With older adults in mind and taking a lifespan perspective, critically review the evidence for attachment as a stable way of relating to others. Consider the implications for clinical psychology research and practice
Introduction
Attachment theory provides a framework for understanding how attachment bonds formed in infancy affect relationships and psychological wellbeing across the lifespan. Indeed, Bowlby claimed that attachments play a ‘vital role’ from the cradle to the grave’. In this paper, I first describe some fundamental ideas pertaining to the theory. I then critique Bowlby’s claim by evaluating literature that pertains to stability of attachment over time. This paper concludes that despite some methodological weaknesses and seemingly inconsistent findings, there is some evidence to suggest that attachment remains relatively consistent throughout the lifespan, but is open to change in certain contexts. I discuss attachment theory in relation to an issue that is more prevalent among older adults; dementia. I then consider the implications for clinical psychology research and practice, by discussing the relevance of attachment theory for working with adults and older adults with mental health difficulties. Throughout this paper I will be interpreting ‘stable way of relating to others’ as ‘stable across time’.
Attachment theory
Bowlby’s attachment theory describes a child’s bond to his/her primary caregiver, and outlines the effect of this bond on subsequent relationships and psychological adjustment throughout the lifespan. Bowlby (1982/1969) proposed the existence of an "attachment system’. This system is designed to promote infants’ survival through maintaining their proximity to their care-giver in times of threat or danger. Bowlby proposed that natural selection would have favoured mammals who formed strong emotional bonds to their care-givers. This would be particularly important in human infants given the extended period of physical immaturity and dependence. Bowlby argued that though the need for the attachment system is obviously at its greatest during infancy, it remains active throughout life, and is evident in the strong feelings, thoughts and behaviours we experience towards loved ones in times of need. In modern life, when we experience hardships, stress or trauma our attachment system is activated and we draw closer those who care for us. Our loved ones provide us with the sense of security that protects our emotional wellbeing and mental and physical health.
As infants our primary care givers are our main attachment figures. However, in adulthood different relationships tend to become more prominent, such as partners, friends, therapists, or God. Attachment theory proposes a hierarchy of attachment figures, with primary attachments being those who we remain intimate with for long periods of time. Adults may not need the physical closeness of an attachment figure in times of threat, as a mental representation of them may suffice (Mikulincer & Shaver 2003).
With this in mind we can understand that Bowlby conceptualised his theory as a way of understanding behaviour throughout the life span, and saw that attachment theory would be relatively stable, but also responsive to subsequent relationships.
Internal working models
Internal working models are important in attachment theory. Bowlby thought that our adult interpersonal styles become embedded through repeated interactions with primary caregivers during childhood. These repeated interactions form cognitive, behavioural and emotional schemas that are designed to maintain proximity to caregivers. As parents have different interpersonal and child rearing styles, so children will have different schemas, or attachment styles, which become ‘roadmaps’ or internal working models for acting in relationships in general (Shorey & Snyder, 2006). For example, if a caregiver is consistent and responsive, a child will learn to trust carers to be supportive when they are in need. These interactions will also shape their understandings of themselves in terms of how worthy they are of care, and therefore how they can expect to be treated by others in the future.
Internal working models are thought to function like ‘self-fulfilling prophecies’, wherein individuals act in ways that precipitate corresponding schema related behaviours from others. These stereotyped interactions then reinforce the validity of the internal working model. Internal working models predispose a person to stable patterns of interactions within relationships. However, they can also produce interpersonal difficulties and mental distress. According to attachment theory, internal working models affect and shape how we see ourselves and how we view and react to others, across the lifespan (Shorey & Snyder, 2006). Indeed, Bowlby claimed, attachments play a ‘vital role’ from the cradle to the grave’ (pg 2 Crowell, Fraley & Shaver, 1999).
A central prediction of attachment theory therefore is that internal working models and attachment schema persist in a relatively stable way over significant portions of the lifetime. However, they are so-called ‘working’ models as they are open to revision in response to significant attachment experiences (Waters, 2000) such as close interpersonal relationships (Rothbard &Shaver 1994 from psychopath paper) or life events that affect care giver responsiveness (Waters, 2000).
