Atlas›Domain I · Psychodynamic & depth psychology›Guide 024
Guide I-024

Attachment-informed psychoanalysis

Bowlby, Holmes, Wallin1988
A 36 · L 44 · M 2028 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: Bowlby, A Secure Base (1988), chapter 8 (the five therapeutic tasks, pp. 138–140) and chapter 6 (on knowing what you are not supposed to know), read through Jeremy Holmes's operationalisations (John Bowlby and Attachment Theory 1993; The Search for the Secure Base 2001; Exploring in Security 2010) and David Wallin's Attachment in Psychotherapy (2007). Adult Attachment Interview (AAI) concepts from Main and Hesse are used only as a way of listening in session, not as an assessment protocol.

This is mainly a theoretical framework applied to psychoanalytic psychotherapy, not a manualised therapy. Bowlby set out five tasks and a therapist stance but no session protocol. Holmes and Wallin describe clinical practice in illustrative, non-manualised form. Everything below that turns this into a sequence of steps is marked [synthesis]. [source: Bowlby 1988 ch. 8, as summarised in Wilkinson 2024; Holmes 2010 publisher description; Wallin 2007 contents]

Core idea of change. People carry internal working models of self and others. These are expectations built from real repeated experience with attachment figures, and they were adaptive at the time. Some memories, feelings and perceptions are defensively excluded because acknowledging them once threatened the attachment bond. The therapist provides a reliable secure base. From it the patient explores current relationships, the relationship with the therapist and the childhood experiences behind their expectations, and so can recognise and revise models that no longer fit. The later authors add three things. First, change also depends on the patient's growing capacity to reflect on mental states (mentalising) and to narrate experience coherently. Second, much of the work happens in nonverbal and enacted experience between patient and therapist. Third, how the patient speaks about attachment (its coherence) tells the therapist as much as what they say. [source: Bowlby 1988; Holmes 2010; Wallin 2007 chs 3, 8–10, 15–17; Main/Hesse coherence as summarised in Beijersbergen et al. 2006]

Neighbouring models: mentalization-based treatment (Bateman & Fonagy) grew from the same research lineage and has its own guide. Coercive “attachment therapy” or “holding therapy” is not part of this lineage (see section 5).

2. Framework

No official phases. Bowlby's five tasks are therapeutic functions, not a strict timetable. Task 1 (the secure base) is a precondition for the other four, and tasks 2–5 overlap and recur throughout treatment. Wilkinson (2024) also reads task 1 as the prerequisite for the rest. Whether Bowlby meant the tasks to be sequential is not stated in the sources. [uncertain] [source: Bowlby 1988 pp. 138–140, via Wilkinson 2024]

Bowlby's five tasks (paraphrased):

  1. Provide a secure base: be a reliable, supportive companion from whom the patient can explore painful aspects of life, past and present.
  2. Help the patient examine their current relationships with significant people, including what they expect of their own and others' feelings and behaviour and the biases in how they choose partners and act.
  3. Help the patient examine the relationship with the therapist, where those same expectations and perceptions come into play.
  4. Help the patient consider how present perceptions, expectations and actions may come from real childhood events and situations, especially with parents, or from what parents repeatedly told them.
  5. Help the patient recognise that these models of self and others may or may not fit their present and future, and so make revision possible.

Holmes's three components (Exploring in Security, 2010): (a) the therapeutic relationship, or secure base; (b) meaning-making, meaning mentalising and narrative; (c) change promotion. [source: Holmes 2010 publisher description; the detail inside each component is [uncertain]]

Wallin's frame (2007): the therapy relationship is a new attachment relationship, a “developmental crucible” (his ch. 11 title). Work is tailored to the patient's predominant state of mind regarding attachment (dismissing, preoccupied, unresolved). It proceeds through three channels: words, evoked and enacted experience, and the body. The therapist aims to deepen the patient's mentalising and mindful stance toward experience. [source: Wallin 2007 contents]

Working arc for practice [synthesis]:

PhaseGoalTypical lengthMove on when
A. Engagement and attachment formulationEstablish a secure base, gather history, listen for discourse coherence, form a working hypothesis of the patient's attachment strategySessions 1–6The patient returns reliably, can state a focus, and you have a provisional formulation (the dominant strategy plus the key losses and separations)
B. Exploration (tasks 2–4, cycling)Link current relationships, the here-and-now with the therapist, and childhood experienceMonths; most of treatmentThe same pattern is recognised across at least two of these three arenas, and affect is accessible without flooding
C. Revision and consolidation (task 5 plus change promotion)Patient questions their old expectations and tries new behaviour outside sessionsOverlaps with BNew behaviour is reported and the old pattern is caught in the moment more often
D. EndingWork the ending through as a separation and a lossAgree the date well ahead; often 1–3 months of ending workFeelings about the ending have been spoken and the patient can picture using others as a secure base

Format. This is individual psychodynamic or psychoanalytic psychotherapy, usually face to face (Wallin's focus on nonverbal and bodily experience presupposes it). It is typically once or twice weekly, either open-ended or time-limited (often 6–24 months in public services). Bowlby and the later authors give no fixed session count. [uncertain; synthesis from general psychodynamic practice] Continuity matters more than frequency. Breaks are clinical events (see 4.10).

3. Guiding principles

[source: Bowlby 1988 chs 6 and 8; Holmes 1993, 2001, 2010; Wallin 2007; one-line practical meanings are [synthesis]]

