19th Nov 2010
Dr Helen Brotherton
Session Outline
 Historical perspectives on Attachment Theory- the
work of Bowlby & others
 Importance of ‘Bonding’ and Infant Mental Health
 Update on Contemporary Attachment Theory
 Disruptions in Childhood Attachment
 Research on links between early attachment and
later mental health difficulties
 DVD- Clinic illustrations of attachment &
How Attachment theory fits in
 Initial Group Exercise
"What does the term attachment mean to
people? What words, phrases, concepts,
understandings etc .......”
“What’s your understanding of Attachment
Theory? ….”
Historical Perspectives on
Attachment Theory
 From 1910 onwards, 2 theories were dominant in
understanding a child’s tie to its mother: Psychoanalytic theory; and
 Social learning theory
 These theories both emphasized that a relationship
developed when the mother feeds the infant ->
leading to a pleasurable relationship when hunger
is satisfied
 These theories were described as ‘secondary drive
dependency theories’ by Bowlby
‘Secondary drive dependency’
Theories of Attachment
 Cupboard love theories, as
they became known, were
therefore dominant
 The rationale being:- we
attach to our mother because
she feeds us (Dollard, Millar,
Freud etc).
 Primary drive is food ->
leading to a Secondary drive
for attachment.
Evidence against ‘Cupboard
Love Theories’
 Bowlby noticed evidence
from animal studies
challenged previously held
 Lorenz noted infant geese
attached to parents who did
not feed them:- therefore,
imprinting seemed to occur
during a critical period due
to exposure
Evidence against ‘Cupboard
Love Theories’
 Harlow observed infant rhesus monkeys
 The studies found that, in times of stress, monkeys
preferred a more comforting cloth-covered
‘mother’ figure to feed them, rather than the wiremesh ‘mother
 Evidence also grew to show that human infants
became attached to people who did not feed them
 So Bowlby (1980) noted:“if the secondary drive dependency theory was
inadequate, what was the alternative?”
Attachment Theory - the
contribution of Bowlby
 Bowlby - British child psychiatrist, part of the
psychoanalytic community, training when objectrelations (Kleinian) theories were dominant
 Supervised and analyzed by Melanie Klein, but
differences began emerging between him and
others in the psychodynamic community
 Bowlby’s view led his to be ignored by the
psychoanalytic community & only considered
relevant in recent years (ie Fonagy, Holmes etc)
Attachment Theory - Differences
between Bowlby & Analysts
 Bowlby’s work evolved from observing the impact
of WWII & working in a home for maladjusted
boys - the impact of separations, losses and
disruptions in close relationships
 The answer came when Bowlby considered the
child’s actual experience with its primary
attachment figures - he considered this to be the
“bedrock of psychic structure” (Lemma, 2003)
Bowlby’s Theory of Attachment
 Bowlby developed an ethological theory, which
suggested that:“the infant attachment bond is an instinctually guided
behavioural system that has functioned throughout
human evolution to protect the infant from danger”
 With this evolutionary based theory, fear of
strangers and other threats to survival is innate
Bowlby’s Theory of Attachment
 Bowlby considered that infants preferred a
principal attachment figure for comfort and
security = ‘monotropy’
 This monotropy theory has gained support, but
some researchers remain critical
 Some writers report ‘attached’ and ‘unattached’
infants and Bowlby thought that without
attachment, we get affectionless psychopathy
 Others have considered there to be no such thing
as ‘no attachment’
Bowlby’s Theory of Attachment
 Attachment behaviours, such as smiling &
vocalizing, are signalling behaviours which alert
mother to child’s interest & bring her to the child
 Others, ie crying, are aversive, but bring mother
->child and signal something needs terminating
 Bowlby believed the attachment process is
assisted by Fixed Action Patterns, which are
instinctive and biological
 Fixed Action Patterns are complex behaviours
which can aid attachment formation, including
grasping, crying and smiling (Ainsworth)
Bowlby (cont)
Attachment behaviours
using mother as a secure base to explore
signalling to mother to ensure her proximity
different behaviours are used with different
types of attachment
So Attachment is about….