Attachment styles
Mary Ainsworth worked to create a classification of internal working models into attachment styles. Mary Ainsworth (1969) created a behavioural experiment to categorise attachment styles, based on infants responses towards their mother. If mothers are emotionally available, relatively consistent and responsive, then infants learn that the mother is dependable and available. They then are then free to explore the world, using the care giver as a secure base, to provide a sense of security and comfort, whenever they feel threatened. These infants are categorised as ‘securely attached’. If, however, the care giver is inconsistent, the infant will be preoccupied with their security needs and hypervigilant to signs of abandonment, thus demonstrating an insecure attachment, specifically the anxious-ambivalent style. If primary care givers are rejecting or absent, a child may learn to supress their emotional need for closeness completely, and an infant will then be categorised as insecure, the anxious-avoidant pattern. Infants displaying disorganised attachment patterns may perceive their caregiver as frightening or hostile, and experience no feelings of being cared for.
In sum, Ainsworth and colleagues created a system to empirically measure infants internal working models, which she called attachment styles. Researchers then were able to test to see if these were stable across time.
Empirical evidence in Infancy and childhood
Several studies using infant samples have confirmed that attachment styles to primary caregivers remain moderately stable across periods of time ranging from 6-7 months in middle class samples (eg Waters 1978, Thompson, Lamb and Estes 1982, Egeland & Sroufe 1981). Research also supports the prediction that changes in attachment from secure to insecure seem to be related to negative life events, where as positive life events are related to changes from insecure to secure (Egeland & Sroufe 1981, Vaughn, Egeland, Sroufe & Waters, 1979).
However, it is important to note that these are only life events that impact on caregiver responsiveness, stressful life events such as moving house don’t seem to influence attachment pattern (Thompson et al 1982).
Moderate stability seems to be less evident in ‘at risk’ samples. Vaughn, Egeland, Sroufe and Water 1979, found that infants who suffered abuse, neglect or maltreatment were categorised more frequently as insecure, and there was less stability in attachment patterns over time than a ‘well cared for’ sample. The authors noted that of the infants who moved from an insecure attachment to a secure attachment, all had some sort of stabilising influence, such as a supportive family member becoming more involved.
To summarise, in line with Bowlby’s prediction, attachment styles to primary caregivers remain fairly stable across 6-7 months of time during infancy, in middle class samples. However, negative attachment related events can cause infants to change attachment style from secure to insecure. An insecure attachment style seems to be maintained by negative attachment events reoccurring, such as abuse, neglect or maltreatment, which are more prevalent in ‘high risk’ samples.
Stability of attachment through infancy to adulthood
Literature looking at stability from infancy to adolescence confirms this view. Two longitudinal studies found significant stability in attachment style, with change from secure to insecure attachment, or maintaining an insecure attachment style, was associated with an attachment related negative life event such as loss of a parent, parent’s mental health difficulty, or abuse by a parent (Hamiliton 2000, Waters 2000).
Weinfield et al 2000 longitudinal study used an ‘at risk’ sample of young mothers, and found significant discontinuity of attachment style, with many participants changing from secure to insecure attachments. The authors found that those that changed from secure to insecure attachments were found to have suffered more attachment related negative life events than the group that were continuous in their attachment style. The sample used were also high poverty and high risk for developmental difficulties, and had experienced a frequency and severity of negative life events than the Hamilton and waters samples discussed above. (Waters 2000).
However, further longitudinal study (Lewis ,Feiring & Rosenthal, 2000), which measured attachment across a span of the first 18 years of life, did not find a high level of consistency in attachment styles, however, individuals from divorced families were more likely to be insecurely attached. This is consistent with the negative attachment related event prediction.
In sum, literature from both infancy and adolescence tell a similar story regarding stability of attachment. Attachment style tends to be relatively stable in middle class samples. However, negative attachment events seem to result in a move from secure to insecure styles, or serve to maintain insecure attachments. Samples that experience more negative life events tend to be more unstable in their attachment styles, as more children move from secure to insecure styles.
Attachment stability in adulthood and older adulthood
There are few longitudinal studies including older adults participants (Shorey & Snyder, 2006).