  • Therapist as secure base and safe haven. Be reliable, attentive and sympathetically responsive. Protect the frame: punctuality, consistency, notice of breaks.
  • The patient does the exploring. Bowlby positioned the therapist as a companion in exploration, not an authority who tells the patient what their experience means. Ask and wonder more than you interpret, and offer interpretations as hypotheses.
  • Real experience matters. Bowlby emphasised actual events (separations, losses, threats, what parents did and said) over unconscious fantasy alone. Ask what actually happened, while staying careful about suggestion (see 5.9).
  • Working models are adaptive in origin. Present “symptoms” made sense as strategies in the original relationships. Frame patterns as once-protective, never as defects.
  • Defensive exclusion. Information that once threatened the bond gets kept out of awareness (Bowlby 1980, 1988 ch. 6). Notice gaps, contradictions and missing feelings, and approach them gradually.
  • Feelings are communications. Anger is often protest that aims at reconnection. Bowlby distinguished the anger of hope from the anger of despair (Bowlby 1973). Treat the patient's anger, including anger at you, as attachment information, not an attack to manage.
  • Separation and loss are central. Breaks, lateness, endings and losses re-activate the attachment system. Track and name reactions around every break.
  • How it is told matters as much as what. Coherence, collaboration and the balance between general claims and specific memories reveal the patient's state of mind about attachment (Main and Hesse, AAI research). Listen to the form of the narrative as well as its content.
  • Mentalising and narrative competence are the goal, not just insight. The aim is a patient who can reflect on their own and others' minds and tell their story flexibly (Holmes 2001, 2010; Wallin ch. 9). Value the patient's moments of reflection over the correctness of your interpretation.
  • Tailor, and often counter, the patient's strategy. With dismissing patients move toward feeling and closeness. With preoccupied patients move toward structure, boundaries and the patient's own mind. With unresolved patients move toward safety and integration (Wallin chs 12–14; Holmes 2001). Avoid matching the patient's defences too closely.
  • The relationship is intersubjective. The therapist's own attachment history and state of mind shape the work, and enactments are inevitable (Wallin chs 10–11, 15). Monitor yourself, use supervision, and own your part.
  • Disruption and repair. Misattunement is inevitable. Collaborative repair is itself therapeutic (Wallin draws on infant-research models of disruption and repair). Look for ruptures and treat repair as core work, not a detour.
  • The nonverbal realm. Much of attachment history is held as the “unthought known” (Bollas's phrase, used in Wallin's ch. 8 title), carried in feeling, body and enactment. Track tone, posture and your own evoked responses as data.
  • Mindfulness as a stance. Relate to experience without being embedded in it (Wallin chs 9, 17). Model and invite curious, non-judging attention to what is happening now.

4. Intervention inventory

There is no official list of techniques. The interventions below gather what Bowlby, Holmes and Wallin describe, plus AAI-informed listening. Step sequences are [synthesis] unless marked otherwise. All example language is illustrative and is not wording from the founders.

A. Bowlby's tasks and related clinical moves [source: Bowlby 1988 chs 6 and 8, pp. 138–140 via Wilkinson 2024; Bowlby 1973, 1980; Holmes 1993]

4.1 Establishing the secure base (Task 1)

  • Purpose / when: From the first contact onward. This is the precondition for all exploration. Return to it whenever the patient's distress rises or trust drops.
  • Steps: (1) Keep a predictable frame: same time, start and end on time, and give advance notice of breaks. (2) Give full attention, and track the patient's affect before their content. (3) Respond to distress with sympathy before you explore it (safe haven first, then secure base). (4) Say explicitly that the patient sets the pace of exploration. (5) Be honest about limits, such as availability between sessions, so that reliability is real and not idealised. (6) Notice any signs that the patient experiences you as unreliable, and raise it.
  • Example language (illustrative): “We can go at whatever pace feels manageable. If something feels too much, tell me and we'll slow down.” / “I'll be here at this time each week. If that ever changes, I'll let you know well ahead.”
  • Watch for: Over-gratifying, meaning extra sessions, rescuing, or contact without limits. That is not a secure base, because it cannot be sustained. Signs it is working: the patient brings harder material, comes back after difficult sessions, and begins to protest openly when you fall short.

4.2 Attachment-focused history and formulation

  • Purpose / when: In the first sessions. It builds a working hypothesis of the patient's strategy (deactivating or dismissing, hyperactivating or preoccupied, unresolved or disorganised) and of key separations, losses and threats. Do not run the AAI protocol clinically unless you are trained in it. Here it informs how you ask and how you listen. [source: Wallin ch. 3; Beijersbergen et al. 2006 on coherence; Steele & Steele 2008 [uncertain]]
  • Steps: (1) Ask about early caregivers, who the patient turned to when upset, ill or hurt, separations, losses and frightening experiences. (2) When the patient gives a general description of a parent, gently ask for a specific remembered episode that illustrates it. (3) Ask how they understand why their parents acted as they did. (4) Note the form of the answers as well as the content (see 4.12). (5) Write a short formulation covering the strategy, the core expectation (e.g., “needing others leads to rejection”), protective function and current cost, the likely transference, and the likely countertransference.
  • Example language (illustrative): “When you were small and upset, what happened? Who did you go to?” / “You said your mother was warm. Is there a moment that comes to mind that shows that?”
  • Watch for: Interrogating rather than inquiring. Treat history-taking as relationship-building. Over-certainty in labelling: categories describe states of mind about attachment, not fixed identities. It is working if the formulation helps you predict in-session patterns.

4.3 Exploring current relationships (Task 2)

  • Purpose / when: Throughout treatment, whenever the patient reports a relational event. It brings the working model into view where it causes current trouble.
  • Steps: (1) Get a concrete recent episode: who, what was said, what the patient felt and expected. (2) Ask what the patient predicted the other person would feel or do. (3) Ask what they did on that basis, and what happened next. (4) Look for the repeating expectation across episodes, including choice of partners. (5) Summarise the pattern tentatively and invite correction.
  • Example language (illustrative): “Before you texted him, what did you expect he'd do?” / “This is the third time someone close has gone quiet and you've concluded they're leaving. Does that fit how it feels?”
  • Watch for: Staying at the level of general complaints. Keep returning to specific episodes. It is working when the patient starts noticing the expectation before acting on it.

4.4 Examining the relationship with the therapist (Task 3)

  • Purpose / when: When the patient's expectations of others show up toward you: fear of being a burden, suspicion, idealisation, anger around breaks, compliance. Bowlby saw transference as working models applied to the therapist.
  • Steps: (1) Notice a specific moment, such as hesitation, an apology, or a change after you said something. (2) Wonder aloud about it, briefly, at a point of moderate affect. (3) Ask what they imagined you were thinking or feeling. (4) Compare it with what actually happened between you. If you did contribute (a yawn, lateness), acknowledge it. (5) Link it to the pattern from 4.3 only when the patient has seen the here-and-now experience.
  • Example language (illustrative): “You stopped mid-sentence just then. What did you imagine I was thinking?” / “You've apologised a few times for taking up time. I wonder if you're expecting me to find you too much.”
  • Watch for: Over-using transference interpretation, which Wilkinson (2024) warns against over-emphasising. Dismissing patients may experience early transference talk as intrusive, so pace it. It is working when the patient can say directly what they feel toward you and survive your non-retaliating response.

4.5 Linking present expectations to childhood experience (Task 4)

  • Purpose / when: Once a current pattern is clear, ask where it was learned. The aim is to show the expectation was a reasonable inference from real experience, or from what the patient was repeatedly told.
  • Steps: (1) Start from the live pattern. (2) Ask when the patient first remembers feeling or expecting this. (3) Explore what actually happened, including what parents said about the patient, threats, and how comfort was or was not given. (4) Ask what sense the child made of it. (5) Draw the link: the expectation fitted then. (6) Return to the present (see 4.7).
  • Example language (illustrative): “When did you first learn that showing you were upset made things worse?” / “Given what you've described, expecting people to pull away was a sensible conclusion for a child to reach.”
  • Watch for: Collapsing into blame of parents. Aim for understanding of their states of mind too, since that is part of coherence. Avoid suggesting events (see 5.9). It is working when the patient's self-criticism softens into understanding.

