Application of Attachment Theory to a Case Study

Application of Attachment Theory in Clinical Social Work

Thomas Joseph Blakely and Gregory M. Dziadosz

This article proposes the use of attachment theory in clinical social work practice. This theory is very appropriate in this context because of its fit with social work concepts of person-in-situation, the significance of developmental history in the emergence of psycho- social problems, and the content of human behavior in the social environment. A literature review supports the significance of the theory. Included are ideas about how attachment styles and working models may be used in assessment and treatment to help clients achieve a secure attachment style.

KEY WORDS: attachment styles; attachment theory; clinical practice; working models

This article was written to promote the use of attachment theory as a framework for assess-ment and treatment in clinical social work practice. The relationship between mental health and attachment is discussed, followed by the history of the theory. Then, the key concepts of the theory are pre- sented, and some examples of its application for social work practice are followed by our proposals for its use in assessment and treatment.

LITERATURE REVIEW Attachment theory was first formulated by John Bowlby. He wrote a report for the World Health Organization titled Maternal Care and Mental Health that contributed substantially to understanding the concepts of mental health and mental ill-health ( Bowlby, 1951). In this monograph, he made it very clear that deprivation of the mother–child relation- ship, depending on the length and type, contributed to psychopathology.

For the moment it is sufficient to say that what is believed to be essential for mental health is that the infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother- substitute) in which both find satisfaction and enjoyment. ( Bowlby, 1951, p. 11)

His work at the London Tavistock clinic with chil- dren, along with the research evidence presented by other psychiatrists and mental health workers around the world, convinced him that the attachment of the

child to the mother or permanent mother substitute was essential to mental health. Bowlby (1969, 1973, 1980) has written extensively on the subject of sepa- ration and loss of the primary caretaker that has a seriously negative effect on mental health, interper- sonal relationships, and social functioning.

Mikulincer and Shaver (2012) described the rela- tionship between attachment theory and mental health: “Attachment theory has proven to be a very fruitful framework for studying emotion regulations and mental health” (p. 11). These authors reviewed a large number of clinical and nonclinical studies and noted that attachment problems occurred frequently with people with mental disorders.

Sonkin (2005) proposed that attachment style (which is discussed later) can be changed during psychotherapy. He commented further that adult attachment research suggested that there is continu- ity in the style from childhood through adolescence and into adulthood in the way a person learns to manage anxiety arising from a lack of a positive at- tachment experience to the primary caretaker early in life. He added that a therapist can become a secure base and fulfill the position of attachment figure so that a client can be helped to achieve a secure at- tachment style that is characteristic of mental health.

One’s mental health is inextricably linked to one’s general health. Thus, attachment theory, as it con- tributes to successful psychotherapeutic interven- tions, also contributes to maintenance of good health. Salovey, Rothman, Detweiler, and Steward (2000) linked emotional states and physical health: “Psychotherapists and practicing physicians similarly

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have recognized the co-morbidity of psychological and physical disorders” (p. 110). Sarah Pressman re- ported on an investigation with Gallup of the effect of human emotion on physical health. “According to Pressman, positive emotions unmistakenly are linked to better health, even when taking into account a lack of basic needs. The inverse holds true as well. Neg- ative emotions were a reliable predictor of worse health” ( University of Kansas, 2009, p. 1).

Based on the foregoing, it is reasonable to conclude that there is a relationship between physical health and mental health and that attachment theory, as one approach to clinical services for people with mental health problems, has a bearing on physical health as well.

Attachment theory already has been broadly used by therapists in various ways. Blatt and Levy (2003) elaborated on the “synergistic relationships between psychoanalysis and attachment theory and research, especially for understanding the nature of psycho- logical disturbances” (p. 107). This relates the applica- tion of attachment theory to psychodynamic psychology, an outstanding psychiatric theory base. Treatment that improved attachment functioning was proposed for people with an eating disorder ( Tasca, Ritchie, & Balfour, 2011). Mary Dozier has written several articles about attachment theory for assisting children, especially those in foster and adoptive care, with attachment issues ( Dozier, 2003; Dozier & Rutter, 2008). She and her colleagues established a lab to study infants and children who have experi- enced adaptation problems with caregivers. The theory also was proposed for adult psychiatry ( Ma, 2006).