Benoit & Parker 1994, found that attachment style of mothers stayed consistent over a period of one year, and also predicted their infants attachment style, but also grandmother’s attachment style in large majority of cases, suggesting that attachment styles are stable through generations.
Zhang & Labourvie-vief, 2004 looked at attachment over a 6 year period during the mid to late 1990’s, with participants ranging from adolescence to late adulthood. Attachment style showed significant stability over the time-period, however, the predictive coefficients of attachment ratings were in the low to middle range. The authors therefore concluded that attachment style was characterised by both stability and fluidity, ‘perhaps more so by fluidity’. Interestingly the authors found that age was significantly related to attachment style, with older adults becoming more secure, more dismissing (avoidant) and less preoccupied than younger participants. Older people being less preoccupied (cite), and more secure and dismissing (cite), has been replicated in other studies.
There are no studies looking at attachment style from infancy all the way through to older adulthood, so it is difficult to comment on stability across the whole life span. However, the evidence discussed suggests it is fairly stable, but marked by fluidity also. Furthermore, as people get older their style may tend towards stable and dismissing-avoidant, rather than preoccupied.
Summary and Critique
The literature reviewed from infancy through to adulthood seems to lend some support to Bowlby’s theory that internal working models of early attachment relationships remain stable throughout the lifespan, unless a significant attachment related event occurs. The studies suggest that if negative attachment related events, that affect the responsiveness of the primary caregiver occur, they can cause a change from secure to insecure attachments, but also maintain an insecure attachment. The literature also suggests that attachment is less stable in ‘high risk’ populations, who have experienced more attachment related negative life events such as child maltreatment and maternal depression. Introduction of stabilising influence, such as a family member becoming more involved, is associated with a move from insecure to secure attachment style. However, there are inconsistent results, with a study showing little consistency in attachment style over an 18 year span, however insecure attachment style was again associated with a negative attachment related event. Finally, a longitudinal study involving older adults suggested that attachment style was highly stable through 3 generations (Benoit and Parker). Another longitudinal study involving older adults was marked by fluidity, or change, as well as stability. The authors did not measure negative life events that may interfere with attachments, so it is difficult to tell whether this was an influence.
Inconsistent results could be due to methodological inconsistencies in the literature, which makes comparisons between studies difficult. For example, different measurements of attachment style are used, ranging from observation, interview, self report and partner reports. It is natural that the attachment measure used for infants would be different than that used for adults, however, with such a range of different measures for adult attachment it is unclear whether they are measuring the same construct (Crowell & Treboux, 1995), or even if they intend to do so. Hamilton, Waters and Weinfield used the Adult Attachment Interview, which makes inferences about the quality of a person’s childhood attachment based on the fluency of childhood narrative memories. This is thought to map on reasonably well to Ainsworth’s Strange Situation categories. Whereas Zhang & Labouvie-vief 2004 used the relationship questionnaire (Bartholomew & Horowitz, 1991), which is a self-report measure of ‘feelings about self’ in adult relationships.
In support of the notion that different constructs are being measured, Milkulincer & Shaver 2003 proposed a hierarchy of working models, wherein we have a main, generic, chronically accessible working model that guides our behaviour in relationships in general, and is based on episodic memories of our primary care giver. However, we also have relationship specific working models, which are made up of memories of how a particular person has responded to us in times of need or distress. Which working model is activated is context dependent, and relies on how the person is feeling as well as external cures. Consequently, it might be the case that different studies are reflecting different working models depending on the measures used and potentially what has occurred for the individual in terms of attachment triggers before testing.
Clinical implications and further research
Research suggests that although attachment networks may get smaller due to death, attachment figures are still important for older adults to provide a secure base, and a ‘safe haven’ in times of distress (cite). Literature also suggests than insecure attachment styles are inversely related to wellbeing, and perception of social support in older people (cite). Therefore, attachment remains very relevant for this population (Kafetsios & Sideridis, 2006).
