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Promoting Healthy AttachmentsReview - Promoting Healthy Attachments
Hands-on Techniques to Use with Your Clients
by Deborah D. Gray
W. W. Norton, 2018
Review by Roy Sugarman PhD
May 7th 2019 (Volume 23, Issue 19)

As you will note from the title, this book is designed for psychologists and the like for use with their clients, rather than beginners who might be interested in Thomas Bowlby or babies sequestrated in hospital wards away from mum.

As the blurb in the cover mentions, there is a lot of theory around attachment, including Suomi's continuing studies on monkeys and their ability to separate comfortably from the maternal guardians of the herd. Those that cannot tend to be those whose maternal history includes anxiety on separation, and thus do not venture far from the grazing parent, until placed with a mother with no such history, where they recover their equanimity and even go on to achieve maternal-herd leadership. The suggestion here is that although the anxiety is inherited, a surrogate mother may provide a healing input and reinforce the bilateral engagement that represents attachment.

Most psychologists would agree that treating clients who have some presentation related to attachment issues, anxious, chaotic or otherwise, is common enough to promote the idea that indeed most of us will have some issues with attachment.

In a previous review of treating attachment (Review - Treating Attachment Disorders: From Theory to Therapy, by Karl Heinz Brisch)  I noted that general systems-based theories of mental illness were often criticized for the perceived neglect of the unconscious in outlining their putative theories of the origins of mental illness.  As with the early criticisms of Bowlby by the Kleinians, many of the near-sacred underpinnings of psychodynamic thought were abandoned in the new approaches to such phenomena as attachment, as described in the above review by Brisch.  In our new era, with the focus on the need for evidence based practice in psychology and medicine, definitions of psychopathology based on theories of the unconscious fall foul of one of the salient demands of empirical science: the concept of the 'unconscious' remains an untestable hypothesis, one which is not subject to empirical investigation and therefore there is the capacity to potentially be refuted by such an investigation. Brisch here was clearly drawing on effectiveness to tell us if the therapy works, i.e. there is strong external validity but weak internal validity in such a model., when compared to laboratory experiments which attempt to investigate the efficacy of such an approach.  Efficacy research is the most scientifically rigorous, in that it relies on randomised clinical trials with a 'double-blind approach', not selected case studies, as Brisch had done there. In offering us proof of the value of his methodology, there are more than just the 'unique' aspects of his therapy acting on the systems in which he is intervening.  The efficacy approach thus is said to possess strong internal validity, as opposed to the external validity provide by Brisch's approach, which generalizes better to therapy as it is normally practiced outside of the laboratory, providing the ecological representativeness alleged by Brisch's choice of a wide variety of clients for his illustrations.

The current author pursues the same approach, keeping the examples live with examples of how one addresses clients in talking to the various contingent points involved in their care. Critical to this process is the approaches she will take to treating children, including changes in their world view and other aspects of the outcome of the impacts of less than optimal attachment. 

Treating the parents and adolescents, within the family should also be considered necessary, given attachment is not a one-way connection, but a patterned bilateral connectedness, and within a few lines, the author refers to the vital word 'reciprocal'. We have all experienced the pain of a failure of relatedness, namely the loss of a likeminded person who shares our concept of the relationship and its goals and trajectory. Our expectations are thus critical, based on how we connect and expect to connect. Relatedness, from Self-Determination Theory, is a similar concept.  No introduction, as I noted in the review above, is complete without mentioning Mary Ainsworth and her colleagues in 1971, reliably identifying the typology of attachments. These include secure, anxious resistant, anxious avoidant, and later on others included disorganized-disoriented in terms of the expectations of this reciprocal relationship and the availability of others to reliably respond to our needs to attach.  The early secure attachment will scaffold and support autonomy, allowing for Bowlby's secure base from which to explore and test the world.

Brisch, in the above review, goes on even further, to flesh out his typology with classifications such as 'no signs of attachment behavior', to 'undifferentiated attachment behavior', 'exaggerated attachment behavior', 'inhibited attachment behavior', 'aggressive attachment behavior', 'attachment behavior with role reversal', and finally psychosomatic symptoms.  This second last lot is a bit hard to distinguish from normal firm attachment, but is less reciprocal, and so is of linear impact, not of the second-order cybernetic and self-regulating type, and hence it is regarded as pathological from a General Systems point of view.  As an aside, Brisch's book and work are not mentioned here at all.