Sonkin (2005) wrote, “Over the past ten years, a number of individuals have begun to explore how this body of knowledge of attachment theory would apply to clinical practice” (p. 72). Dutton and Sonkin (2003) described the use of attachment theory as a base for the treatment of men who commit assault. Attachment theory has informed the treatment of depression in adults ( Bettman, 2006). Fraley and Shaver (1997, 1999) described its use in managing unwanted thoughts in obsessive–compulsive disorder and with regard to bereavement and detachment in managing grief. Knowledge of attachment theory and its application enables the social work therapist to promote changes in a client’s feeling and thinking with an increased sense of security that leads to a secure attachment style.

HISTORY OF ATTACHMENT THEORY Bowlby’s training in psychoanalysis occurred at about the same time Anna Freud, Melanie Klein, and Donald Winnicott were beginning to use object relations theory with children. Bowlby departed from their focus on infantile fantasy, instead working directly with children in close interpersonal relation- ships ( Levy & Blatt, 1999). Following his departure from traditional psychoanalysis, Bowlby began his own research unit to study child–mother separation. He originated attachment theory, postulating based on ethological theory that attachment behaviors were adaptation responses to  separation from the primary attachment figure or primary caretaker and generally the mother ( Bretherton, 1992). There also are secondary attachment figures in the father, siblings, and other family members or people directly involved in the care of the child.

Bowlby originally viewed attachment theory as an extension of object relations theory ( Bretherton, 1992). Although he disagreed with Klein, he was affected by his history with psychoanalysis and the contributions Freud made to mental health assess- ment and treatment.

KEY CONCEPTS IN ATTACHMENT THEORY The Attachment Behavioral System (ABS) is a central concept in attachment theory. The ABS is concerned with the proximity of the primary attachment figure to the child or adult of interest. It is activated when- ever there is a threat of separation from the attachment figure. If that person is nearby and responsive to the child’s or adult’s needs, the child or the adult will feel secure and function normatively. If the attachment figure is not nearby or is not responsive, the child or adult will display anxious behaviors that continue until the attachment figure returns and pays attention to the child or adult ( Fraley, 2014). The reaction of the ABS is consonant with attachment styles and working models ( Mikulincer & Shaver, 2007).

Attachment style is the second central concept. This is an adaptation to signals received by the ABS from primary attachment figures. Mary Ainsworth developed the Strange Situation experiment to study the individual secure and insecure attachment styles among children in their reactions to separation from the primary attachment figure ( Ainsworth, Blehar, Waters, & Wall, 1978). Styles are patterns of expecta- tions, needs, emotions, and social behaviors that result from attachment experiences.

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The Strange Situation is a 20-minuite miniature drama with eight episodes. Mother and infant are introduced to a laboratory playroom, where they are later joined by an unfamiliar woman. While the stranger plays with the baby, the mother leaves briefly and then returns. A second separa- tion ensues during which the baby is completely alone. Finally, the stranger and the mother return. ( Bretherton, 1992, p. 777)

Observations of the interaction with the actors in the experiment enabled Ainsworth to determine the features of a secure and two insecure attachment styles, anxious–ambivalent and anxious–avoidant. A third insecure style, disorganized, was added by Main & Solomon (1990).

A secure attachment style is established by a secure base provided by the primary attachment figure who actively cares for a child or another person in an adult relationship. It generates confidence and the person’s ability to be comfortable in maintaining attachment relationships, even when those figures are not read- ily available. It also engenders a feeling of being cared for by others. Insecure attachment styles are charac- terized by negative working models in which a per- son has decreased self-esteem and self-confidence and a lack of trust in relationships with others, com- plicated by the view that others are not caring and responsive ( Mikulincer & Shaver, 2007).

The insecure anxious–ambivalent style is charac- terized by a negative view of self and a positive view of others. This style is generated by an inconsistent caretaker—one who praises one day and condemns the next or one who says one thing today and a dif- ferent thing tomorrow—leaving a child, or the other in a relationship, ambivalent about how to respond. The anxious–avoidant style is characterized by a positive view of self and a negative view of others. A critical or dismissive caretaker generates this style. This caretaker is critical of the child and dismissive of the child’s feelings. Rather than internalizing the critical views of the caretaker, a person with this style avoids interaction with others or dismisses them.

The disorganized style may be the most insecure. In this style, the view of both self and others is nega- tive. The caretaker is perceived as an object of fear, leaving the child with no organized plan about how to cope. These children feel helpless, cannot regulate their emotions, and cannot focus. Social functioning is limited ( Graham, 2008).