Further longitudinal studies need to done, from infants to older adults, using consistent attachment measures, to get investigate whether primary attachment models persist in a stable way throughout the lifespan. However, it is useful to hold in mind that our personal histories of attachment based negative experiences may have left an imprint on how we view others in relationships, whether we think they are trustworthy and safe. For older adults who may present with behavioural difficulties, we should enquire about the individuals attachment history, which could explain how they respond to staff in times of threat, in terms of their attachment style. It is promising to note that literature suggests that for children, the introduction of a new attachment figure can change someone’s way of relating from insecure to secure. This could mean that attachment informed modes of care could be beneficial: providing a secure base, and helping the individual to self sooth, or regulate their emotions in times of distress, potentially in a way that has been absent in their life up until this point. Further research using an older adult population is needed to understand whether this point can be generalised to this population.
In sum, the reviewed literature could provide some useful hypothesis when working with older adults experiencing relationship difficulties. It might be useful to explore significant relationships, and also any negative attachment related events. Their attachment history could allow for an understanding of their style of relating to others, and how this might be affecting their ability to access care. It is important recognise that these are theories, not applicable to everybody. However, for hypothesis, or possible lines of enquiry, they could prove useful.
Although it is difficult to determine with certainty that a primary, working model of attachment persists throughout life, it has been shown that older adults are rated as more secure, more dismissive (avoidant) and less preoccupied (ambivalent) than younger adults or infants. Older people are likely to have sustained more attachment related losses than younger people, such as deaths of friends and spouses, and spouses declining in their ability to satisfy attachment needs. Which may explain a move towards a more dismissive attachment style for psychological protection (circirelli, 2010 and refs from here).
Milkulincer & Shaver 2003 propose that internal working models are made up of memories of behavioural strategies the person has used to get their needs met in different contexts. Depending on the attachment figures response they may escalate proximity seeking behaviour, with corresponding increase in emotional cues of distress which requires a lot of energy (hyperactivation), or they may shut down proximity seeking behaviour and supress emotional expressions to avoid further psychological distress (deactivating strategy) in reaction to an unavailable attachment figure. Older people may be using deactivating strategies to deal with prolonged unavailability of attachment figures. They may also reduce energy expending ways of dealing with distress (hyperactivation or preoccupied attachment style) as they decline in energy. This is a useful observation to bear in mind clinically, as if an older adult presents with a dismissing attachment style, rather than view this as problematic, it may be an adaptive way of coping with multiple losses. However, once again it is important to get to know the individual, rather than make assumptions based on hypothesis.
Dementia and attachment
Bowlby highlighted that attachment behaviour is especially evident in times of loss, but also in times of ill health, both of which could be more frequent in older adults. I continue to discuss whether attachment is a ‘stable way of relating to others’, by discussing whether attachment bonds persist during dementia, and continue to exert an influence on how we relate to others.
There are no longitudinal studies looking at attachment styles across the lifespan including throughout the course of dementia. However, studies do suggest that attachment bonds persist and continue to influence how we relate to others during the illness. Magai 1997 studied individuals in residential settings, who were in the mid to late stages of dementia. The authors found that retrospective ratings of pre-morbid secure attachment styles were related to greater expressions of joy when with family and staff. Ratings of pre-morbid avoidant attachment style were related to expressions of anger. The same relationships between secure attachment and positive affect, and avoidant attachment and negative affect, are also found in non-dementia samples (cite). These findings suggest that pre-morbid attachment style may have persisted through dementia and continues to affect relations with others.
Magai and Cohen 1998 speculate that an explanation for the findings is that, just like in non-dementia populations, patients who were more securely attached are able to seek comfort in their caregivers, and reduce negative affect. However, those that are avoidently attached still attempt to maintain self-reliance, and reject interpersonal comfort and distance themselves through hostile behaviours, such as aggression.
Magai and Cohen 1998 found that participants who were rated as having pre-morbid avoidant attachment style displayed more paranoid delusions than securely attached individuals. Participants rated as having a pre-morbid anxious ambivalent (preoccupied) attachment style were rated as displaying more anxiety pre-morbidly, and also during the course of the illness, compared to other attachment styles.
These findings suggest that pre-morbid attachment style may continue to affect how we feel about ourselves, and how we relate to others during dementia (‘stable across time’).