4.6 Helping the patient know what they were not supposed to know

  • Purpose / when: When memories, perceptions or feelings appear blocked, contradicted or disowned. Bowlby described children pressured to disbelieve what they saw (for example, a parent's suicide), to see a rejecting parent as loving, or to accept blame for a parent's behaviour. These experiences then stay segregated from awareness. [source: Bowlby 1988 ch. 6 (originally 1979); detail recalled from the book]
  • Steps: (1) Notice gaps such as missing years, flat accounts of dramatic events, or contradictions between the official family story and the episodes recalled. (2) Name the contradiction gently. (3) Give explicit permission to see and feel what the patient was discouraged from seeing and feeling. (4) Stay with the affect that emerges, which may be grief, anger or fear. (5) Help the patient put the excluded memory together with the official story.
  • Example language (illustrative): “The family version is that nothing was wrong, yet the moments you remember sound frightening. Both can be held here.” / “It makes sense you weren't allowed to be angry. You're allowed to notice it now.”
  • Watch for: Pushing faster than the patient can bear, or supplying content yourself. It is working when new specific memories and feelings appear and the patient's account becomes more coherent.

4.7 Recognising and revising working models (Task 5)

  • Purpose / when: When the patient can see a pattern and its origins, help them test whether the old model still fits.
  • Steps: (1) State the model in the patient's own words. (2) Ask for current evidence for and against it. (3) Use the relationship with you as a test case: did the predicted rejection happen? (4) Invite small experiments with acting differently outside the session (overlaps with 4.18). (5) Review the results without judgement.
  • Example language (illustrative): “The rule was 'if I need someone, they'll leave.' When you told me you'd been struggling, what actually happened?” / “Which parts of that rule still seem true, and which might be out of date?”
  • Watch for: Intellectual agreement without emotional change. Look for revision shown in behaviour and in the moment. It is working when the patient catches the old prediction as it happens and chooses differently.

4.8 Facilitating mourning

  • Purpose / when: Unresolved or disordered mourning. Bowlby described chronic mourning and the prolonged absence of conscious grieving. It shows as unexplained low mood, anniversary reactions or idealisation of the dead. [source: Bowlby 1980]
  • Steps: (1) Ask concrete details of each significant loss: how they learned of it, the funeral, who comforted them. (2) Welcome yearning, protest, anger and guilt as normal parts of grief. (3) Help the patient see beliefs that keep the loss unreal, such as searching or a sense of being responsible. (4) Allow the waves of grief over time rather than forcing a single catharsis.
  • Example language (illustrative): “What happened in the days after she died? Who was there for you?” / “It sounds like you were never allowed to be angry that he left you, even though he couldn't help dying.”
  • Watch for: Losses never mentioned, and losses described without feeling. It is working when grief appears with feeling and then eases, and when talk about the loss becomes clearer.

4.9 Working with anger as protest

  • Purpose / when: When anger appears at others or at you, or is visibly absent where it would make sense. Bowlby saw functional anger as aimed at restoring the bond, and dysfunctional anger as arising when hope of reconnection is lost. [source: Bowlby 1973]
  • Steps: (1) Do not retaliate or withdraw. (2) Name what the anger seems to be protesting. (3) Link it to the need behind it. (4) When the anger is aimed at you, accept the part that is justified.
  • Example language (illustrative): “You're furious I cancelled last week. Underneath that, I think you're telling me it mattered.”
  • Watch for: Anger that turns into self-harm or violence. Then follow risk procedures (see 5.10). It is working when anger becomes speakable and is linked to need, and outbursts or sulking reduce.

4.10 Working with breaks and separations

  • Purpose / when: Before and after every holiday, illness or cancellation, and around missed sessions. These are live separation experiences that activate the attachment system. Holmes and Wallin both treat the frame and separations as attachment events. [source: Holmes 1993, 2010; exact Bowlby wording [uncertain]]
  • Steps: (1) Announce breaks well in advance, with dates. (2) Ask about feelings about the break and about past separations. (3) After the break, look for indirect reactions such as lateness, detachment, sudden criticism or a new symptom. (4) Link these to the separation tentatively. (5) Agree a crisis plan for the break for at-risk patients.
  • Example language (illustrative): “I'll be away for two weeks from the 3rd. What comes up as you hear that?” / “You've seemed a long way off since I got back. I wonder if that's what happens after someone's been gone.”
  • Watch for: Dismissing patients saying breaks don't matter, which may be true or may be deactivation. Watch the behaviour, not just the words. It is working when the patient can register missing you and still function.

4.11 Working through the ending

  • Purpose / when: The final phase. Ending is a planned separation and a chance to experience a goodbye that is not abandonment. Holmes devotes a chapter of Exploring in Security to ending therapy. [source: Holmes 2010 contents [detail uncertain]]
  • Steps: (1) Agree the end date jointly and well ahead. (2) Invite feelings about ending, and expect re-emergence of the old pattern (withdrawal, symptom return, premature leaving). (3) Review what has changed and what the patient takes with them. (4) Discuss other secure bases in the patient's life. (5) Agree whether and how follow-up or return is possible.
  • Example language (illustrative): “We have eight sessions left. What's it like to know that?” / “Some of the old feeling of being dropped seems to be back as we finish. Let's look at it together rather than let it decide how we end.”
  • Watch for: Avoiding the topic, either by you or the patient, or a sudden flight before the date. It is working when the patient feels sad but held, rather than abandoned or indifferent.

B. AAI-informed listening (Main, Hesse) and Holmes's narrative and mentalising work [source: Main and Hesse coherence framework as summarised in Beijersbergen et al. 2006 and Beijersbergen 2008, pp. 21–22; Wallin 2007 ch. 3; Holmes 2001, 2010 [Holmes detail from the books: uncertain]]

The AAI is a research instrument. Classifying it needs formal training and reliability. Clinically, its concepts serve as a lens for listening. Nothing here reproduces the interview protocol or the coding.