Working models is the third central concept. They are the internal processes of attachment style ( Bretherton, 1992). Bowlby developed the concept of internal working models, or mental representa- tions, that are a set of expectations and beliefs about the self and others. Working models are established in the first few years of life, and as children get older, they become increasingly resistant to change. If a child is feeling bad and receives a prompt response from a loving adult who makes her feel better, she will learn that her behaviors are linked with the positive behaviors of a caregiver. Then, a feeling of deserving of being loved and nurtured will occur, and a more generalized view that others are likely to be there to help and protect also develops. These are characteristics of a secure attachment style. On the other hand, a negative or uncaring response from a caretaker will lead to an internal working model of the attachment figure as rejecting. This can lead to a feeling of being unworthy of care and that others cannot be expected to provide help and support ( Bowlby, 1969). This type of working model is as- sociated with the insecure attachment styles.

Bowlby (1969) observed that these models are es- tablished in the first few years of life, and, as children get older, they become increasingly resistant to change. Children’s behaviors become organized around ex- pectations of themselves and others, and in time, that will influence how others relate to them. Positive and negative cycles of reinforcement follow. People who feel good about themselves and expect others to re- spond positively will present themselves to others in a way that suggests trust; those who expect rejection and have low self-esteem send messages distancing themselves from others that generally result in their withdrawal and a negative feedback loop of perceived rejection ( Bowlby, 1969).

APPLICATION TO CLINICAL SOCIAL WORK We propose that social workers can broadly use at- tachment theory for the assessment and treatment of the psychosocial problems their clients present. Social workers are skilled in developing client social histories and are experienced in obtaining the information that can be interpreted in the context of attachment the- ory. They can then plan effective intervention strate- gies to assist clients in organizing appropriate pathways to correct negative self and object working models toward the objective of adopting a secure attachment style.

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A major concept of social work practice has been the person-in-situation paradigm that relates well with attachment theory ( Cornell, 2006). Putting together the dynamics of personality and the effect of environmental challenges into a holistic assessment is a developed skill in clinical social work. This skill may be applied in gathering and interpreting data about family relationships and primary and second- ary attachment figures.

An important part of psychotherapy is the work- ing alliance that enables client and clinician to work together to achieve treatment goals. Within this al- liance, social workers have relationship building skills that prepare them to resolve problems in the alliance that may occur because of a client’s insecure working models that are projected onto the clini- cian. They are trained to understand and deal with the nuances of relationship and are prepared to be- come a secure base for a client.

Providing clinical services to a client begins with an assessment. Bartholomew and Horowitz (1991) proposed that assessment include “the mechanisms by which an attachment style is maintained” (p. 241). Their idea was that people behave in ways that gener- ate reactions in others that confirm working models. Determining which insecure style is characteristic of a client is, therefore, important. Style is directly af- fected by a client’s developmental history, so gather- ing these data from the client and whatever other sources are available is a place to begin. The nature of threats to the ABS and the client’s reaction to these threats aid in determining style. Exploring the work- ing models of both self and others when insecure styles are apparent is essential. Answers to questions about how relationships are managed will suggest whether a client has an ambivalent, avoidant, or dis- organized attachment style. Asking clients for details about perception of themselves and others, in both personal and casual relationships, will reveal the be- haviors related to working models. Answers to ques- tions about relationships with parents and siblings, especially the primary attachment figure, also will provide assessment information. The clinician also will sense how the client is relating to her or him according to the observed attachment style and work- ing models ( Sonkin, 2005).

An assessment also requires knowledge of attach- ment figures. They are special people to whom one turns for protection, comfort, support, and relief. Bowlby used the term “secure base” for these peo- ple ( Bretherton, 1992). There are two reactions to

separation from an attachment figure, especially one who has been a secure base. These are hyperactivation and deactivation. Hyperactivation is engaging in inten- sive demands for attention, whereas deactivation is regulating the need for the attachment figure through the learned ability to self-soothe. Children who are neglected early in life generally do not become pro- ficient at self-soothing and likely will hyperactivate, experiencing more emotional distress ( Mikulincer & Shaver, 2007). An accurate assessment of reactions and a client’s ability to self-soothe are important.

