assume the role of caregiver. Their
children might be the ¿rst to argue that perhaps residential care is the best option.
Old people whose attachment styles are ambivalent and preoccupied are
most likely to complain that their needs are not being recognised, that they feel
neglected, and that their children have a duty to look after them given all that they,
as parents, have done for their children over the years. Their children are likely to
feel that they are being emotionally blackmailed and although they might agree
that mum or dad can come to live with them, the role of caregiver for such a needy
parent is likely to be fraught with conÀict, dif¿culty, exasperation and resentment.
Of course these mini-scenarios are caricatures, but they hint at some of the pos-
sible uses of an attachment-informed practice in the support and understanding of
old people and their families.
Conclusion
One of the more intriguing ¿ndings of attachment theory is the importance of
being sensitively kept-in-mind by others, particularly at times of need and stress.
This, in turn, helps people learn to keep others in mind. For social workers who
value the importance of the relationship in their work, these ideas help give shape,
substance and direction to their practice. The many different ways in which most
of social work’s clients have not been kept safely in mind by the important people
in their lives explains their particular attachment style, behavioural traits and rela-
tionship conduct. Attachment, therefore, offers social workers a powerful model
with which to understand and work with people who have dif¿culties, are dif¿cult,
or both.
References
Ainsworth, M. D. S., Blehar, M. C., Waters, E. & Wall, S. (1978). Patterns of Attachment:
a psychological study of the Strange Situation, Hillsdale, NJ: Erlbaum.
Baim, C. & Morrison, T. (2011). Attachment-based Practice with Adults: understanding
strategies and promoting positive change, Brighton: Pavilion.
Bateman, A. & Fonagy, P. (2006). Mentalization-based Treatment for Borderline Person-
ality Disorder: a practical guide, New York: Oxford University Press.
Bentall, R. (2009). Doctoring the Mind: why psychiatric treatments fail, London: Allen
Lane.
182 David Howe
Bion, W. (1962). Psycho-analytic study of thinking. International Journal of Psychoanaly-

sis, 43: 306–310.
Bower, M. (2005). Psychoanalytic theories for social work practice. In M. Bower (ed.)
Psychoanalytic Theory for Social Work Practice, London: Routledge, pp. 3–14.
Bowlby, J. (1997). Attachment and Loss: Volume I: Attachment, London: Hogarth Press
Pimlico Edition (Original edition 1969).
Crittenden, P. M. (2008). Raising Parents: attachment, parenting and child safety, Cul-
lompton: Willan Publishing.
Crittenden, P. M. & Ainsworth, M. D. S. (1989). Child maltreatment and attachment the-
ory. In D. Cicchetti & V. Carlson (eds) Child Maltreatment: theory and research on
the consequences of child abuse and neglect, New York: Cambridge University Press,
pp. 432–463.
Farnfield, S. & Holmes, P. (eds) (2014). The Routledge Handbook of Attachment: assess-
Farnfield, S. & Stokowy, M. (2014). The Dynamic-Maturational Model (DMM) of attach-
ment. In P. Holmes & S. Farnfield (eds) The Routledge Handbook of Attachment:
theory, London and New York: Routledge.
Fonagy, P. (2006). The mentalization-approach to social development. In J. G. Allen &
P. Fonagy (eds) Handbook of Mentalization-based Treatment, Chichester: John Wiley,
pp. 53–100.
Fonagy, P., Gregely, G., Jurist, E. & Target, M. (2002). Affect Regulation, Mentalization,
and the Development of the Self, New York: Other Press.
Gross, D. R. & Capuzzi, D. (2007). Helping relationships: from core dimensions to brief
approaches. In D. Capuzzi and D. R. Gross (eds) Counseling and Psychotherapy (4th
ed.) Upper Saddle River, NJ: Pearson, pp. 3–25.
Holmes, P. & Farnfield, S. (eds) (2014). The Routledge Handbook of Attachment: theory,
Howe, D. (2005). Child Abuse and Neglect: attachment, development and intervention,
Houndmills: Palgrave Macmillan.
Howe, D. (2011). Attachment Across the Lifecourse: a brief introduction, Houndmills:
Palgrave Macmillan.
Johnson, S. & Whiffen, V. (eds) (2005). Attachment Processes in Couples and Family
Therapy, New York: Guilford Press.
Lyons-Ruth, K., Bronfman, E. & Parson, E. (1999). Maternal disrupted affective communi-
cation, maternal frightened or frightening behaviour, and infant disorganized strategies.
In J. Vondra & D. Barnett (eds) Atypical Patterns of Infant Attachment, Monographs of
the Society for Research and Clinical Implications 64(3): 67–96.
Magai, C. (2008). Attachment in middle and later life. In J. Cassidy & P. R. Shaver (eds)
Handbook of Attachment: theory, research and clinical applications, New York: Guil-
ford Press, pp. 532–551.
Main, M. & Cassidy, J. (1988). Categories of response to reunion with the parent at age
6: predictable from infant attachment classifications and stable over a 1-month period,
Developmental Psychology, 24: 415–426.
Main, M. & Hesse, E. (1990). Parents’ unresolved traumatic experiences are related
to infants’ disorganized attachment status: is frightened and/or frightening parental
behaviour the linking mechanism? In M. Greenberg, D. Cicchetti & E. Cummings
(eds) Attachment in the Pre-School Years, Chicago: University of Chicago Press,
pp. 161–182.
Main, M. & Solomon, J. (1986). Discovery of a new, insecure disorganized/disoriented