4.12 Listening for coherence

  • Purpose / when: Throughout treatment. Coherence is the strongest marker of security in AAI research. Main applied Grice's conversational maxims to judge it. Quality: is the account truthful and supported by evidence? Quantity: is it succinct yet complete? Relation: does it stay relevant? Manner: is it clear and orderly? Dismissing speech typically breaks quality and quantity, through idealisation not backed by memories, claims of not remembering, or very short answers. Preoccupied speech typically breaks quantity, relation and manner, through long, tangential, entangled, angry or vague passages.
  • Steps: (1) Listen to a stretch of attachment-related talk. (2) Ask yourself whether the general claims are backed by specific episodes, whether the length fits the question, whether the speaker stays on topic, and whether the language is clear and current. (3) Note your own state: confusion, flooding, boredom or exclusion. (4) Use these observations to choose an approach (4.24–4.26), not to label the patient aloud.
  • Example language (illustrative): For a preoccupied drift: “We've moved a long way from where we started. Can we go back to what happened on Tuesday?” For dismissing brevity: “'Fine' is a big word. What did it look like?”
  • Watch for: Treating clinical impressions as AAI classifications. They are not equivalent (Beijersbergen et al. stress the need for expert training). It is working when the patient's narrative becomes more coherent over months. Holmes and others treat this as a marker of change [uncertain].

4.13 Linking general claims to specific memories

  • Purpose / when: When the patient gives general descriptions (“a normal childhood”, “dad was strict”) with no remembered episodes, or episodes that contradict the general verdict. It tests and opens up idealisation or derogation.
  • Steps: (1) Acknowledge the general description. (2) Ask for one concrete memory. (3) If none comes, note that without pressing. Absence of memory is itself information. (4) If the memory contradicts the general claim, reflect both side by side and wonder about the gap.
  • Example language (illustrative): “You described your childhood as happy. When you picture being, say, seven, what scene comes up?” / “The memory you just told me sounds lonely, though you began by saying it was all fine.”
  • Watch for: Sounding like you are cross-examining. Keep the tone curious. It is working when more episodic memories emerge, along with feeling.

4.14 Responding to lapses around loss or trauma

  • Purpose / when: When the patient talks about death or abuse and shows brief disorganisation. Examples: speaking of the dead as alive, sudden shifts into a eulogistic or frozen style, long silences, losing track of the sentence, or odd beliefs about having caused the event. In AAI terms these point to an unresolved state. [source: Main and Hesse concept; detail not taken from a primary text: uncertain]
  • Steps: (1) Slow down. (2) Name gently that something shifted. (3) Ground the patient: present time, the room, their breathing (see 4.22). (4) Return to the material only when they are regulated, with smaller amounts at a time. (5) Note the topics that trigger this for formulation and pacing.
  • Example language (illustrative): “You went somewhere just then as you talked about him. Can we pause and notice where you are now, here with me?”
  • Watch for: Pressing into detail during dissociation, which risks retraumatising. It is working when the lapses become shorter and the patient can speak of the loss or trauma while staying present.

4.15 Story-making (Holmes)

  • Purpose / when: With patients whose narratives are thin, absent or over-controlled, typically dismissing. Holmes describes therapy as helping people build a coherent, owned story of their experience. He calls this autobiographical or narrative competence. [source: Holmes 2001 [uncertain]]
  • Steps: (1) Collect fragments: episodes, feelings, bodily states. (2) Put them in sequence with the patient (what happened, then what). (3) Add feeling and motive (what you felt, what they might have felt). (4) Offer a tentative joint account, and invite the patient to edit it.
  • Example language (illustrative): “Let's put it together: you were sent away at eight, you came back and no one mentioned it, and you learned to keep going. Is that close?”
  • Watch for: Imposing your own story on the patient. It is working when the patient retells the story themselves with more detail and feeling.

4.16 Story-breaking (Holmes)

  • Purpose / when: With patients stuck in a rigid, repeated or overwhelming narrative, typically preoccupied, or in a fixed grievance. The aim is to loosen the old story so that new experience can enter. [source: Holmes 2001 [uncertain]]
  • Steps: (1) Recognise the repeated story. (2) Point to an exception, a contradiction or a moment that does not fit. (3) Bring in the here and now: what is happening between you as the story is told. (4) Invite a different perspective, such as the other person's or the younger self's.
  • Example language (illustrative): “That's the story you know well. I'm struck that what you just said about your sister doesn't quite fit it.”
  • Watch for: The patient hearing a challenge as invalidation. Validate first, then loosen. It is working when the patient becomes more flexible about the story and less consumed by it.

4.17 Meaning-making and promoting mentalising (Holmes)

  • Purpose / when: Constantly, and especially when affect is high and understanding is low. Holmes's second component is meaning-making: helping the patient reflect on their own and others' mental states. Mentalization-based treatment is the dedicated, manualised version of this and has its own guide. [source: Holmes 2010 description; Wallin chs 4, 9, 17]
  • Steps: (1) Slow the account down to a specific moment. (2) Ask about the patient's feelings and thoughts at that moment, then the other person's. (3) Offer alternative readings of the other person's mind. (4) Model not-knowing and curiosity. (5) When affect is too high for reflection, regulate first (see 4.1 and 4.22).
  • Example language (illustrative): “What do you imagine was going on in her mind when she didn't reply?” / “I'm not sure I've understood. Help me see it from where you were standing.”
  • Watch for: Pseudo-mentalising, meaning fluent psychological talk without feeling. It is working when the patient spontaneously wonders about minds, their own and others'.

4.18 Change promotion (Holmes)

  • Purpose / when: Holmes's third component. Once there is security and meaning, actively encourage the patient to explore new ways of relating outside sessions. [source: Holmes 2010 description; specific techniques [uncertain]; steps are [synthesis]]
  • Steps: (1) Identify a concrete situation where the old model operates. (2) Plan a small step toward the new stance, such as asking for help or tolerating closeness. (3) Anticipate the urge to revert. (4) Review the outcome in the next session, including how the patient felt about telling you.
  • Example language (illustrative): “What might be one small way this week to let someone know you're struggling?”
  • Watch for: Compliance, where the patient does the task to please you. Explore that as a pattern. It is working when the patient initiates the experiments themselves.

C. Wallin's clinical operationalisation [source: Wallin 2007, chapter structure confirmed from the Guilford contents page; the techniques inside each chapter are described from the book: treat specifics as [uncertain]; steps are [synthesis]]

4.19 Using evoked experience: countertransference as data (Wallin ch. 15)

  • Purpose / when: Whenever you notice a strong or unusual feeling, image or impulse in session. Wallin treats what the patient evokes in the therapist as a main route to the patient's nonverbal, unthought-known experience.
  • Steps: (1) Notice your feeling, for example boredom, irritation, protectiveness or confusion. (2) Hold it before acting on it. (3) Ask whose experience this might be: the patient's dissociated feeling, the role of one of their early figures, or your own history. (4) Use it to shape your next intervention, or to disclose selectively (4.21).
  • Example language (illustrative, internal): “I'm drifting off while she describes her father's death. Maybe this is how feeling got switched off in that house.”
  • Watch for: Attributing all of your feelings to the patient. Check against supervision and your own history (4.28). It is working when these hypotheses lead to interventions that deepen contact.