Further evidence that the attachment bond persists in dementia comes from Misen (1993) who has written about parent fixation (PF), a phenomena he observed in Alzheimers patients, who believe their deceased parents are still alive. The patient may reference them in a conversation, ask to go home, or cry out for their parents.
Misen (1993) devised an experiment which was similar to Ainsworth’s ‘Strange Situation’ (Ainsworth, 1969). The patient was left in a room with stranger, a family member comes in for a surprise visit, then the family member leaves again. Attachment related behaviours (i.e. crying, touching, running after family member), and PF behaviours were measured. Misen found that, in general, patients in the initial stages of the disease (higher cognitive ability) displayed more attachment related behaviours, and less PF, than patients in the later stages (lower cognitive abilities). Misen interpreted his results in the framework of attachment theory, and speculated that dementia is a threatening situation; as memory and ties to the outside world deteriorate, feelings of safety and security diminish, and the attachment system is activated. In the initial stages of the disease attachment related behaviours and subsequent comfort are enough to reassure and sooth. However, as memory deteriorates further, this is no longer sufficient as sufferers cannot hold recent events in mind. As new memories recede old memories come to the fore, and parents, who were an important part of the past, become important once again. The belief that parents are still alive provides a sense of security and safety.
Methodological Limitations
The main limitation of the Magai 1997 and the Magai and Cohen 1998 studies is that pre-morbid attachment style is assessed retrospectively, by family members and caregivers. The validity of ratings made both retrospectively, by family members, using a measure that was designed for self-report, has not been firmly established (Bradley & Cafferty, 2010). Using retrospective ratings introduces difficulties such as how reliable the informers memory is, subjective bias of the family member, and ratings could also be influenced by caregiver’s own attachment style (Browne & Shlosberg 2005). It is therefore not possible to confidently conclude that attachment style remains preserved (‘stable’) through the course of dementia. Further studies should be done; ideally, there would be measures taken to assess attachment style before the onset of illness, and during illness.
There are some methodological concerns with Misen’s study also, such as a small sample size, so it is difficult to generalise to a larger population of dementia sufferers. Furthermore, some fairly big inferences are made when he interprets his results in terms of attachment theory (cite 2nd review) It could be that parent fixation is purely a result of a deterioration in recent memories, such that old memories of parents are all that are left.
These studies provide some evidence to suggest that premorbid attachment style may continue to influence how individuals relate to others, when someone is experiencing dementia. However, further research needs to be done to conclude that the attachment system remains intact and influential interpersonally through illness.
Clinical implications of dementia research
Biomedical model explanations of dementia can reduce subjective experiences of patients to symptoms of a disease, and shut down opportunities to understand the person’s past and current circumstances. More recently there has been a shift in dementia care, and theories emphasising the patent’s experience have increased (Browne & Shlosberg 2005). Attachment theory is part of this shift in understanding, and invites enquiry into a person’s historical and current attachment bonds, and how they may be exerting an influence on their emotional state and their relationships with others. This information can feed into a team formulation to build up a better understanding of the person and why they might be behaving or reacting in certain ways, and build a compassionate and cohesive approach to care. PF behaviours such as calling out for parents that have long since deceased, can be extremely upsetting for staff, and make them feel helpless (cite review). Misen offers an alternative interpretation that most people can relate to; the experience of feeling vulnerable and frightened, and a desire to regain a sense of security and safety. In this way attachment theory can potentially bring back the humanity of the individual.
This is relevant in the context of national and regional guidance and policy for working with people with dementia. The Department of Health has stated that the use of anti-psychotic medication for dementia patients needs to be reduced. The Division of Clinical Psychology (Briefing paper), understands that ‘behaviours that challenge’ should not be viewed purely as symptoms of a disease, but in the context of a distressed individual with unmet needs. ‘National Dementia Vision for Wales’ highlights a need for evidence based care for the growing number of people with dementia, including inpatients and those in the community. This includes better information provision for carers, and training for staff. Clinical Psychologists (CPs) are well placed to take the lead on providing training, education and team formulations, to enhance understanding and compassion, and help patients ‘live well’ with dementia.
