Seven hundred fifty-two pages does not make for a light read. However, Attachment Disturbances in Adults: Treatment for Comprehensive Repair, by Daniel P. Brown and David S. Elliott, does offer a thorough review of research on attachment disturbances, how they develop, and how to treat them. The book offers an in-depth background on theory, assessment methods, treatment approaches, and relation to other mental health concerns. It also introduces the co-authors’ Three Pillar treatment approach, step-by-step methods for the Three Pillars, and material around identity and relationships with others.
Brown and Elliott start with an overview of the four types of attachment: secure, dismissing, anxious, and disorganized, which includes a reference on the possible manifestations of adult attachment types as an overview for clinicians who want a sense of where their clients may show disturbances based on symptoms, behaviors, and attitudes. For Dismissing Attachments, manifestations include avoidance, aloofness, fear of closeness, and remaining distant. Those who tend to be Anxious-Preoccupied worry constantly about relationships, need approval, fear abandonment, and tend to withdraw. The Disorganized/Fearful style have a disorganized view of their internal world and their own behavior. This last style is an outcome of frightening parental behavior and unresolved trauma or loss.
The book provides a very thorough guide of how attachment disturbances can be related to psychopathology such as emotional distress, somatic disorders, trauma, addictions, and personality disorders. For example, the chapter The Orphanage Study: Attachment and Complex Trauma provides a specific example to readers of attachment distributions resulting from severe trauma experienced by children.
Rather than criticizing or finding fault with approaches other than their own, they objectively highlight the key features of each type. They start with Bowlby’s attachment-based therapy before moving on to psychoanalytical approaches, dynamics-maturational model integrative treatments, as well as internal working models. Some of the newer models, such as schema therapy and Accelerated Experiential Dynamic Psychotherapy (AEDP), are introduced as well. Many traditional treatment methods rely on trauma, environment, and biology and miss this foundational piece of attachment. A core message is that the therapist needs to present a secure-base as a foundation for successful treatment by representing safe attachment with their verbals and nonverbals.
After a thorough review of the development and methods of treatment, Brown and Elliott explain their treatment model, the Three Pillars, and how to use it with the different attachment types. They note that half of the people presenting for mental health treatment do not present common concerns, such as depression or anxiety. Rather their difficulty is rooted in trouble with relationships or how they view themselves.
The first pillar is the Ideal Parent Figure (IPF) Protocol. This foundational step helps the client feel secure, seen, and supported. Brown and Elliot explain, “The therapist helps the patient to evoke and engage with imagery of positive attachment figures and of secure attachment experience with those figures, and repetition and elaboration of contact with this imagery establishes a new internal model, or map, of secure attachment.” The difference from traditional treatment is the focus on the patient’s relationship with attachment figures rather than the relationship with the counselor. However, a therapeutic relationship still clearly applies.
Second is fostering metacognitive skills, which include self-awareness, acknowledging the impact of one’s past, and understanding interdependence. For this to happen, the client needs to first be aware of their internal experience and state of mind. Counselors encourage clients to be aware of negative self-talk and prompt them for underlying assumptions when they express a maladaptive belief.
And the final step is fostering collaborative nonverbal and verbal behavior. Attachment disturbances impact the “emergence of natural, innate collaborative functioning.” Successful outcomes from this pillar include verbal communication skills that demonstrate the ability to dialogue and actively listen. Also, the patient values the benefits of healthy communication in day-to-day matters as well as how it relates to their attachment style.
Brown and Elliott then move on to application of treatment to the three primary disturbances: dismissing, anxious-preoccupied, and disorganized attachment. With the dismissing style, the counselor actively engages the client and invites them into a collaborative process in reaching therapeutic goals. With anxious-preoccupied clients, therapists need to have a consistent presence for the client since anxious-preoccupied clients are constantly scanning for clues on how to respond. Brown and Elliot say, “Tacitly the therapist communicates, ‘You keep looking to me to see what I expect, so what I expect is that we both keep looking to you and your state of mind’.” And finally, disorganized clients demonstrate contradictory attachment behaviors so the therapist’s initial goal is to promote a feeling of safety and match the nonverbals presented by the client.
The final chapters offer a step-by-step treatment guide and successful treatment outcomes. Primary treatment goals naturally include achievement of secure attachment, a positive internal working model for future relationships, and healthy collaboration.
Overall, I do not recommend this book for clients who struggle with attachment disturbances or for the loved ones who are trying to support them. The complexity of the book will overwhelm the lay-person, both in length and technicality. However, this is an incredibly thorough resource for someone who needs an advanced understanding of attachment issues for a course or for the mental health professional who wishes to integrate this information into their work.
Attachment Disturbances in Adults
W.W. Norton & Company, Inc., September 2016
Hardcover, 752 pages