4.20 Working with enactments (Wallin chs 10, 15)

  • Purpose / when: When you and the patient find yourselves acting out a familiar pattern, for example you rescuing while the patient becomes helpless, or you distancing while the patient detaches. Wallin, drawing on relational psychoanalysis, sees enactments as inevitable and useful once they are recognised together.
  • Steps: (1) Recognise the repetition, often after the fact. (2) Own your part without excessive self-blame. (3) Invite the patient to look at what has been happening between you. (4) Link it to the patient's pattern and, where useful, to the relationships in which it began. (5) Try a different way of being together.
  • Example language (illustrative): “I notice I've been giving a lot of advice lately, and you've been agreeing and then not finding it helpful. I wonder if we've slipped into something familiar.”
  • Watch for: Blaming the patient for the enactment. It is working when the patient can co-observe the pattern and the relationship feels more alive afterwards.

4.21 Selective disclosure of the therapist's experience (Wallin ch. 15)

  • Purpose / when: When naming your own reaction would help the patient see their impact on others, or would move a stalemate. The aim is to give the patient experience of a mind that is affected by them yet stays steady.
  • Steps: (1) Check your motive: is this for the patient's benefit or your relief? (2) Disclose briefly, and only the here-and-now feeling, not your personal history. (3) Frame it as information, not accusation. (4) Ask how it lands. (5) Explore the patient's response.
  • Example language (illustrative): “As you told me that so quickly, I found myself feeling quite sad, more than you seemed to. I wonder what you make of that.”
  • Watch for: Over-disclosure, and burdening the patient with your feelings. Avoid this with patients who are prone to caretaking. It is working when disclosure opens the patient's own affect or curiosity.

4.22 Working with the body (Wallin ch. 16)

  • Purpose / when: When affect is cut off (dismissing), overwhelming (preoccupied) or dissociated (unresolved). Wallin draws on body-oriented approaches to reach implicit, early-learned patterns.
  • Steps: (1) Track posture, breath, gesture, voice and gaze. (2) Name a bodily shift neutrally. (3) Invite curious attention to it. (4) Ask what feeling, image or memory goes with it. (5) For regulation, use grounding: feet on the floor, breathing, orientation to the room.
  • Example language (illustrative): “As you said 'it doesn't matter', your hand went to your chest. What do you notice there?” / “Let's slow down. Feel your feet on the floor and look around the room for a moment.”
  • Watch for: Shame at being watched. Ask permission and keep it collaborative. It is working when bodily awareness gives access to feeling, or regulates arousal.

4.23 Cultivating a mindful and mentalizing stance (Wallin chs 9, 17)

  • Purpose / when: To help the patient move from being embedded in experience, where feelings feel like facts, to relating to experience: noticing it, naming it and reflecting on it. Wallin presents mentalizing and mindfulness as complementary, the double helix of his ch. 17 title, and includes the therapist's own mindfulness practice.
  • Steps: (1) Pause on a moment of strong experience. (2) Invite non-judging noticing: what thoughts, feelings and sensations are present right now. (3) Help the patient label them as mental states (“a thought that…”). (4) Model this stance yourself. (5) Optionally, suggest brief mindfulness practice between sessions [synthesis].
  • Example language (illustrative): “Can we notice that thought, 'I'm unlovable', as a thought that's showing up right now, rather than a fact?”
  • Watch for: Using mindfulness to bypass feeling, which is a risk with dismissing patients. It is working when the patient shows more distance and choice in how they relate to their states.

4.24 Tailoring for dismissing patients (Wallin ch. 12)

  • Purpose / when: The patient minimises the importance of attachment, idealises or derogates, recalls little and is self-reliant. Wallin's chapter title frames the direction as moving from isolation to intimacy.
  • Steps: (1) Accept the self-reliance at first, and don't force closeness. (2) Track small signs of feeling or need and name them warmly. (3) Use your evoked feelings of exclusion or boredom as clues (4.19). (4) Focus on the here and now, including the body. (5) Bring the relationship with you gradually into focus.
  • Example language (illustrative): “You said that very matter-of-factly, but your voice changed for a second.” / “I wonder what it's like to come here and need anything from me at all.”
  • Watch for: Intellectualised therapy where you collude in staying on safe facts. It is working when the patient shows feeling, reports dreams or longing, and protests about breaks.

4.25 Tailoring for preoccupied patients (Wallin ch. 13)

  • Purpose / when: The patient is flooded and entangled, with angry or passive preoccupation with attachment figures, and is highly reactive to your availability. Wallin's chapter title frames the direction as making room for a mind of one's own.
  • Steps: (1) Provide a steady, consistent frame and clear boundaries. (2) Slow down, focus and summarise rather than amplify. (3) Turn attention from the other person to the patient's own experience. (4) Help the patient regulate and tolerate a separate mind, including yours. (5) Reflect patterns rather than repeatedly validating each grievance.
  • Example language (illustrative): “We've heard a lot about what she did. What's happening in you as you tell me?” / “Let's stay with one moment rather than the whole history.”
  • Watch for: Escalating contact between sessions, and you becoming over-involved or else withdrawing. It is working when the patient tolerates gaps, self-soothes more and speaks more coherently.

4.26 Tailoring for unresolved patients (Wallin ch. 14)

  • Purpose / when: The patient has unresolved trauma or loss, with dissociation, frightened or frightening states, and sometimes a disorganised relationship to the therapist. Wallin's chapter title frames the direction as healing the wounds of trauma and loss.
  • Steps: (1) Put safety and stabilisation first, including a risk assessment and a crisis plan. (2) Track dissociation and use grounding (4.14, 4.22). (3) Work through trauma in tolerable doses, within the window of tolerance [synthesis term]. (4) Help connect dissociated states. (5) Stay steady through the patient's frightened or frightening states.
  • Example language (illustrative): “We'll approach this bit by bit. You can stop us at any point.” / “Part of you seems to have gone away. Can you hear me? Look around and tell me three things you see.”
  • Watch for: Retraumatisation and escalating self-harm. Consider a trauma-specialist adjunct. It is working when there are fewer and shorter dissociative episodes and the patient can tell the story while staying present.

