Why Attachment Matters in Adult Psychotherapy

By Dr. David Elliott and Dr. Traill Dowie

At the IAT Institute, a common question we get asked regularly is why attachment matters to adults? While we do not believe attachment is a catch-all that explains all mental health problems, it is unquestionably an important part of human psychological life. Research varies, but it is widely thought that attachment insecurity affects a minimum of around 40% of adults in the USA. Estimates of the prevalence in other countries range from 30% to over 90% (the latter in Russia). Critically, for those interested in psychological treatments, a wide range of psychological conditions are correlated with attachment insecurity, largely due to the manner in which individuals suffering from insecure attachment often face difficulties in developing a coherent sense of self, struggle relationally, and exhibit poor emotion regulation.

So, what is this idea of attachment that is so popular today? Attachment theory traces its origins to the 1930s when the so-called father of attachment theory, John Bowlby, a psychoanalyst who was fascinated by the scientific field of ethology, began his research on child development and maternal deprivation while working in a home for maladjusted boys. His clinical experience and subsequent studies laid the groundwork to highlight the profound impact of disrupted early caregiver relationships on child and later life mental health. In the 1940s, Bowlby developed the initial concepts of attachment theory. In 1958, he introduced the concept of the 'attachment behavioural system' in The Nature of the Child's Tie to His Mother. 

Cross-cultural studies into attachment were pioneered in the 1960s by who we consider the mother of attachment theory, Mary Ainsworth.  She conducted the Uganda Study of Infant Care and Development. 

Bowlby's and Ainsworth's work outlines and explains that our experiences of early interactions with caregivers get internalized in the form of what Bowbly termed internal working models (IWMs). IWMs develop between 12 and 20 months of age and are based on our early attachment experiences. These models reflect and represent what we've experienced in our early relationships, and influence our future relationships and mental health by functioning as templates that create expectations of what we'll experience in relational life. 

Through the studies of Mary Ainsworth and several of her close graduate students, attachment theory has identified several distinct attachment patterns: The most well-known are secure, and three forms of insecure: anxious-preoccupied, dismissive-avoidant, and disorganized. Each of these patterns has a distinct impact on psychological and relational development.

Individuals with insecure attachment patterns are more vulnerable to a whole host of psychological difficulties and even disorders. They often report struggling to form and maintain healthy relationships, and of experiencing difficulties in trust, intimacy, and conflict resolution. Let's look now at some research findings about the association between attachment insecurity and major psychological disorders.  

Mood Disorders, such as Major Depression and Bipolar Disorder, are known to be significantly influenced by genetic factors, with heritability rates in some studies as low as the thirty percent and in other studies ranging all the way up to around eighty-five percent (Sullivan et al., 2000; Kendler et al., 2018).  While mood disorders are significantly influenced by heritable factors, attachment research into mood disorders such as depression indicates a moderate association between depression and attachment insecurity (Spruit et al., 2020). Additionally, it has long been recognised that early loss and inadequate care are identified as increasing the risk for developing depression in later life (Bifulco et al., 1987, Bifulco et al., 2002). As such attachment insecurity should be recognised as an important dimension of depressive presentations in clinical practice.

Similarly, Anxiety Disorders, such as Generalized Anxiety Disorder (GAD), Panic Disorder, Phobias, and Obsessive-Compulsive Disorder (OCD), have been shown through research to have various attachment-related predictors (Picardi et al., 2013; Nielsen et al., 2017). For instance, resistant attachment in infancy is linked to anxiety in adolescence (Warren et al., 1997). GAD has a high heritability rate and is associated with parental rejection and role reversal (Cassidy, 1995). Panic disorder and agoraphobia are often preceded by early separations from mothers (Faravelli et al., 2001).

An incredibly important area implicated in attachment insecurity is trauma. Studies have shown that high levels of adverse childhood experiences (ACE) may result in an insecure attachment pattern and low psychological and emotional resilience, which likely contributes to higher levels of later life psychological distress and trauma. Thus we may consider attachment and resilience as important factors to consider for both preventative and responsive interventions within mental health care. (Katie, et. al, 2024).  Traumatic presentations are frequently include the presence of a Dissociative Disorder. Individuals with dissociative disorders frequently report a high incidence of past abuse (Putnam, 1991). Disorganized attachment in infancy is a predictor of dissociative symptoms (Liotti, 2006), and unresolved trauma is often associated with these symptoms (Macdonald,et.al, 2008). 