A number of assessment tools can help a clinical social worker identify attachment style with some confidence. The Strange Situation is an assessment strategy for children ages nine to 18 months that still has current value in assessment. The Adult Style In- terview developed by Bifulco and Thomas (2012) is helpful in assessing attachment styles in families. Hazen and Shaver (1987) developed the Adult Prototype Style measure, which also has been used for assess- ment. Fraley, Waller, and Brennan (2000) developed Experiences in Close Relationships—Revised, which also may be used as part of assessment. The Q-Pack Assessment tool also may be helpful. This consists of three self-report questionnaires: the Strengths and Dif- ficulties Questionnaire ( Goodman, 1997) for assessing children, the Vulnerable Attachment Style Question- naire ( Bifulco, Mahon, Kwon, Moran, & Jacobs, 2003) for adults, and the Recent Life Events Ques- tionnaire ( Brugha, Bebington, Tennant, & Hurry, 1985) for families.

Treatment should begin with an explanation of attachment theory, attachment styles, and working models so a client has a beginning understanding of these concepts. Bowlby’s primary goals for treatment are as follows: Help a client understand accumulated, often forgotten, and misunderstood attachment ex- periences; identify and revise working models, and transform them so they are secure and more effective; and help a client to learn ways to have comfortable intimacy through freedom from ineffective working models ( Mikulincer & Shaver, 2007). This calls for a review of developmental experiences with attach- ment figures, with a focus on feelings about them. Reframing reactions to these experiences will change feeling reactions. Working models also will emerge from this review and can be analyzed for ineffective- ness and change.

Bowlby (1998) also suggested treatment tasks that are guidelines for treatment of insecure attachment styles and negative working models. Providing a secure

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base is the first task. Within the relationship between a client and a securely attached clinician, a client can do the therapeutic work of recalling painful dysfunc- tional and maladaptive beliefs, behaviors, memories, and emotions that contributed to an insecure adap- tive style and accompanying inefficient working models. The second task is to examine current rela- tionships to identify thinking and behavior charac- teristic of an insecure attachment style. Discussing these relationships will help the client reflect on the maladaptive responses in these relationships and begin to relate them to events and experiences as a child who established an attachment style and work- ing models. The third task is for the clinician to examine a client’s reaction to her or him. Bowlby proposed that working models are projected onto new relationships ( Bowlby, 1978). This task will pro- vide a focus on how a client’s working models affect the client–clinician relationship.

The fourth task is a focus on the origin of working models through experiences with childhood primary attachment figures. This will promote self-awareness of maladaptive ideas and responses characteristic of an insecure attachment style and ineffective working models. The fifth task is to help a client recognize that the working models of an insecure style contrib- ute to their distress. This will promote reflecting on ways to reevaluate and revise working models char- acteristic of a secure attachment style ( Bowlby, 1998).

The characteristics of a client’s attachment style will be clearer after the completion of the previous tasks. A client’s awareness of the dynamics of trans- ference in their relationship with the clinician can help a client surrender the behaviors of an insecure attachment style and adopt those of a secure style.

People who have an anxious–ambivalent attach- ment style continuously seek the caretaker’s attention and protection. For a client who has this style, the clini- cian should use a deactivating strategy ( Mikulincer & Shaver, 2007). This means maintaining emotional distance from the client and encouraging the client’s taking the lead in the exploration of memories relat- ing to the style’s development. The purpose for this is to better manage the intensity of the client’s need for closeness that will draw attention away from the therapeutic process.

If a client has an anxious–avoidant style, the clini- cian can use a hyperactivation strategy ( Mikulincer & Shaver, 2007). This means probing more deeply into a client’s memories about early relationships that contributed to it. People who have an avoidant

attachment style do not permit conscious awareness of emotion, because doing so in the past was rejected by the caretaker. Treatment requires these memories to be brought to consciousness. This is a challenge to the clinician, who has to be aware of the transference and countertransference reactions while maintaining the position of a secure base.

People with a disorganized attachment style may need intensive psychotherapy. Multiple personality dis- order ( Barach, 1991) and dissociative disorder ( Liotti, 2004) have been related to this style. Mikulincer and Shaver (2007) concluded that “attachment insecuri- ties are clearly prevalent among people with a wide variety of psychological disorders, ranging from mild neuroticism and negative affectivity to severe, disor- ganizing, and paralyzing personality disorders and schizophrenias” (p. 403).

Both terms, hyperactivation and deactivation, were discussed previously as labels for a client’s reaction to separation from the attachment figure. Here, the same terms are used to describe a technique for clinicians in treating two insecure attachment styles.