4.27 Repairing ruptures (Wallin chs 10, 15)

  • Purpose / when: After misattunement, a hurtful comment, a boundary decision, or the patient's withdrawal or confrontation. Repair after disruption is a developmental mechanism Wallin borrows from infant research. The rupture-repair procedure itself comes from Safran and Muran [uncertain].
  • Steps: (1) Notice the signs: withdrawal, silence, over-compliance or anger. (2) Raise it non-defensively. (3) Invite the patient's view of what happened. (4) Acknowledge your part specifically. (5) Explore the feelings and meanings involved. (6) Link to attachment patterns only once the patient feels heard.
  • Example language (illustrative): “Something shifted after I mentioned the fee. I'd like to understand how that came across.” / “You're right, I did cut you off. I'm sorry.”
  • Watch for: Over-apologising, which can burden the patient. It is working when the relationship recovers and the patient says repair is new for them.

4.28 Monitoring your own attachment state (Wallin ch. 11)

  • Purpose / when: Ongoing. Wallin stresses that the therapist's own attachment history and state of mind shape what the therapist can perceive and allow. Research suggests secure therapists respond less complementarily to patients' insecure strategies, and that therapist security is associated with better outcomes. [source: Mikulincer, Shaver & Berant 2013; Dozier et al. 1994]
  • Steps: (1) Know your own default pattern, for example retreating into intellect or over-caring. (2) After sessions, note when you went into that mode. (3) Bring recurrent pulls to supervision or personal therapy. (4) Use this awareness to choose a deliberately non-complementary response.
  • Example language (illustrative, internal): “I've been organising his life for him all session. That's my rescuing pull, and it keeps him passive.”
  • Watch for: The same impasses recurring with different patients. It is working when you can predict and step out of your own pulls.

5. Handling problems

The primary sources frame most difficulties as attachment strategies showing up in therapy, rather than as obstacles to it. That framing comes from Bowlby, Holmes and Wallin. Most of the specific responses below are [synthesis] unless a source is given.

5.1 Stuck: flat, intellectual, “nothing to talk about” (often dismissing)

  • Read this as deactivation, not lack of motivation (Wallin ch. 12). Shift from content to process: the here and now, the body (4.22), and your own evoked feelings (4.19).
  • Ask for specific episodes (4.13). Note small signs of affect.
  • Bring up the relationship lightly: “It may be hard to imagine that talking to me could help.” (illustrative)
  • [synthesis] If nothing moves after several months, review the focus jointly. Consider whether a time limit, or a more structured adjunct, would help.

5.2 Resistance: avoidance of particular topics or memories

  • Understand it as defensive exclusion (Bowlby 1980, 1988 ch. 6). The avoidance once protected the bond. Name the avoidance and its function, not just the content being avoided.
  • Respect the pace (4.1). Approach from the edge, such as the feeling before the memory.
  • “Something makes it hard to go near that. Perhaps it once wasn't safe to.” (illustrative)

5.3 Overwhelm and flooding (often preoccupied or unresolved)

  • Shift from exploring to regulating: slow down, ground (4.22), and focus on a single episode (4.25).
  • Close each session with containment. Leave a few minutes to come back to the present and to the plan for the week [synthesis].
  • Reduce the pace of trauma work. Watch for dissociation (4.14, 4.26).

5.4 Non-attendance, lateness and between-session tasks not done

  • In this model, missed sessions and lateness are communications about closeness and distance. Explore them as such before treating them as administrative problems (Holmes, Wallin: frame as an attachment event).
  • Keep the frame consistent: hold the session time, and apply your policy for missed sessions without being punitive.
  • If change-promotion experiments are not done (4.18), explore what doing them would have meant, for example fear of failing in front of you or resentment at being told what to do.
  • [synthesis] For repeated non-attendance, write a warm, non-pursuing note. With dismissing patients, pursuing can intensify withdrawal. With preoccupied patients, not responding can feel like abandonment.

5.5 Ruptures, hostility and devaluation

  • Use the repair sequence (4.27). Treat anger as protest (4.9). Own your part.
  • In confrontation ruptures: stay non-defensive, find the part that is true, then explore. In withdrawal ruptures: name the withdrawal gently and invite it into the open [synthesis].
  • Where devaluation persists, explore what it protects against, such as needing you.

5.6 Idealisation, dependency and requests for contact between sessions

  • A secure base does not mean being always available. Agree clear between-session contact rules early (4.1, 4.25).
  • Interpret idealisation as hope and as a defence against disappointment. Expect it to give way to disappointment, and work that through.
  • [synthesis] Increasing dependence in the middle phase is often expected and is not in itself a failure. The test is whether the patient's exploration outside therapy is growing.

5.7 Crises around breaks and endings

  • Prepare early (4.10, 4.11). Agree a written crisis plan for the break, with cover arrangements.
  • Expect a return of symptoms near the ending, and interpret it as a separation response rather than a reason to extend therapy automatically [synthesis].
  • If the patient leaves suddenly, write once acknowledging the ending and leaving the door open, so the ending is not a silent abandonment [synthesis].

5.8 Therapist pulled into a complementary pattern

  • Signs: you feel bored and detached with a dismissing patient, or over-involved and anxious with a preoccupied patient.
  • Use 4.28: supervision, and a deliberately non-complementary response. With dismissing patients, warmth and focus on feeling. With preoccupied patients, calm structure.
  • [source: Wallin ch. 11; therapist security research summarised in Mikulincer, Shaver & Berant 2013]

5.9 Parent-blaming, or uncertain memories of abuse [synthesis]

  • Bowlby's emphasis on real events is not licence to suggest events. Do not propose abuse that has not been reported. Do not use leading questions or treat a reconstruction as fact. Let the patient's memories lead.
  • Grievance that collapses into blame is a preoccupied pattern. Aim for coherence, including a realistic picture of the parents' own minds and limits (4.5, 4.16).
  • If abuse is disclosed, follow safeguarding duties where others are currently at risk.

5.10 Suicidality and self-harm

  • Holmes's Exploring in Security includes a chapter on suicide and deliberate self-harm. He frames them partly as attachment communications, often around separations [uncertain].
  • Clinical response: conduct and document a standard structured risk assessment, a safety plan and service crisis pathways. The attachment framing adds understanding but does not replace these. Watch closely around breaks and endings (4.10, 4.11). Consult and refer as your setting requires.

5.11 Borderline-level and complex presentations

  • Holmes has a chapter on working with borderline clients. For high-risk, high-instability presentations, consider mentalization-based treatment (separate guide) or another specialist programme. In open-ended weekly work, keep a clear frame and team support [source: Holmes 2010 contents; recommendation is synthesis].