attachment pattern. In T. Brazleton & M. Yogman (eds) Affective Development in
Infancy, Norwood, NJ: Ablex, pp. 95–124.
Meins, E. (1997). Security of Attachment and the Social Development of Cognition, Hove:
Psychology Press.
Meins, E. (1999). Sensitivity, security and internal working models: bridging the transmis-
sion gap, Attachment & Human Development, 1(3): 325–342.
Robertson, J. (producer) (1953). A two-year old goes to hospital: a scientific film record.
[Film]. Nacton, UK: Concord Film Council.
Shah, P. & Strathearn, L. (2014). Similarities and differences of the ABC + D Model and
the DMM classification systems for attachment: A practitioner’s guide. In P. Holmes &
S. Farnfield (eds) The Routledge Handbook of Attachment: Theory, London and New
York: Routledge.
Slade, A. (2008). Working with parents in child psychotherapy: engaging the reflective.
In F. N. Busch (ed.) Mentalization: theoretical considerations, research findings, and
clinical implications, London: The Analytic Press, pp. 207–234.
Stevenson, O. (1974). Editorial, British Journal of Social Work, 4(1): 1.
Van Rosmalen, L., Van IJzendoorn, M. H. & Bakermans-Kranenburg, M. J. (2014). ABC +
D of attachment theory: The Strange Situation Procedure as the gold standard of attach-
ment assessment. In P. Holmes & S. Farnfield (eds) The Routledge Handbook of Attach-
ment: Theory, London and New York: Routledge.
Wilson, K., Ruch, G., Lymbery, M. & Cooper, A. (2011). Social Work: an introduction to
contemporary practice (2nd ed.), Harlow: Pearson Education Ltd.
Winnicott, D. W. (1965). The Maturational Processes and the Facilitating Environment,
London: Hogarth Press.
Index
AAI see Adult Attachment Interview After Adoption 162