So attachments are valued, no matter what they are classified as. Unfortunately, comfort arises from familiarity, so they may seek out the old familiar patterns experienced in childhood, even though the rules that worked then, might not fit the current pattern well or optimally. She identifies four key areas essential to analysing and preparing to altering attachment patterns. These are states of mind towards attachment, effectiveness in recognizing and meeting the needs of the other in attachment relationships, high stress including trauma and finally, emotional state regulation. In this way, parents who form secure attachments, or create those environments, proceed with a state of mind that values attachment in the first place, an ability to meet attachment needs in a timely, sensitive and consistent way, a capacity for stress regulation and coregulation, and an ability to repair.  This last set of values could also fit nicely into the hexi-flex scenario for psychological flexibility proposed by Hayes and colleagues for ACT approaches in therapy and predicting psychopathology. In this way, both dependency needs, and the need for autonomy can be supported. Parents should thus not ignore children, and cooperate with their child's moods rather than rejecting them or seeking control in an insensitive way.  Understanding their own feelings and needs leads to understanding of others, and thus social competencies. This in turn, namely self-awareness, can also support Theory of Mind approaches which suggest we can identify other's thoughts and feelings to a certain extent.

A confident parent should reflect in having an autonomous child; insecurity leads to anxiety, and an insecure-ambivalent parent may be dismissive and preoccupied, such a child may have an approach-avoidant, push-pull mix of approaches to relationships, and so on through the typology, producing the author's preferred approach, which to identify patterns rather than categories, such as the DSM-V's.

In ameliorating these conditions, allowing for more optimal emotional behaviour and attachment, promoting these as per the title, adult relationships that begin to coregulate rather than fail each other, are a reasonable early target, and so child-parent and preschool parent therapies have been shown to have merit, amongst others discussed here.  The target is thus to increase resource in the family, as well as increase support and reduce stress via enhanced social and behavioural capacity. Amongst the direct therapy experiences, bolstered by the Observational Checklist, which runs to pages and pages, are the provision of both clarity and targets for intervention, which largely emphasise repair and hope. Evidence emerges for the effects on executive function, which suffers when the individual has experienced chronic stress and trauma.  This would include dysfunction of the underpinning working memory, especially auditory working memory, a focus on detail rather than the bigger picture, difficulty in generalizing from one situation to another, impulsivity of response and poor regulation of emotion and behaviour, classifying new and challenging information and finally difficult in effortful attentional focus. Treatment for attachment, and related trauma and loss which compromise effective and secure attachment are also a key issue, and there are multiple headings here, dealing with multiple issues.

Treatment for children is vital, given the subject matter.  Children may have changed homes, as in foster care, a subject close to this author's heart as she writes, they may have unresolved grief or trauma, or they have experienced excessive separations from their family. High stress or temperamental difficulties alone may result in referral, and by their nature, will be easier to treat in shorter timespans. In both the previous and current chapters, the author sets out the order of the tasks of treatment, from parent stabilization across the span of the therapy, to the child's social skills and engagement in daily life, towards the end. A tiered approach to problem solving is also applied over 80 plus pages of headings and techniques.

The next chapter does the same for parents, only 30-odd pages though, transferring affect into empathy, dealing with transference issues, the interfering effects of relatives into the family structure and function, and includes techniques such as showing affection directly via palm and cheek contact. Only 20 pages follow for adolescents, often for mood and behavioural issues, and a section deals with the problems evoked by the interaction of teens and society, again with some focus on touch, and of course safety, and intimacy vs autonomy and the development of a sense of theory of mind.

Many of Gray's families appear quite stressed, but she includes now a chapter on working with highly stressed families, which may in turn test our own stress limits as they shift their burden somewhat. Given the impact on adults, and especially children, in respect of changes in Executive Function, Gray speaks here of accommodations one can make to accommodate them and enhance communication efficiencies. As much as we have spoken about the need to respect and support autonomy as well as foster connection, the achievement of mastery, or a sense of it at least, is an essential focus.

Spirituality is dealt with as an important feature, especially if God can be seen as an attachment figure, who fails to deliver in moments of trauma. The importance of play is likewise left to the end of the book, "because it is fun", and various aspects of how play enhances connection and theory of mind (social competency) are explained.

The book is more freewheeling rather than structured, drawing on as much of Gray's own approaches as one could expect, as this is the focus of the book.  She covers an awful lot of ground here, detailing a personalized series of views on targeting her approaches to promoting attachment in children, adolescents and parents, at varying degrees of discomfort. Overall, however, I think this work reflects a great deal of Gray's approach as a Clinical Social Worker, and so for most Clinical Psychologists and Clinical Neuropsychological-orientated rehab and therapy folk, her philosophies and science reflect more of that discipline than say ACT, CBT or other baseline or background to associate with. Although it is easy to see the touchpoints as I have noted above, with motivational science or ACT for instance, a more direct relationship would make this book more attractive to other clinicians such as myself, or my colleagues. Her particular circumstances appear to be in the small end of town socio-economically, whereas those of us who may work in more affluent circles might find it hard to relate to her milieu, but nevertheless can see the commonalities.

Overall this book is full of helpful approaches and does deliver in a seamless and simple way, making it valuable to those seeking to understand this area of endeavour, and combined with Brisch's book from earlier years, will manage a spectrum of attachment dysfunction in their practice.


© 2019 Roy Sugarman


Roy Sugarman PhD, Director: Applied Neuroscience, Performance Innovation Team, Team EXOS, Phoenix, USA


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