 …the ability of individuals to use attachment
figures as a secure base from which to
explore and
 …a safe haven in times of fear, distress or
 …the extent to which caregiver responses are:
 Reciprocal
 Sensitive (accurate interpretation of signal)
 Consistent
 Offer comfort, calm & enable feelings of safety
Schafter’s Theory of Attachment:
Separation Anxiety
 Shafter’s work particularly looked at attachment
and separation reactions
 Three stages of attachment, generally presented
as: 6/52-3/12 - attach to anyone
 3-8/12 - knows strangers are different but not scared of
 8+/12 - separation and stranger anxiety
 From 3 years, develop trust in mother’s permanence
and can move away from them
Ainsworth: Separation
 Ainsworth, colleague of Bowlby,
did pioneering naturalistic
observations of mothers and
 She developed the ‘Strange
Situation’ assessment, studying
parent-infant reactions
 Study = parents in lab setting are
separated then reunited with their
Ainsworth: Separation
 Ainsworth (& Main later) developed three
main types of attachment A, B & C (plus
later type D- disorganised)
 Intra and cross cultural differences and
children can move between groups
 Key is mother’s sensitivity to needs
‘Strange Situation’ results Responses to Separation
 Type A- Insecure Avoidant (20%)- little bond with
mother, not too upset by separation, but hates being
alone so comforted by stranger, whilst actively
avoids seeking contact with parent
 Type B- Securely attached (60%)- distressed by
parent leaving but seeks parent and can easily be
consoled on return
 Type C- Insecure Ambivalent (20%)- little security
in bond initially, when separated becomes very
distressed, difficulty being soothed on reunion
The Importance of the Very Early
Life - Infant Mental Health
 Attachment theorists emphasize the impact
of very early bonding experiences, as well
as later childhood events
 In terms of development, Bowlby
considered that the 1st year is a ‘sensitive
period’, but the critical period for
attachment may be up to 3 years
The Importance of Infant Mental
Health 0-12 months
Pregnancy, birth and ‘bonding’
- during these processes, parents experience
negative & positive feelings, from distress and
anxiety to intense happiness
- when baby is born, he/she is also at the mercy of
such extreme feelings
- ‘bonding’ is the development of a deep
relationship, through painful experiences as well
as good times
Infant Mental Health
0-12 months
First few days
- babies have distinct personalities and
different responses to the trauma of birth
- early stages can feel ‘messy’ both
emotionally & physically for parents
- parents can be struggling to live up to ideals
- getting to know the baby and developing a
relationship is the primary task
Infant Mental Health
0-12 months
Tavistock Case material
“A central belief … is that a baby cannot be
understood in isolation. She is born into a
complex relationship with her primary carers ….”
“things will not be broken beyond repair:
recovering from difficulties … for both baby and
parents, is an essential part of getting to know and
love each other.”
(Boswell, 2004; p.9)
Infant Mental Health
0-12 months
The first 6 weeks
- both parents and babies can feel at their
most vulnerable and terrified
- babies will be feeling bewildered and lost,
and life feels chaotic, frightening and
without boundaries
- the parents’ moods affect the baby and the
baby’s moods affects the parents
Infant Mental Health
0-12 months
Tavistock Case material
* Matt, becoming a father for the 1st time….
“I’d never known my own father, and suddenly
here I was being a father to Thomas. One day … I
was washing up and suddenly I was in floods of
tears. I never remember missing my father when I
was growing up, but I suddenly felt I was missing
him now.” [p.30]
Infant Mental Health
0-12 months
Three to six months
- importance of feeding -> highlights babies’
individual temperaments & personalities
- baby begins to separate from mother &
already uses play to make sense of feelings
- parents’ and baby’s emotions are closely
entwined- each is intensely affected by the
Infant Mental Health
0-12 months
Tavistock Case material
“A baby of 6 months is much more aware of
her feelings.. No longer so bewildered by
the newness of life, no longer at the mercy
of chaotic feelings or happenings which
spring out from nowhere, she has a secure
base around her, and growing resources
inside.” [p.48]
Infant Mental Health
0-12 months
Six to Twelve months
- baby begins to integrate his/her feelings and
thoughts, creating a more coherent view of the self
and others
- life is full of emotional extremes for baby
- baby’s emotional development depends on his/her
parents’ ability to bear frustration and to allow
themselves & baby to be human
Infant Mental Health
0-12 months
Tavistock Case material
 Seeing himself in a new light
“Feeling less passive,more in control and more of
an individual, he will gradually join the rest of
humanity” [p.50]
 Seeing his mother in a new light
“now, the baby is discovering that his mother is a
whole, separate person, someone who … can…
fail to understand his needs” [p.50]
Infant Mental Health ->
Attachment theory and Bonding
Attachment theory focuses on …
- how loss and separation need to be continually,
and frequently, negotiated in the 1st year of life,
with weaning, parental return to work etc
- how babies need to experience being fully known
and ‘held in mind’ for the child to feel integrated,
secure and understood
- the impact of normal disruptions and the
importance of 'good enough' parenting ….