ABC model of attachment 2 Ainsworth, M.D.S. et al. 1, 2, 11, 60, 84,
ABC programme see Attachment and 118, 147, 168, 180
Biobehavioral Catch-up (ABC) Allen, J.G. et al. 13, 18
programme Alvarez, A. 36, 45–6
ABC + D model of attachment 3, 170 ambivalent attachment 33–4, 43, 47, 84,
ABFT (attachment-based family 177–9
therapy) 14 American Psychiatric Association
acceptance 110, 112 Diagnostic and Statistical Manual 5
ADHD (Attention De¿cit Disorder) 39 (DSM 5) 11
adoption and fostering 8, 147–64; A-R Dialogue see Affective-ReÀective
assessing adoptive parents 155: (A-R) Dialogue
(Adult Attachment Interview 156–9; Aron, L. 47
Attachment Style Interview 159); ASD (Autistic Spectrum Disorder) 39
assessing attachment in children 150–2; ASI see Attachment Style Interview
assessing foster carers 159–61; assessment of attachment 8–9; and
attachment-based interventions 15–16; adoption 150–2; foster carers 159–61;
child abuse, neglect, trauma 147–8, legal perspective 139, 141–2, 145;
149; children’s needs 152–3: (coherent observation 9, 66; representational
life story 16, 154; move to adoptive measures 9–10
family 153); context 148–9; loss and asylum seekers 148; see also immigrant
grief 126; placement planning 150; communities
supporting adoptive parents and attachment 118–19; and culture 120–3
carers 161–3; supporting children Attachment and Biobehavioral Catch-up
154–5, 163 (ABC) programme 16, 21–2, 95–6
Adoption Reform Programme 149 attachment-based family therapy
Adoption UK 162 (ABFT) 14
Adult Attachment Interview (AAI) 9, 17, attachment-based interventions 3–4;
54, 72, 76, 156–8; in legal cases 139; adoption and fostering 15–16;
loss and trauma 119–20; memory evidence 12; family systems 14;
systems 11–12; for prospective individual therapy for adults 13–14;
adopters 15, 16, 158–9 individual therapy for children 12–13;
adults: individual therapy 13–14 see also attachment-based parent–child
affect regulation 53, 58, 60 interventions
Affective-ReÀective (A-R) Dialogue 111, attachment-based parent–child
112 interventions 4, 7, 14–15, 19–22,
AFFT (Attachment-Focused Family 83–98; ABC intervention 16, 21–2,
Therapy) 107 95–6; attachment security 83–5,
Index 185
86–7; Child–Parent Psychotherapy 20; Booth, P. 105

Circle of Security 14, 20, 105; Borderline Personality Disorders
disorganised attachment 87; (BPD) 11, 57–8
Infant–Parent Psychotherapy 20; Bower, M. 173
for maltreated children 96–7; Bowlby, J. 1, 17, 32, 35, 49, 59, 67–8, 83,
meta-analyses of sensitivity and 117–19, 129, 147, 167, 180
attachment interventions 85–7; Bowlby, R. 121
parental sensitivity 84–7; practical Brazelton, T.B. 36, 44
implications 97–8; Steps Towards Byng-Hall, J. 65
Effective, Enjoyable Parenting 19;
Sunderland Infant Programme 21; Cafcass see Children and Family Court
University of California at Los Angeles Advisory and Support Service
Family Development Project 21; Can You Tell Me? 9
Watch, Wait and Wonder 21; see also Capuzzi, D. 176
Video-feedback Intervention to promote CARE-Index 9, 21
Positive Parenting care proceedings see legal perspective
attachment classi¿cations 171–2 CBT see cognitive behaviour therapy
Attachment-Focused Family Therapy Child and Adolescent Mental Health
(AFFT) 107 Services (CAMHS) 155, 161
attachment-focused interventions 105–6; Child Attachment Interview 9
see also Dyadic Developmental child protection 8–9, 168–9; see also legal
Psychotherapy perspective
attachment-informed psychotherapy 3, 4 child psychotherapy: adopted/fostered
Attachment Pathology 37 children 161
Attachment-Q set 9 child psychotherapy and attachment
Attachment Style Interview (ASI) 15, 159 theory 6, 32–50; clinical cases
attachment theory 1–3, 71 32–4: (Grace 46–9; Lucas 42–6;
‘attachment therapy’ 106 Trevor 37–42)
Attention De¿cit Disorder (ADHD) 39 Child–Parent Psychotherapy (CPP) 20
attunement 113 The Children Act 1989 132, 139
Autistic Spectrum Disorder (ASD) 39 Children and Families Act 2014 149
autonomous adults 156 Children and Families Bill 2013–2014 133
avoidant attachment 43–4, 45, 61, 84, Children and Family Court Advisory and
176–7 Support Service (Cafcass) 133, 144
children in care 142–4, 148–9
‘Baby P’ case 133–4 children: individual therapy 12–13
Bakermans-Kranenburg, M.J. et al. 11, 60, children with chronic illnesses 59–60
61, 85, 86–7, 93, 94, 95, 96, 97 children with emotional/behavioural
Barenboim, D. 62 problems 7, 104–5; attachment-focused
Beebe, B. 45 interventions 105–6; see also Dyadic
behavioural problems see children with Developmental Psychotherapy
emotional/behavioural problems Children’s Guardians 33, 140–1, 142, 143
Bentall, R. 172 Cicchetti, D. et al. 20
Berant, E. 3 Circle of Security 14, 20, 105
bereavement 59; see also loss Cline, F. 106, 107
Berlin, L. et al. 59 Coan, J.A. 14
Bernard, K. et al. 22, 95–6, 97 coercion theory 91; see also Sensitive
Bifulco, A. et al. see Attachment Style Discipline
Interview cognitive-based techniques 11
biological system 5 cognitive behaviour therapy (CBT) 10, 13
Bion, W. 173 College of Social Work 133
Black, M. 16 Conduct Disorder 39
186 Index
containment 173 Eye Movement Desensitisation and