The Equality Act 2010 states that it is illegal to be treated differently due to age or disability, CP’s therefore have a duty to uphold equal access for all levels of need, and should try to empower individuals to express how services can provide appropriate support.
Attachment theory and mental health
This section will focus on the implications of the theory for clinical psychology practice, by considering the implications of attachment on mental health. Literature examining links between mental health and attachment style at different stages of the lifecycle will be reviewed, following which ideas for attachment based clinical work will be discussed.
Empirical evidence from infancy through to adolescence
There is evidence to suggest that insecure attachment styles can have a negative effect on mental health and how we relate to others across the lifespan. In a prospective longitudinal study, Carlson (1998) measured attachment styles during infancy, behaviour during schooling years, and mental health during adolescence. The author found that attachment disorganisation was related to physical abuse, psychological unavailability and neglect of the caregiver. Disorganised infants, compared to infants with other attachment styles, displayed significantly more socio-emotional difficulties through to adolescence. They had behaviour problems in preschool, dissociative experience during primary school, and had diagnostic ratings of psychopathology by 19.
In a further longitudinal study, Allen, Hauser & Borman-Spurrell (1996), compared a group of adolescents with no diagnosed mental health difficulty, with a group who were given a psychiatric diagnosis and admitted into an inpatient unit at age 14. Assessment measures were taken at age 14 and 25. The authors found that only seven per cent of the previously hospitalised sample were securely attached, compared with nearly half of the comparison sample. The high prevalence of insecure attachment style was due to a high frequency of unresolved attachments, which is the adult equivalent of disorgnaised. This style reflects a lack of resolution following an abusive or frightening care giver.
Further studies have replicated the finding that adolescents who have been hospitalised for mental health difficulties ‘overwhelmingly’ have insecure attachment styles (Rosenstein, Harvery 1996).
In sum, this study lends support to the prediction that the quality of caregiver-infant early interactions, and attachment style, contribute to later mental health difficulties.
Empirical evidence from adulthood
Further evidence that early difficulties with attachment may result in later mental health problems and difficulties relating to others, comes from studies examining attachment in people who have been given a diagnosis of a personality disorder (PD). Many theorists have speculated that PD’s are disorders of attachment and understand this difficulty as placed on a spectrum as opposed a clear presence or absence of a ‘disorder’ (Shorey & Snyder, 2006). Borderline personality disorder (BPD) describes a chronic difficulty in relating to other people, intense and overwhelming emotions, disturbance in self-image, and frantic efforts to avoid real or imagined abandonment. In a review of studies, Agrawal, Gunderson, Holmes & Lyons-Ruth, 2004, found that secure attachments were inversely related to BDP, and the attachment styles found to be most frequent in people with a diagnosis of BPD were unresolved, preoccupied, and fearful. All studies concluded that diagnosis of BDP were correlated with insecure styles of attachment.
The diagnosis is congruous with the features of these insecure attachment styles as well as Lineham’s conception of BDP. Inconsistent or unpredictable parenting, leads to hyperactivation of attachment behaviours and difficulties self soothing (intense and overwhelming emotions), and individuals are either preoccupied with their attachment figures whereabouts (abandonment fears) or they are vacillate between wanting to be close to others and wanting to protect themselves. They are thought to have internalised a sense of themselves being not acceptable, or unlovable in the eyes of their caregiver (disturbance in self image). Furthermore, people with these attachment styles show a strong desire for close relationships but apprehension regarding rejection and dependency. This supports the central role of interpersonal difficulties seen in BDP, ‘ambivalent and erratic feelings in close relationships’. Finally, the unresolved attachment style is also congruent with numerous studies showing that a diagnosis of BPD is frequently associated with past abuse (i.e. Jonson, Cohen, Brown Smailes & Bernsein 1999).
In sum, studies have linked insecure attachment styles to people with a diagnosis of BDP, which is marked by with emotion dysregulation and interpersonal difficulties. This lends support to the notion that insecure attachment styles may lead to the development of mental health and interpersonal difficulties, though, of course, these are studies do not demonstrate causality.