Contemporary Attachment
Four main findings from Attachment Theory:1) Universality hypothesis- in all cultures, human
infants become attached to 1+ specific caregivers
2) Normality hypothesis- secure attachment is
numerically & physiologically normal (70%)
3) Sensitivity hypothesis- attachment security is
dependent on sensitive & responsive caregiving
4) Competence hypothesis- differences in
attachment security lead to differences in social
[Van Ijzendoorm & Sagi, 1999]
Contemporary Attachment
Holmes (2001) added three further hypotheses:5) Continuity hypothesis- childhood attachment
patterns significant impact on relationship skills &
mental representations in adulthood
6) Mentalization hypothesis- secure attachment
leads to capacity to reflect on self & others’ states
of mind (mentalization)
7) Narrative competence hypothesis- childhood
secure attachment is reflected in how adults’ talk
about their lives, past, relationships & related pain
Contemporary Attachment
 Attachment Relationship can be defined
by: i) proximity seeking to preferred figure;
ii) the secure-base effect; and iii) separation
protest (Weiss, 1982)
 Attachment categories/styles:- i) secure
(2/3); ii) insecure avoidant (1/5); iii)
insecure ambivalent (1/6); and iv)
disorganized (1/20)
How do different Attachment
Categories/Styles emerge?
 Bowlby- recognized importance of environment,
contexts, circumstances, relationships and
interactions in a way not previously considered
 Emotional development was recognized as as
important as physical development
 Events/interactions that disrupted the interaction
with attachment figures were seen as crucial to
emotional development
 Further work focusing on emotional development
was conducted by Ainsworth, Main, Lyons-Ruth
Overview: Attachment strategies
We use the most effective strategy to ensure
responsiveness of caregiver…..
 ‘Security’ is about flexible integration of both
minimizing and maximizing expressions of
attachment needs
 So called ‘Disorganized’ classifications are
thought to occur where no single strategy works
effectively, and where caregiver is simultaneously
a source of comfort and fear ie childhood abuse
Overview: Attachment strategies
We use the most effective strategy to ensure
responsiveness of caregiver…..
 For some, this means emphasising exploration &
minimizing expression of attachment needs
[minimizing/ ‘deactivating’ strategies]
 Overemphasis = ‘Avoidant’/ ‘Dismissing’
 For some, this means emphasising attachment &
maximizing expression of attachment needs
[maximizing/ ‘hyperactiviting’ strategies]
 Overemphasis =‘Ambivalent’/ ‘Preoccupied’
Are Attachment Strategies
constant from infant to adult?
Different perspectives…
1) Two Models of Attachment stability/instability:i)existing representations are revised/updated
with new experiences- early styles ‘overwritten’
ii) representations from 1yr are preserved &
continue to influence behaviour thru life [Fraley]
2) Client’s ‘constant attitude’ (Reich)
-> one attachment style? Category? (AAI)
3) Repertoire of attachment styles? -> Dimensions
rather than discrete categories? (Holmes, 2001)
Contemporary Attachment
Early attachment factors leading to patterns: i) Secure - parents-children play, ‘good enough’
parenting, child can express negative emotions
 ii) Insecure avoidant - parent rejects child’s
contact/ emotions -> child withdraws
 iii) Insecure ambivalent - emotionally
inconsistent parent,‘parentified child’
 iv) Disorganized - parent doesn’t have child in
mind, attachment figure may be maltreating child
Contemporary Attachment
Implications in Adult life/relationships: i) Secure - working model of self as worthy of
care, autonomous, regulates negative emotion
 ii) Insecure avoidant - dismisses rels, compulsive
self-reliance, shuts down to avoid distress
 iii) Insecure ambivalent - clinging/ neediness, self
worth low, hyper-vigilance to distress
 iv) Disorganized - chaotic, fear of intimacy,
expects rejection (approach/avoidance conflict)
Adult Attachment Types - AAI
Adult Attachment Interview (AAI) (Main): i) Secure-autonomous - logical, concise, coherent
 ii) Insecure Avoidant - unelaborated, childhood
amnesia (life seen as good, but don’t know why)
 iii) Insecure Ambivalent - rambling, inconclusive
 iv) Disorganized - disjointed, broken narratives
• Clinical use/research base - see Steele & Steele
Disruptions in Childhood/Early
Group Exercise: What may we actually mean by childhood/
early attachment disruptions?