Cook, A. et al. 104 Reprocessing therapy (EMDR) 13
Cook-Cottone, C. 16
Cooper, P. 36 family justice system see legal perspective
countertransference 44 Family Rights Group 133
court proceedings see legal perspective family sculpting 11
CPP (Child–Parent Psychotherapy) 20 family systems 62; attachment-based
Cramer, B.G. 36, 44 interventions 14; theory 5–6;
Crittenden, P.M. et al. 2, 3, 10, 11, 67, triangulation 72; see also systemic
71, 168, 171, 173, 176; see also Adult family therapy practice
Attachment Interview; School Age family therapy 12, 14, 107; see also
Assessment of Attachment systemic family therapy practice
culture see social and cultural systems Farn¿eld, S. 7
curiosity 110, 112 father–infant interaction 98; see also
parent/maternal sensitivity
Dallos, R. 65 Feldman et al. (1995) 58
DDP see Dyadic Developmental Feldman, R. et al. 98
Psychotherapy Field, T. et al. 46
deferred imitation 45 Fletchman Smith, B. 129
depression, maternal 46, 57 Fonagy, P. et al. 3, 7, 17, 36, 54, 58, 104,
Developmental Trauma Disorder 104 170, 174
Diamond, G.S. et al. 14 fostering see adoption and fostering
differential susceptibility 94–5 Fraiberg, S. et al. 14, 20, 62
disabled children 180 fun 45, 53
discipline see Sensitive Discipline
disorganised attachment 3: (adults 157; genetic system 5, 6
cases 33, 39, 42; in children 56, 84–5, George, C. et al. 119–20
87; classi¿cation 171; from parent’s Green, M. 120
perspective 56–7) Greenspan, S.I. 36
dispositional representations 3 grief 126
DMM see Dynamic-Maturational Model Groeneveld, M.G. et al. 93
DMM-AAI 11, 16 Gross, D.R. 176
domains of attachment theory 71 Grossman, K. et al. 107
doubling 114
Dozier, M. et al. 15–16, 21, 95–6, 160–1 Hall, B. 126
DSM 5 (American Psychiatric Association Heinicke, C.M. et al. 21
Diagnostic and Statistical Manual 5) 11 Henderson, K. 162
Dyadic Developmental Psychotherapy Hesse, E. 57, 84
(DDP) 7, 106–15; Affective- Hobson, R.P. et al. 58
ReÀective (A-R) Dialogue 111, Hodges, J. et al. 15–16, 151
112; characteristics 107–8; inter- Hoffman, K.T. et al. 20, 105
subjectivity 108; inter-subjectivity in ‘holding therapy’ 4, 36
therapy 108–11; Phase One 111–12; Holmes, J. 36, 61, 71, 117–18, 128
Phase Two 112–15 Holmes, P. 5, 7
Dynamic-Maturational Model (DMM) 3, Hopkins, J. 36
67, 158; see also DMM-AAI Howe, D. 163
Egeland, B. et al. 19 immigrant communities 8, 117–30;

emotional problems see children with attachment 118–19, 120–3; care of
emotional/behavioural problems children in urban communities 120;
empathy 39, 44, 110–11, 112 loss 119–20, 125–7; nonverbal
expert witnesses 132, 134, 138, 140, 145 communication 129–30; race
externalising disorders 11 and culture 117, 118, 127–9;
Index 187
separation 119, 123–5; somatised lawyer’s dilemmas: confusions in