5.12 Brief or time-limited settings [synthesis]

  • Keep the five tasks, but narrow the focus to one core relational pattern in current relationships and with you. Name the time limit from the start, because the ending is the work. Use the attachment formulation (4.2) to choose your stance.

5.13 Culture and family norms [synthesis]

  • Norms for independence, closeness and emotional expression vary. Before calling a pattern defensive, ask what it meant in the patient's family and culture. Coherence of narrative is a more culture-neutral guide than any particular style of expression.

5.14 Not this: coercive “attachment therapy” (historical note)

  • A separate set of practices, including holding or rage-reduction therapy and rebirthing, was marketed in the 1980s–2000s for children labelled with attachment disorders. They used physical restraint and confrontation. The stated rationale was to provoke and release rage so the child would bond.
  • Documented harm: in 2000, Candace Newmaker, aged 10, died of asphyxiation during a rebirthing session in Colorado. The therapists were convicted of reckless child abuse resulting in death, and Colorado then banned rebirthing (2001). An American Professional Society on the Abuse of Children (APSAC) task force (2006) condemned coercive restraint-based attachment therapies. [source: historical record recalled: uncertain on details]
  • These practices have no basis in Bowlby's work. They contradict its core principle that security comes from sensitivity and responsiveness. Current ethical limit: no physical restraint, coercion or provoked distress as therapy.

Harm account: coercive "attachment therapy", holding therapy and rebirthing (including the Candace Newmaker case)

What was actually done. The practices form one lineage with changing names. [source: Wikipedia, Attachment therapy; APSAC Task Force, Chaffin et al. 2006]

  • Origins. In 1960s–70s California, Robert Zaslow developed "rage-reduction" (the "Z-process"). He held children down, at first mainly autistic children, to provoke rage, on the theory that this would force attachment. He surrendered his California psychology licence in 1971 after a patient was injured. Foster Cline adapted the method in Evergreen, Colorado. His clinic, first the Youth Behavior Program, became the Attachment Center at Evergreen and, around 2002, the Institute for Attachment and Child Development. Martha Welch's Holding Time (1988) brought a parent-led version to mothers, later renamed "prolonged parent–child embrace". [source: Wikipedia, Attachment therapy]
  • Who received it, and how it was sold. The children were mostly adopted or fostered and often had histories of maltreatment or institutional care. They were labelled "attachment disordered", often from checklists circulated online that included items such as "lack of conscience" or poor eye contact, which APSAC says guarantee many false positives. The pitch to parents rested on a few claims: suppressed rage from early abandonment blocks attachment; the child is controlling and lacks a conscience; the child's "character" must be broken before bonding can happen; untreated children become psychopaths; conventional therapy fails or makes things worse. APSAC says the rage theory rests almost entirely on clinical observation and the psychopathy predictions have no empirical support. Parents, often desperate, gave consent. The children were not asked, and their protests were reframed as "resistance". [source: APSAC 2006, pp. 77–82]
  • What happened in sessions. The child was held across the laps of one or more therapists or pinned by several adults and made to keep eye contact. Therapists added physical provocation: forceful tickling, pinching or knuckling of the ribs, gripping the face, shouting at close range. They demanded answers and compliance. APSAC reports sessions of 3–5 hours or longer. Struggling, crying or saying it hurt was read as manipulation and met with more force. Once the child "gave up", a "reparenting" phase followed, with cradling, rocking, bottle- or pacifier-feeding and sometimes diapering of school-age children. [source: APSAC 2006, pp. 78–79]
  • Rebirthing. In this variant the child was wrapped in a sheet or blankets and covered with pillows and the weight of several adults to "simulate the womb". The child was told to fight their way out to be "born" to the adoptive parent, and any struggle was met with more pressure. [source: APSAC 2006, p. 79; CNN 2001]
  • Format. Programmes were often two-week "intensives" for a substantial fee: $7,000 in the Newmaker case. Between sessions the child lived with "therapeutic foster parents", and children who did not comply could be threatened with detention or foster placement. [source: Wikipedia, Death of Candace Newmaker; Wikipedia, Attachment therapy, citing Speltz 2002]
  • At home. Parents were trained to carry on the regime:
    • "strong sitting", meaning long periods of enforced stillness and silence;
    • control of all food, water and toilet access, and in some cases forced fluids;
    • isolation from peers, with home-schooling favoured;
    • hard or pointless chores;
    • obedience "fast and snappy and right the first time";
    • withholding information from the child about future placements.
    Parenting was framed as a battle the adult had to win. [source: APSAC 2006, pp. 78–79; Wikipedia, Attachment therapy]

The Candace Newmaker case, step by step.

  • Candace was adopted by Jeane Newmaker, a paediatric nurse practitioner in North Carolina, in 1996, after a series of foster homes. Her adoptive mother described increasingly disruptive behaviour and took her to Evergreen, Colorado, for a two-week intensive costing $7,000. It was run by Connell Watkins and Julie Ponder. Neither was licensed, and both had let their Colorado psychotherapist registrations lapse. [source: CNN 2001; Wikipedia, Death of Candace Newmaker]
  • Earlier in the intensive Candace went through "holding" sessions. Trial testimony described a two-hour session in which her face was grabbed about 90 times, her head was shaken 309 times and she was shouted at from inches away 68 times. Other sessions involved adults lying on her, cutting her hair and enforced stillness. [source: Quackwatch, Sarner 2001]
  • In the rebirthing session (18 April 2000, per CNN and Quackwatch) she was first given "art therapy", then wrapped in a flannel sheet and covered with pillows. Four adults pressed on her for about 70 minutes while she was told to fight to be "born". The trial videotape shows her screaming that she could not breathe and was going to be sick. She said she was dying, and was answered with "Go ahead. Die right now" and "Quitter". She vomited and soiled herself inside the sheet and was kept wrapped. The last 20 minutes or so were silent, and at one point the adults left the room. When she was unwrapped she was not breathing and had no pulse. She died the next day of asphyxia. Prosecutors said earlier rebirthings by the same team had lasted no more than six minutes. [source: CNN 2001; Wikipedia, Death of Candace Newmaker] Wikipedia's infobox gives a different session date. [uncertain]
  • Outcome. On 20 April 2001 Watkins and Ponder were convicted of reckless child abuse resulting in death and sentenced to 16 years, the statutory minimum. Watkins was also convicted of unlawful practice of psychotherapy and criminal impersonation, and was paroled in 2008. The court excluded defence testimony on the method's efficacy because it lacked scientific validation. The two assistants pleaded guilty to criminally negligent child abuse and received probation. The adoptive mother pleaded guilty and received a suspended sentence, later expunged. Colorado passed "Candace's Law" unanimously in April 2001, criminalising therapy that re-enacts birth using restraint that could injure or kill. North Carolina passed a similar statute. [source: Quackwatch 2001; Wikipedia, Death of Candace Newmaker]

How it caused harm.