Empirical evidence from older adulthood
Researchers have identified a need for more studies into attachment theory using an older adult population (cite), and studies investigating the impact on attachment styles and mental health are no exception. In a longitudinal study, Zhang & Labouvie-Vief (2010), looked at attachment style and indicators of mental health and wellbeing over time. The sample included a wide age range, including older adults. The authors predicted that as attachment theory delineates that a fundamental role of the attachment system is to regulate emotions, they would expect to find different ways of coping with distressing emotions to be related to attachment style. This is indeed what they found. At any age, when an individual was feeling more secure, they were using more adaptive coping mechanisms and were less depressed, but when individuals were insecure, they scored higher on measures of defensive’ maladaptive coping and depression measures.
In sum, this study demonstrated that across a broad range of ages, including older adults, when individuals feel more secure they use more adaptive ways of regulating their emotions, and when they feel insecure they tend to use less adaptive methods and feel more depressed.
Clinical implications of mental health research
Attachment styles are thought to affect how we regulate emotions, our mental health, and how we relate to other people, across the lifespan. Studies have shown that a very high number of service users, both inpatients and outpatients, have insecure attachment styles (van Ijzenboorn & Bakermans-Kranenburg, 1996), and many have abusive and traumatic histories (cite report).
It seems probable that this has a big impact on therapeutic work. Individuals who have an insecure attachment style due to a difficult upbringing may have internalised a sense of other people being untrustworthy. Such individuals may find it extremely difficult to form new relationships. Clinical staff may face a challenge when working with such individuals, to form and maintain an alliance, which is widely recognised as the cornerstone of therapeutic change.
The BPS recommends that CP’s use attachment theory to inform formulations. This might be helpful for team formulations which include staff members, to increase understanding and compassion. Attachment theory could shed light on behaviours that staff might find confusing, frustrating, or even frightening. For example, clients who have a dismissing style, may not engage with the therapeutic relationship, and be deemed treatment resistant by staff. From an attachment theory perspective, individuals who have grown up with hostile parents, and used emotional suppression and compulsive self reliance as an adaptive strategy, understandably find it difficult to form new relationships. Alternatively, clients who are preoccupied may seek proximity to clinicians in a way that is deemed emotionally draining (Bucci, Roberts, Danquah & Berry 2014). Attachment theory would understand these individuals as having unpredictable caregivers, and so using ‘hyperactivation’ strategies when feeling threatened, as they fear abandonment, and want to maintain proximity to someone they view as a ‘safe base’.
Individuals who have been given a diagnosis of borderline personality disorder can elicit strong emotions from staff teams, and often ‘split’ them, with some staff feeling very positive about the service user, and others feeling extremely negative. Attachment theory could again be helpful to inform a shared understanding. Children who have grown up with abusive or frightening caregivers may have used ‘splitting’ defences to maintain an attachment bond. Rather than perceive that their parent does not care about them, or actively wishes them harm, they internalise this negativity, and attribute their rejection as due bad behaviour on their part. In this way they can maintain a view of their parent as caring. However, when this strategy is repeated, it leads to black and white thinking, and people are perceived as all good, or all bad, creating intense and chaotic interpersonal relationships. This understanding, when created and shared within a team, can help staff increase empathy towards service users that may be challenging interpersonally. CP’s could also run reflective groups, and staff training, to help staff normalise and process strong feelings. These are recommended aspects of attachment informed services (Bucci, Roberts, danquah & Berry 2014). CP’s are well placed to help set up and implement such services, which would be applicable across the lifespan.
Conclusion
Bowlby thought that early interactions with primary caregivers provide a template for relationships and wellbeing later in life. This template, or IWM, remains stable throughout the lifespan, and new experiences are assimilated into it. This is the case unless a significant attachment experience occurs, such as a new relationship, either a positive one, or an abusive one, which can change the template. In this way development is viewed as a product of both our attachment history and our present circumstances. Attachment style, which is an external measure of this template, is thought to continue to affect how we relate to others, and regulate our emotions, throughout the lifespan, and even during illnesses such as dementia. Insecure attachments are related to mental health difficulties. Using attachment theory to create attachment informed services could help staff deal compassionately with ‘behaviour that challenges’.