distress: case study 127 public law 140–4; lawyer’s dilemmas
Incredible Years parent training in private law 144–5; mothers and
programme 15 babies 138; process of assessment 134:
Independent Reviewing Of¿cers (pre-proceedings 134–7, 145; fact-
(IROs) 142, 144 ¿nding and welfare stages 137–9);
individual development 66–71, 108, 180 Public Law Outline (PLO) 132; the way
individual therapy for adults 13–14 ahead 145
individual therapy for children 12–13 Leiden parenting programmes see
inductive discipline 91 Video-feedback Intervention to promote
Infant–Parent Psychotherapy 20 Positive Parenting
insecure attachment 3, 10; adults 12, 157; Leupnitz, A. 62
children 56, 84, 85 Lewis-Morrarty, E. et al. 96
inter-personal systems 5, 7; see also Lieberman, A.F. et al. 20, 105
children with emotional/behavioural life story work 16, 154
problems; sensitive parenting; systemic Lindhiem, O. 15
family therapy practice loss 59, 119–20, 125–7
inter-subjectivity 105, 108–11 Loxtercamp, L. 154
intercultural therapy 117, 128 Luyten, P. 58
intergenerational transmission of Lyons-Ruth, K. et al. 56
attachment patterns 54–6, 122
internal working models 2, 3, 35, 49, 108, Macaskill, C. 16
151, 152, 160 Main, M. 3, 57, 84, 168
internalising disorders 11 maltreated children 14, 20, 96–7,
interviews about caregiving 9–10 147–8, 149, 175; see also child
intra-personal systems 5, 6–7; see also psychotherapy
child psychotherapy and attachment Marris, P. 120
theory; psychotherapeutic work with Mason, B. 66
parents Mason, J. 140
IROs see Independent Reviewing Of¿cers Meins, E. 174
Meltzoff, A.N. 45
Jacobvitz, R. 17 memory systems 11–12
Jernberg, A. 105 mental health social work 180
Juffer, F. et al. 92, 93 mentalisation-based therapy (MBT) 7,
13–14; for children 12; family
Kalinauskiene, L. et al. 93 therapy 14
Kaniuk, J. et al. 157, 159 mentalisation/mentalising 3, 13–14, 36,
Kareem, J. 117, 125, 128 55, 60, 174–6
Kennedy, H. et al. 105 Mesman, J. et al. 93
Kenrick, J. 152–3 migrants see immigrant communities
Klein Velderman, M. et al. 93 Mikulincer, M. et al. 53
Mills, J. 37
Lachmann, F.M. 45 mind-mindedness 173–4, 181
Landini, A. 11; see also Adult Attachment Moran, G. et al. 19
Interview Moss, E. et al. 96–7
lawyer–client relationship 137 mothers see depression, maternal; parent/
legal perspective 8, 132–45; attachment maternal sensitivity
assessments 139, 141–2, 145; Munby, J. 132, 133, 134
Care Proceedings Protocol 137–8; Murray, L. et al. 36, 46, 57
court proceedings 139–40; expert
witnesses 132, 134, 138, 140, 145; Naber, F. et al. 98
family justice system reform 132–4; Nafsiyat Intercultural Therapy Centre 117,
lawyer–client relationship 137; 128
188 Index
narrative story stems see story stems PTSD (post-traumatic stress disorder) 13
narrative styles 54 Public Law Outline (PLO) 132
negativity 56
neurobiology 55–6, 98 Quinton, D. et al. 16
nonverbal communication 108, 114,
129–30, 151, 176 race and culture 117, 118, 127–9; see also
social and cultural systems
Obegi, J.H. 3 Reactive Attachment Disorder (RAD) 12,
Object Relations Theory (ORT) 3 104
observation 9, 66 reciprocity 44
Ogden, P. 42 Reddy, V. 36
older people 180–1 Rees, J. 154
oxytocin 55, 98 reÀective functioning 66, 74, 108, 159,
174
PACE (playfulness, acceptance, curiosity, refugees see immigrant communities
empathy) 7, 109–11, 112, 114, 115 regression therapies 36
Panksepp J. 36 relational problems see children with
Parent-Infant Psychotherapies 105 emotional/behavioural problems
parent/maternal sensitivity 14, 15, 55, representational measures 9–10
58–9, 61, 84–7; see also Representations of Interactions
psychotherapeutic work with parents; Generalized (RIGs) 49
Video-feedback Intervention to promote resilience 156
Positive Parenting Robertson, J. 167
Parent–child Interaction Therapy 13 role-play 61
parent–child interventions see attachment- Rustin, M. 159
based parent–child interventions
parent–child psychotherapy 15 Said, E. 62
Pearce, C. 126 Sander, L. 36
Phillips, M. 125 Sargent, N. 162
play therapy 11, 12, 105 School Age Assessment of Attachment 72
playfulness 109–10 Schore, A.N. 36, 53
playing together 89 Scott, S. et al. 162
PLO (Public Law Outline) 132 secure attachment 48, 55–6, 83–4, 85,
Porges, S.W. 109 86–7
post-traumatic stress disorder (PTSD) 13 self-protection 10, 17
PPT (psychodynamic psychotherapy) 21 self-report measures 12
preschool-parent psychotherapy (PPP) 20 Selwyn, J. 163
Prime Minister’s Review of Adoption 163 Sensitive Discipline (VIPP-SD) 88, 90t,
process and measurement of change 17–18 91–2, 93, 94–5, 97–8
projective identi¿cation 3, 62 sensitivity see parent/maternal sensitivity;
Psycho-educational Parenting therapist sensitivity
Intervention 20 separation 119, 123–5; see also Strange
psychoanalytic psychotherapy 35 Situation procedure
psychodrama 11 Sharpe, J. 129
psychodynamic psychotherapy (PPT) 21 Slade, A. 117, 127, 159, 175
psychotherapeutic work with parents 6–7, social and cultural systems 5, 8, 67,
53–62; clinical implications 59–62; 118, 120–3; see also adoption and
disorganised attachment from parent’s fostering; immigrant communities; legal
perspective 56–7; families 61–2; perspective; social work
intergenerational transmission of social learning theory 15
attachment patterns 54–6; intervention social work 8, 166–81; assessments,
studies 58–9; parents with Borderline supports, interventions 176–9;
Personality Disorders 57–8 attachment across client groups 180–1;
Index 189
attachment and relationship-based This Is My Baby interview (TIMB) 21