The psychiatric disorder with a strongest and most consistent correlation with attachment insecurity is Borderline Personality Disorder (BPD). Characteristics of BPD include an unstable sense of self and prominent instability in relationships, fear of abandonment, and significant emotional dysregulation. BPD is often linked to early abuse, prolonged separations, and maternal neglect (Crawford et. al, 2009, Zanarini et. al., 2000). Across studies, 64% to 90% of BPD patients have a prominent form of attachment insecurity, particularly preoccupied or disorganized patterns (e.g., Fonagy et al., 1996). 

Eating Disorders such as Anorexia have been linked to the dismissing attachment pattern, while bulimia has been associated with the preoccupied pattern (Fonagy et al., 1996). Among women with eating disorders, one study reported that 79% were classified as dismissing, and 27% as unresolved/disorganized (Barone & Guiducci, 2009). 

These and other findings make clear that attachment dynamics have a prominent role in mental health and distress across a variety of presentations. When someone comes for psychotherapy for any mental health condition, there is great value in assessing whether the person's attachment dynamics reflect security or insecurity.  If insecurity is present, addressing that first, even before the specific issue that led the person to therapy, can make the therapy more effective and more efficient for resolving the presenting problems.  We have found that this is especially true when someone comes to therapy for a post-traumatic condition. 

References:

Barone, L., & Guiducci, V. (2009). Attachment mental representations in eating disorders: A pilot study using the Adult Attachment Interview. Attachment & Human Development, 11(4), 405-417. 

Bifulco, A. T., Brown, G. W., & Harris, T. O. (1987). Childhood loss of parent, lack of adequate parental care and adult depression: A replication. Journal of Affective Disorders, 12(2), 115-128.

Bifulco, A., Moran, P. M., Ball, C., & Bernazzani, O. J. S. P. (2002). Adult attachment style. I: Its relationship to clinical depression. Social Psychiatry and Psychiatric Epidemiology, 37, 50-59.

Cassidy, J. (1995). Attachment and generalized anxiety disorder. In D. Cicchetti & S. L. Toth (Eds.), Emotion, cognition, and representation (pp. 343–370). University of Rochester Press.

Crawford, T. N., Cohen, P. R., Chen, H., Anglin, D. M., & Ehrensaft, M. (2009). Early maternal separation and the trajectory of borderline personality disorder symptoms. Development and Psychopathology, 21(3), 1013-1030.

Faravelli, C., & Paionni, A. (2001). Panic disorder: Clinical course, morbidity and comorbidity. In Anxiety Disorders: An Introduction to Clinical Management and Research (pp. 51-79).

Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., … & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64(1), 22.

Liotti, G. (2006). A Model of Dissociation Based on Attachment Theory and Research. Journal of Trauma & Dissociation, 7(4), 55–73. https://doi.org/10.1300/J229v07n04_04

Macdonald, H. Z., Beeghly, M., Grant-Knight, W., Augustyn, M., Woods, R. W., Cabral, H., … & Frank, D. A. (2008). Longitudinal association between infant disorganized attachment and childhood posttraumatic stress symptoms. Development and Psychopathology, 20(2), 493-508.

Nielsen, S. K. K., Lønfeldt, N., Wolitzky-Taylor, K. B., Hageman, I., Vangkilde, S., & Daniel, S. I. F. (2017). Adult attachment style and anxiety–The mediating role of emotion regulation. Journal of Affective Disorders, 218, 253-259.

Picardi, A., Caroppo, E., Fabi, E., Proietti, S., Di Gennaro, G., Meldolesi, G. N., & Martinotti, G. (2013). Attachment and parenting in adult patients with anxiety disorders. Clinical Practice and Epidemiology in Mental Health: CP & EMH, 9, 157.

Putnam, F. W. (1997). Dissociation in children and adolescents. Guilford Press.

Spruit, A., Goos, L., Weenink, N., Rodenburg, R., Niemeyer, H., Stams, G. J., & Colonnesi, C. (2020). The relation between attachment and depression in children and adolescents: A multilevel meta-analysis. Clinical Child and Family Psychology Review, 23, 54-69.

Sullivan, P. F., Neale, M. C., & Kendler, K. S. (2000). Genetic epidemiology of major depression: Review and meta-analysis. American Journal of Psychiatry, 157(10), 1552-1562.

Warren, S. L., Huston, L., Egeland, B., & Sroufe, L. A. (1997). Child and adolescent anxiety disorders and early attachment. Journal of the American Academy of Child & Adolescent Psychiatry, 36(5), 637-644.

Zanarini, M. C. (2000). Childhood experiences associated with the development of borderline personality disorder. Psychiatric Clinics of North America, 23(1), 89-101.