  • Deaths. The direct mechanism was compression and asphyxia. Weight on the chest and abdomen restricted breathing, and the belief system turned the child's warning signs ("I can't breathe") into evidence of manipulation, so the adults escalated rather than stopping. The same belief system ran through other deaths:
    • Krystal Tibbets, 3 (Utah, 1997), was killed by her adoptive father using "compression therapy". APSAC reports that the parents used compression on therapists' suggestion.
    • Cassandra Killpack, 4 (2002), died of water intoxication after forced fluids. APSAC describes a fatality in which parents enforced total control of eating and drinking, allegedly on therapists' instruction.
    • Other children's deaths have been linked to the parenting regime.
    APSAC notes critics' claim of six or more deaths, though the exact number is uncertain. It also documents injuries during restraint, licence sanctions and prosecutions. [source: APSAC 2006, pp. 82–83; Wikipedia, Attachment therapy] [uncertain on individual case details sourced only from Wikipedia]
  • Psychological mechanisms. The method overpowers, frightens and humiliates children who were usually already maltreated, so caregivers become a source of terror rather than a secure base. It rewards submission and calls it attachment, and it teaches the child that distress signals do not work. Isolation removes outside adults who might notice or protect. Labels like "future psychopath" and "manipulative" shape how parents see the child, which justifies harsher control and risks placement breakdown. [synthesis, drawing on APSAC 2006 pp. 79–86 and Bowlby's sensitivity principle]
  • Misdiagnosis. Over-inclusive checklists meant children with other problems (autism, ADHD, trauma reactions, ordinary adjustment difficulties) were labelled as attachment disordered and steered away from effective help. [source: APSAC 2006, pp. 81–82, 85]
  • No evidence of benefit. AACAP: "There is no scientific evidence that such coercive interventions are effective"; the techniques "violate the fundamental human rights of the children subjected to them". [source: AACAP policy statement 2003, reaffirmed 2022]
  • Long-term effects in adult survivors. These have not been systematically studied in the sources. One UK former client brought a civil claim against a provider. [uncertain] [source: Oxenham 2013]

Recognising it today.

  • Names. "Attachment therapy", "holding therapy" or "holding time", "rage-reduction", "compression holding", "rebirthing", "prolonged parent–child embrace", "Evergreen model", "corrective attachment therapy", and parenting programmes that teach "strong sitting" or total control of food and toilet. Labels change often. [source: Wikipedia, Attachment therapy; AACAP 2022]
  • Still around. In the UK, holding has been used in at least one service for looked-after children, which was studied by Sudbery et al. (2009/2010). A 2013 report described a Crown Prosecution Service decision not to prosecute because the funding council had known of and consented to the therapy. [source: Sudbery et al.; Oxenham 2013] [uncertain on current UK prevalence]
  • Red flags in the belief system (APSAC):
    • attachment disorder diagnosed from online or unvalidated checklists;
    • claims that the child "has no conscience";
    • predictions of psychopathy;
    • "only our method works; ordinary therapy makes it worse";
    • the child described as cunning or manipulative;
    • "healthy family, sick child";
    • testimonial-based marketing and urgency;
    • telling parents to cut the child off from school, peers or other professionals. [source: APSAC 2006, pp. 78–86]
  • Red flags in practice:
    • planned physical holding or restraint as therapy, as opposed to brief emergency restraint for safety;
    • deliberately provoking rage or catharsis;
    • forced eye contact;
    • regression (bottles, nappies) for older children;
    • control of food, water or toilet;
    • enforced sitting, isolation or humiliation;
    • the child's distress dismissed as manipulation;
    • residential "intensives" with special foster carers. [source: APSAC 2006, pp. 85–86]
  • How legitimate attachment-based work differs. It targets caregiver sensitivity and a stable, predictable environment, not the child's supposed pathology. Physical comfort follows the child's lead and stops when the child signals distress, and distress is taken seriously. Ordinary behaviour management (time-out, loss of privileges, brief restraint for safety) is not what APSAC condemns. [source: APSAC 2006, pp. 77, 85] In this guide's adult work, "holding" in the psychoanalytic sense is a metaphor for containment, never a physical intervention. Working with the body (4.22) means attending to bodily experience, never restraining or provoking. [synthesis] Dyadic developmental psychotherapy (Hughes) came out of this lineage but rejected coercion. Critics still place it within the attachment-therapy paradigm, so ask any service exactly what it does. [uncertain] [source: Wikipedia, Attachment therapy]

What to do instead / helping those harmed.

  • Instead, for children. Get a comprehensive evaluation by qualified professionals, and diagnose an attachment disorder only when DSM-5 or ICD criteria are met, after considering more common conditions. Use evidence-based options such as video-feedback and parental-sensitivity programmes, parent–child psychotherapy, trauma-focused CBT for maltreated children, and intensive carer training and support. NICE advises against medication for attachment difficulties themselves. APSAC's first-line principles are stability, safety, patience, sensitivity, consistency and nurturance, with ongoing support for parents. [source: NICE NG26; AACAP 2022; APSAC 2006, p. 85]
  • Assessing clients who went through it (adolescents or adults): [synthesis]
    • Ask directly, because clients may not call it abuse. It was presented as "therapy", often with their parents' sincere consent, which can leave strong loyalty conflicts.
    • Screen for trauma symptoms.
    • Treat an old "RAD" label as unverified.
    • Avoid anything that could re-enact the experience: physical contact, demands for eye contact, confrontational or provocative interventions, or pressure on pacing.
  • Parents who used it. Many acted on professional advice and may carry guilt. Offer psychoeducation that is not shaming. [synthesis]
  • Ethical and reporting duties.
    • APSAC advises treating restraint, deliberately provoked distress, and withholding of food, water or toilet as suspected abuse, to be evaluated through child-protection channels. [source: APSAC 2006, p. 86]
    • Rebirthing is a criminal offence in Colorado and North Carolina. [source: Quackwatch 2001; Wikipedia, Death of Candace Newmaker]
    • The American Psychiatric Association (2002) warned clinicians and carers against coercive holding and rebirthing. [source: Psychiatric News 2002]
    • Report a practitioner or service using these methods to the relevant licensing or registration body and, where a child is at risk, make a safeguarding referral under local procedures.
    • Do not refer families to services whose methods you have not checked. [synthesis]

Sources

Sources

Books and papers cited

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