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Attachment from a

Clinical Perspective

Jon G. Allen, PhD


Director of Psychology
The Menninger Clinic

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Some pioneers
John Bowlby
founder of attachment theory, based on his investigation of
mental health implications of children’s reactions to
separation
Mary Ainsworth
investigated individual differences among infants in patterns
of attachment
Mary Main
pioneered research on attachment in adults
Peter Fonagy
articulated the role of mentalizing in attachment
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058
Core functions of attachment
safe haven provides a feeling of security (regulation
of emotional distress and physiological arousal)

secure base fosters exploration of the outer world


and the inner world, including exploring the mind
(mentalizing)

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Ainsworth’s Strange Situation
Infant and mother brought into an unfamiliar but
comfortable room filled with toys
Stranger enters
Mother departs, leaving infant with stranger and toys
Mother returns, pausing to give the infant a chance to
respond to her return
Stranger leaves the room
Mother leaves the infant alone in the room
Mother returns
Test: infant’s response to reunions with mother
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058
Patterns of infant attachment
Secure
reunites with mother after separation to regulate distress
then confidently returns to play
Avoidant
seemingly indifferent to mother’s absence and return but
unabated physiological arousal reflects attachment distress
Resistant (Ambivalent)
makes contact with mother but distress does not abate;
clingy and frustrated
Disorganized
no stable attachment strategy; fright without solution
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058
Attachment relationships beyond infancy
Parents
Siblings
Extended family
Friendships
Romantic relationships
Teachers/mentors
Clergy
Therapists

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Attachment as a model for relationship with self
Secure
confident in self-concern, understanding, and
compassion (mentalizing, with the freedom to
think and feel)
Avoidant
self-neglect; lack of attunement to self; dismissing
attitude toward problems and distress
Ambivalent
abusive relationship; self-hating; frustrated with
self

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Patterns of adult attachment
Secure
confident in the physical and emotional availability of the
attachment figure
Dismissing (avoidant)
lack of reliance on attachment to regulate distress;
counterdependent; turn down the dial on attachment
Preoccupied (entangled)
intense attachments characterized by feeling deprived and
frustrated; turn up the dial on attachment; “kick and
cling”
Fearful (disorganized)
no workable attachments; isolated and fearful
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058
Adult attachment from a dimensional
perspective
calm

SECURE DISMISSING

close distant

PREOCCUPIED FEARFUL

anxious
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058
Defining mentalizing
ƒ Attending to mental states in self and others
ƒ Holding mind in mind
ƒ Holding heart and mind in heart and mind
ƒ Mindfulness of mind
ƒ Understanding misunderstanding
ƒ Seeing oneself from the outside and others
from the inside
ƒ Knowing how your mind works

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Mentalizing interactively

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Mentalizing interactively and emotionally

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Intergenerational transmission:
Overview
parental security of attachment ↔ parental mentalizing capacity

mind-minded interactions with infant

infant secure attachment (comfort seeking)

enhanced mentalizing capacity in childhood

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Attachment trauma
ƒ Trauma that occurs in an attachment relationship,
in childhood or adulthood

ƒ Trauma that adversely affects the capacity for


secure attachment (e.g., evokes fear, distrust,
expectation of betrayal)—abuse and neglect,
primarily

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Intergenerational transmission of trauma

parental attachment insecurity ↔ impaired parental mentalizing capacity

non-mentalizing interactions with infant

infant attachment insecurity

impaired mentalizing capacity in childhood

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Psychotherapy from an attachment perspective

John Bowlby: the role of the psychotherapist is “to


provide the patient with a secure base from which
he can explore the various unhappy and painful
aspects of his life, past and present, many of which
he finds it difficult or perhaps impossible to think
about and reconsider without a trusted companion
to provide support, encouragement, sympathy,
and, on occasion, guidance.” (a secure base)
Jon Allen: “The mind can be a scary place.”
Patient: “Yes, and you wouldn’t want to go in there
alone!”

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Attachment and mentalizing in hospital treatment

ƒ Therapeutic alliance: active collaboration based on trust in


the staff’s commitment to helping and a feeling of acceptance
ƒ Safe haven: sense of safety in the milieu
ƒ Secure base: climate conducive to exploration
ƒ Mentalizing stance: exploring mental states in self and others
with an attitude of:
inquisitiveness
curiosity
open-mindedness
compassion

Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058


Attachment and hope
Hope is based on belief in some benevolent disposition
toward yourself somewhere in the universe, conveyed
by a caring person.
—Paul Pruyser

It has been shown over and over again that if the


encouragement is dogged enough—and the support equally
committed and passionate—the endangered one can nearly
always be saved…It may require on the part of friends, lovers,
family, admirers, an almost religious devotion to persuade the
sufferers of life’s worth, which is so often in conflict with a sense
of their own worthlessness, but such devotion has prevented
countless suicides. —William Styron
Copyright © 2008 The Menninger Clinic. MenningerClinic.com – 800-351-9058