 What events, circumstances, relationship
patterns etc do you think we would be looking
for, in the histories our child or adult patients
with insecure or disorganized attachments?
 How may disrupted attachments present?
Disrupted Attachment
 Spitz- breaking attachment in
first few years leads to
depression with physical and
mental deterioration (studied
privation in institutions)
Short term separation
 Bowlby considered a universal
pattern of reactions to shortterm separation ->
Protest -> despair ->detachment
Disrupted Attachments: Risk
Factors to Babies/Infants
Negative risk factors to attachment & bonding in
infants [the bad news…]
 Difficulties with pregnancy, labour & birth
 Child’s developmental difficulties
 Parents’ mental health problems -> post-natal
depression, past abuse histories
 Domestic violence & other forms of abuse
 Single parenthood, teenage parenthood and poor
social support
 Child’s temperament
Disrupted Attachments: Risk
Factors to Babies/Infants
Negative risk factors for babies [more bad news..]
• Gerhardt (2004) ‘Why love matters’ book
”quality of the relationship between parent and
child influences both the biochemistry and the
structure of the brain” (p.211)
• The baby’s nervous system is more vulnerable
early on -> very early experiences are crucial
• Early experiences of affection, nurturing and
attachment impact on both emotional & cognitive
development -> early brain developments continue
to have an impact in later life
Disrupted Attachments: Risk
Factors to Children
Most disruptive if:
7-36/12 old
poor language
have pre-existing behavioural problems
initial bond was poor
no previous history of separations
only one attachment
Disrupted Attachments: Risk
Factors to Children
Negative risk factors [more bad news ….]
 All forms of abuse can cause disruptions to the
security and attachment of a child:- physical,
sexual and emotional abuse.
 Neglect has interestingly been found to have some
of the most profound effects - are inconsistent
attachments better than no attachments at all?
 This research influences current policy to try and
keep families together, despite their difficulties
Positive Factors for Infant and
Child Attachment
The Good news for infants ….
• Mothers mis-attune with their babies more times
than they attune (about 70%) - human beings are
therefore very forgiving & resilient (60-70%
‘securely’ attached)
• ‘Angels in the nursery’ - One secure figure may
be enough, even if parental bonding is poor
• Child’s temperament
• Resilience and normal pathology!
Impact of long term disruptions
 Most common is death and divorce
 Contexts around death and divorce can lead to
more or less traumatic responses
Long term disruption
 Can lead in children to:
separation anxiety
psychosomatic reactions
aggressive and demanding behaviour
clinging or detachment from other attachments
Disruptions in Childhood/Early
Attachment- the Research
a) Loss- incl actual loss & prolonged absences,
eg parental illness, death, family disruptions leading
to foster/care placements circumstances/
 caregiving before & after the loss are also critical
b) Stressful Events- incl marital conflict, divorce,
parental illness/dysfunction, parent-child conflict
 affect attachment when child perceives threat to
the attachment bond or caregiver availability
 an insecure child defensively distorts signals/
strategies, perceiving a threat
Disruptions in Childhood/Early
Attachment- the Research
c) Abuse & Trauma- incl sexual, physical or
emotional abuse, and neglect
 abuse impacts on child’s attachment style, both as
trauma and context in which abuse occurs
 nature of the abuse/abuser is important
 ‘perverse paradox’ of abuse [Holmes]- vicious
circle where adult carer is both attachment figure
child turns to for protection and is the main source
of threat child needs protection from More frightened/in pain child becomes, the more
they cling to the perpetrator
Disruptions in Childhood/Early
Attachment- the Research
d) Quality of caregiving- inadequate caregiving’s
been linked to all forms of later psychopathology
 Perceived threats to carer availability incl: prolonged absence * emotional disengagement
 rejection * harsh discipline *neglect [most sig?]
 inadequate control * over-protection
 unresponsiveness *physical inaccessibility
 disrupted communication
 witnessing violence/suicide
Disruptions in Childhood/Early
Attachment- the Research
Most importantly, it is not just disruptions per se that
influence attachment responses…..