social work 172–6; attachment Toth, S.L. et al. 20
classi¿cations 171–2; and child transitional attachment ¿gures 173
protection 168–9; de¿nition 166; mind- treatment selection 10–12
mindedness and mentalisation 173–6; Trevarthen, C. 107, 108
origins of interest in attachment 167–8; triangulation 72
past/present interactions 169–71; Type A 2, 10, 11–12
supervision 176; see also adoption and Type B 2, 11, 12
fostering; legal perspective Type C 2, 10, 11, 12
Solomon, J. 3, 84, 168
somatised distress 127 University of California at Los Angeles
splitting 3 Family Development Project 21
Sroufe, L.A. et al. 68, 104
SSP see Strange Situation procedure Van IJzendoorn, M. et al. 11, 58–9
Steele, H. 157 Van Zeijl, J. et al. 93
Steele, M. et al. 16, 157, 160 Verheugt-Pleiter, A.J.E. 12, 18
Stein, A et al. 93 Vetere, A. 65
Steinberg, G. 126 video feedback 15, 61, 62n, 151
Steps Towards Effective, Enjoyable Video-feedback Intervention to promote
Parenting (STEEP) 19 Positive Parenting (VIPP) 7, 19;
Stern, D.N. 36, 49, 107, 113 development of 88; and differential
Stevenson, O. 172 susceptibility 94–5; effectiveness 92–4,
story stems 9, 151–2, 155, 161 92f; father–infant interaction 98;
Strange Situation procedure (SSP) 2, 9, interventions 89–90, 97–8; Sensitive
54, 118, 150 Discipline (VIPP-SD) 88, 90t, 91–2, 93,
Strathearn, L. et al. 55 94–5, 97–8; sensitivity themes 90–1,
Sunderland Infant Programme 21 90t; supporting sensitive parenting
systemic family therapy practice 7, 61–2, 87–8; VIPP-Child Care 93
65–81; attachment as enhancement of Video Interaction Guidance (VIG) 15,
approach 66–71; attachment as systemic 105
lens 71–3; case study 74–81; role of
the therapist 73–81; systems sensitive Wakelyn, J. 160
model of individual development 67–71 Wallin, D.J. 127
systems 5–6; see also inter-personal Ward, H. et al. 149
systems; intra-personal systems; social Watch, Wait and Wonder (WWW) 21
and cultural systems Waters, E. 53
Webster Stratton, C. 162
Tavistock clinic 32, 35, 167 Wilson, K. et al. 166
therapeutic self-reÀexivity 66 window of tolerance 42
therapist as attachment ¿gure 17–18 Winniccott, D.W. 48, 49
therapist sensitivity 60 Woolley, H. et al. 93
Theraplay 15, 105 World Health Organization 115