A number of resources are available to social work- ers who want to increase their skills in applying at- tachment theory in their clinical practice. Bowlby’s attachment and loss trilogy ( Bowlby, 1969, 1973, 1980) and his book A Secure Base: Clinical Applications of Attachment Theory ( Bowlby, 1998) cover treatment using attachment theory. Cassidy and Shaver (2010) edited a volume on the development of the theory, biological perspectives, and ways in which attach- ment affects individuals, interpersonal relationships, and mental health for all age groups. Fraley (2014) reported about attachment theory and some of the completed research that supports its use in clinical work. Celebrese, Farber, and Westen (2005) wrote about the relationship between object relations the- ory and attachment theory, so those clinicians that have been using object relations theory will experi- ence a familiarity when using attachment theory.

CASE EXAMPLE A is a 43-year-old woman who requested marriage counseling. At the intake interview, she expressed frustration over her husband’s behavior. His job re- quires him to be away from home during the week, so all the responsibility for maintaining the house and taking care of her two teenage children falls on her. She is angry about this but has not expressed this to her husband, as she perceives he does not listen.

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At the next session, A’s developmental history was discussed. She is the oldest of five children. She has two younger sisters and two younger brothers. The sisters and brothers are about a year and a half apart in age. Her father was a farmer who worked long hours without any hired help. A remembers her mother as being overwhelmed with work, taking care of five children without anyone, except A, to help her. A had few friends. She recalls that she was shy and withdrawn and always felt out of place. She recalls that one of her brothers picked on her unmercifully and that her mother never protected her from that. She remembers feeling inadequate as a child, and this feeling has persisted. She often wondered whether she met her parents’ expectations. She regularly has spontaneous negative thoughts, and these are bother- some.

A was assessed as having anxious–ambivalent at- tachment style. Her interactions with others based on this style have been troublesome. She feels inad- equate and that her husband doesn’t care for her. She sometimes wonders if she is accepted and appreciated at work, where she makes an extensive effort to please. Her self working models are negative, as she did not have a secure base in her mother or her fa- ther. Her others working models are confused. She tries hard to please and generally likes others but perceives their response as guarded. This reaction reinforces A’s view that they are not caring.

Attachment theory was explained to her in detail, with specific reference to her developmental experi- ence and her relationship with her mother. As we talked about this relationship, she remembered not feeling very close to her mother or father, seeing herself as primarily being a child care person for her mother. Further talk brought more memories to A’s mind about things that happened when she was a child and how she reacted. She blamed herself for the lack of closeness to her mother and came to see that her negative self-thoughts arose from that belief. There was talk about her working models for self and others. It was, at first, hard for her to make connec- tions between her history and the models, but after a couple of sessions of discussing this, she developed more self-awareness and realized the effect her family and her environment had on how she perceived both self and others. After more sessions, she gradually changed her perspective and said she realized that she needed to see the difference between her internal child and her adult self and become more mindful. This realization created a stronger positive feeling

about herself. There was a change in both working models, as evidenced by a more positive attitude about herself and coworkers. She expressed more self- confidence in her work and in parenting and domes- tic responsibilities. She said that she had become more assertive with her children and her husband, and that produced positive results. Our assessment was that she had found a secure base in her therapist and had moved to a secure attachment style.

SUMMARY AND RECOMMENDATIONS This article has encouraged the use of attachment theory for clinical social work. The concept fits the content of the human behavior and social environment sequence in social work education. It meets many of the Council on Social Work Education (CSWE) foun- dation competencies ( CSWE, 2014). We recommend that attachment theory be given a more prominent place in the graduate social work curriculum, as it is a useful clinical framework. We also recommend that this theory become more prominent in practice through continuing education and presentations at social work conferences. Last, we recommend that the National Association of Social Workers give a more prominent place in its written materials regarding the utility and success of attachment theory as a base for assessment and treatment in clinical social work.

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Thomas Joseph Blakely, PhD, MSW, is emeritus professor, School of Social Work, Western Michigan University, Kalamazoo, MI. Gregory M. Dziadosz, PhD, is independent mental health consultant and researcher, University of Wisconsin–Madison. Ad­ dress correspondence to Thomas Joseph Blakely, 5250 Blakely Drive, Belmont, MI 49306; e­mail: [email protected].

Original manuscript received June 10, 2014 Final revision received October 13, 2014 Accepted October 28, 2014 Advance Access Publication August 25, 2015

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