But cognitive appraisals/perception of threat
following separation/loss-> these develop into
‘Internal Working Models’ of adult attachment
A child’s attachment responses will therefore be
based on: i) Intrapersonal processes- IWM; strategies
 ii) Interpersonal processes- sensitivity; positive
parenting; open communication
Links between early attachment
& later mental health difficulties
Holmes:- We can speculate about different forms of
abuse/loss underlying attachment styles, ie
 Avoidance may arise with parental aggression
 Ambivalent patterns may follow from CSA by
 Disorganized style may result from parental
neglect, where child despairs of finding a
workable attachment strategy
But, this is over-schematic, with mixed patterns
more common in clinical presentations
Links between early attachment
& later mental health difficulties
Holmes- thought about obvious links between adult
psychological reactions and attachment styles: Sadness- if an attachment bond is severed
 Depression- if there are threats to status in a group
 Anger or Anxiety- if an attachment bond is under
threat; Phobias- excessive fears of attack
 Mania- has a triumphant/delusional sense that
attachment bonds can be dispensed with
 BPD- where minor threats to attachment bond are
experienced as devastating
Research on links between early
attachment and later AMH
Conclusions from research: “Attachment-related events, such as loss and
abuse, lead to modifications in these internal
representations and affect a child’s strategies for
processing thoughts and feelings.”
 Therefore, they become “more vulnerable to
psychopathology” [Handbook of Attachment]
 But, are Holmes’ predictions of associations
between particular attachment styles and
development of specific disorders borne out in
research findings?
Research on links between early
attachment and later AMH
 Evidence looking at linking infants’
behavioural strategies to psychopathology
in adulthood is limited
 More research is available looking at links
between attachment-related events in
childhood and later psychopathology/
mental health conditions
Research on links between early
attachment and later AMH
 Extensive, but complicated body of research
 Some longitudinal studies look specifically at
attachment-> childhood/adolescent/adult
psychopathology, ie
 Minnesota Parent-child project
 Lyons-Ruth et al
 Key attachment researchers to consider are:Ainsworth; Main; Sroufe; Egeland; Cassidy;
Lyons-Ruth; Crittenden; Fonagy etc
Research on links between
attachment strategies and AMH
Insecure defensive strategies [Main, Holmes etc]: a) ‘Minimizing strategies’[‘deactivating’]defensively turning attention away from distress
= develop limited access to own feeling
-> predispose child to externalizing disorders
 b) ‘Maximizing strategies’[‘hyperactivating’]defensively turning attention towards own distress
= unable to accurately appraise threats
-> predispose child to internalizing disorders
Research Conclusions
 Findings re: Attachment states of mind
show some consistencies & inconsistencies
 Classification system has changed over time
& comorbidity is difficult to assess
 Overall though, psychiatric disturbance is
nearly always linked to insecure states,
unresolved states and disorganized patterns
are over-represented
Summary of links between
Attachment and Mental Health
 Mood Disorders- linked to all 3 attachment types
 Bipolar Disorder- under-researched
 Anxiety Disorders- ‘preoccupied’ but also
‘unresolved to trauma’
 Eating Disorders- predominantly insecure, mixed
categories depending on classification
 Schizophrenia- high proportion of ‘dismissing’
but difficult to assess
 BPD- strong links with ‘disorganized’ categories
 Antisocial PD- ‘unresolved’ & ‘dismissing’
DVD- Exploring attachment
links to AMH difficulties
Cases of mothers with PND….
 Mothers’ attachment patterns have been shown to be
correlated to their baby’s patterns
‘Help me love my baby’ DVD
 Look at the mirroring between mother & child
 Think about how the mother’s early attachment
disruptions may have impacted on her attachment style
and her later development of post-natal depression
 Think about the mothers’ narratives attachment
strategies, both in her early life and now in adulthood
 Think about the infant’s attachment strategies, both at 6
months and at 16 months- why these styles?

Attachment presentation - the Peninsula MRCPsych Course