Paul Holmes, Steve Farnfield - The Routledge Handbook of Attachment - Implications and Interventions-Routledge (2014)

Uploaded by

Copyright:

Available Formats

Paul Holmes, Steve Farnfield - The Routledge Handbook of Attachment - Implications and Interventions-Routledge (2014)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Paul Holmes, Steve Farnfield - The Routledge Handbook of Attachment - Implications and Interventions-Routledge (2014)

Uploaded by

Copyright:

Available Formats

The Routledge Handbook of

Attachment: Implications and

The Routledge Handbook of Attachment: Implications and Interventions offers

ISBN: 978–1–138–01672–9 (pbk set)

Typeset in Times New Roman

2 Attachment theory and its uses in child psychotherapy 32

3 Where the child is the concern: working psychotherapeutically

4 The marriage of attachment theory and systemic family therapy

5 Attachment-based interventions: sensitive parenting is the key

6 Attachment-focused therapeutic interventions 104

7 Clinical implications of attachment in immigrant communities 117

8 Attachment: a British lawyer’s perspective 132

9 The applications of attachment theory in the ¿eld of adoption

10 Attachment and social work 166

Psychotherapy (Routledge, 2010). He was recipient of the 2009 New York

International Contributions to Child Development award of the Society for

This volume is a companion to The Routledge Handbook of Attachment: Theory

Attachment is ¿rst and foremost a relational theory. It has given us a way of

• Type A Carers of infants in Type A are predictably rejecting of ‘unneces-

One starting point – two theories of attachment

her colleagues developed a fourth category, disorganised-disorientated (Main &

Other related theories

What are ‘attachment-based’ interventions?

occurred following a particular treatment. At a minimum this requires pre/post

Do we need specific attachment-based treatments?

Wheels within wheels: systems within systems

Genetic That which is inherited but which is open to change after

To take a very brief, simple, example:

Inter-personal system The difficulties caused by a distressed and angry act-

It must be stressed, however, that there are always reciprocal interactions

Genes and biology

Social and cultural systems

The assessment of attachment: an overview

discussions of how to use assessments of attachment in forensic settings see Main

The selection of treatment

Treatment by memory systems

Attachment-based interventions – what is the

Individual therapy for children

might be treating post-traumatic stress disorder (PTSD) in children. A variety of

Individual therapy for adults

Mentalisation- based treatments (MBT)

¿gure in childhood) distorts the capacity to mentalise. Attachment is about rela-

Adoption and fostering

foster parents had a disproportionate number of children rated disorganised (Doz-

Life story work

The process and measurement of change

The therapist as an attachment figure

Parent–child attachment-based interventions

Video-feedback Intervention to promote Positive Parenting (VIPP)

The Steps Towards Effective, Enjoyable Parenting (STEEP)

Infant or Child–Parent Psychotherapy (CPP)

The Circle of Security

Watch, Wait and Wonder (WWW)

University of California at Los Angeles (UCLA) Family Development Project

Sunderland Infant Programme

Attachment and Biobehavioral Catch-up (ABC)

maltreating families through preventive interventions’, Development and Psychopathol-

for family court decision-making: A forensic protocol for empirically-based evidence

with traumatized young children in kinship care: Adaptation of an evidence-based