APPLYING ATTACHMENT THEORY

IN CLINICAL PRACTICE:
TRANSFORMING
DEVELOPMENTAL DEFICITS
AND BUILDING SECURE
ATTACHMENT

Linda Cundy, April 2023

for PESI
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WELCOME TO LONDON!

WHAT THIS DAY OFFERS

• Coherent model
• Evidence-based
• No specific techniques
• No ‘one way’ to apply Attachment Theory
• Useful model for assessment, supervision,
reviewing, ending
• When therapy feels stuck
• Client groups and settings
• Time frame; time-limited, open-ended…

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 BRIEF HISORY OF ATTACHMENT
• John Bowlby’s Classical Attachment Theory
• Attachment, separation, loss
• Maternal deprivation
• WHO report: Maternal Care and Mental Health
• Forty-four Juvenile Thieves
• Empirical and prospective evidence
• Young Children in Brief Separations: work of
James and Joyce Robertson
• Ainsworth’s Ganda study
• Colin Murray Parkes: interviews with widows
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FORMALISED RESEARCH
• Strange Situation Test
• Longitudinal studies
• Adult Attachment interview
• Developments (e.g. Crittenden’s dynamic
maturational model, Bifulco’s Attachment Style
Interview etc.)
• Adverse Childhood Experiences research,
meta-data
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ATTACHMENT THEORY ALSO…

Integrates findings from:
• Ethology
• Animal laboratory findings
• Linguistics
• Trauma theory and research
• Neuroscience
• Affect regulation theory
• Mentalisation / reflective function theory
• Object relations theory

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 ‘MATERNAL DEPRIVATION’
• What is a ‘mother’?
• Survival, safety, security
• Actual absence of Attachment Figure (AF)
• -> Threat of separation
• -> Physically present but unattuned, emotionally
absent
• -> Deprived of essential building blocks of secure
attachment
• Developmental deficits

EVOLUTIONARY MODEL
• We have adapted our environment to suit us but
maintain instincts that evolved to ensure survival
of species
• Primacy of attachment / caregiving system
• Attachment-seeking behaviours are innate
• But how attachment needs are expressed is
shaped by culture
• And distorted or disguised by unique micro-
culture we grow up in

SURVIVAL OF THE ‘FITTEST’…

• Humans are born with unfinished brains
• And own unique potentials
• We adapt to fit into our relational ecosystem
• Adaptions are creative solutions but…
• How much must the infant adapt?
• How much does the relational environment
accommodate the infant?
• Distorted attachment-seeking strategies, defences
• Insecure, suboptimal patterns of attachment
• Or psychopathology (Unresolved Trauma, Cannot
Classify)
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 “Gradually, incrementally but inevitably, the self-system
shapes the child to fit into the niche supplied by the
personalities of his significant others. The myriad
potentialities of the child become slowly and inexorably
honed down as he becomes the son of this particular
mother, of this particular father. The outline of the child’s
personality is sharply etched by the acid of the parents’
anxiety.” (Mitchell & Black 1995, p.70)

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ATTACHMENT CATEGORIES
PARENT/CHILD ADULT
SST AAI
SECURE SECURE-AUTONOMOUS
AVOIDANT DISMISSING
AMBIVALENT PREOCCUPIED
DISORIENTED / UNRESOLVED TRAUMA /
DISORGANISED LOSS
CANNOT CLASSIFY
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WHY DOES THIS MATTER?

• Early relationships are internalised
• Patterns of attachment-seeking and defences
become ‘default’
• Affecting how we perceive the world, other
people, relationships, ourselves…
• Internal Working Models / Relational Models
• From Strange Situation Test to Adult Attachment
Interview there is 68 - 75% continuity of
attachment pattern

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 STATES OF MIND
• Not static
• Relational dynamics: feeling secure with some
people, preoccupied or dismissing with others,
even disorganised / unresolved in some situations
• But default position, core defences – CORE
PATTERN
• Can be modified by later experiences
• Relationships
• And by therapy
• ‘Earned security’
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EARLY OUTER WORLD -> LATER INTERNAL

WORKING MODEL /
DISPOSITION
CONSISTENTLY RESPONSIVE -> SECURE

CONSISTENTLY UNRESPONSIVE -> AVOIDANT (FEARFUL,

DISMISSING, WITHDRAWN)

INCONSISTENTLY RESPONSIVE -> PREOCCUPIED /

ENMESHED / ANXIOUS
AMBIVALENT

TRAUMATIC DISRUPTION / -> DISORGANISED /

ABUSE UNRESOLVED
(Tirril Harris, 2004)
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DISMISSING
• Adapt by becoming self reliant
• Highly defended
• Difficulties with trust, intimacy
• Cut off from emotions
• ‘Left-brain’ bias
• Resistant to introspection or retrospection
• Often harsh, demanding, critical relationship with
self
• May be arrogant, bullying, contemptuous
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 PREOCCUPIED
• Adapt to inconsistent relational environment by
hyperactivating affect
• Angry protest, helplessness
• Impulsive
• ‘Right-brain’ bias
• ‘Relational defences’; clinging, protesting,
collapsing
• Tend to make enmeshed relationships
• Undifferentiated, poor sense of self, little agency
• Difficulty focusing on future
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UNRESOLVED TRAUMA
• Result of severe neglect or abuse in early life
• Overwhelming fear, anger, confusion prevents
coherent sense of self developing –
developmental trauma
• Difficult to adapt to environment that is both
unpredictable and frightening
• No coherent adaptive strategies in early life
• Later strategic attempts include ‘agonistic,
seductive and compulsive care-giving’
strategies (Liotti)
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• Easily dysregulated, strategies break down

• Chaotic relationship to world, other people
and self
• Inability to trust others – longing for closeness
alternates with terror of intimacy
• Attempts at regulating intense feelings can be
problematic
• ’Unresolved for Trauma’ is a secondary
classification
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 PREOCCUPIED +
UNRESOLVED TRAUMA
• Likely to be chaotic in most areas of life
• Work may offer some containment and structure
• Close relationships are intense, labile
• There is a sense of being out of control in
relationships
• Often a lot of anger – feeling persecuted or provoked
• Splitting – idealising or denigrating
• Dysregulated affect
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BORDERLINE / EMOTIONALLY
UNSTABLE PD
• “Claustro-agoraphobia” – desperate longing for
closeness then panic, rejecting it
• Chaotic relationship with self: self-harm, addictions,
putting self at risk, suicide attempts…
• Possible dissociation
• Often associated with history of emotional / sexual
abuse

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DISMISSING +
UNRESOLVED TRAUMA
• Tightly self-controlled
• Cold, without emotions
• Superficially charming or charismatic
• Calculating, may manipulate, bully
• Contempt for vulnerability, “weakness”
• Narcissistic, highly sensitive to criticism
• Violence may erupt if challenged or shamed
• Dissociated state
• Or may get pleasure from harming others

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 NARCISSISTIC / ANTISOCIAL PD
• Psychopathy
• Linked to violent physical abuse or extreme neglect in
early life
• Violence turned against the other - identification with
aggressor
• Coercive control, domination
• Forensic settings

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MORE ON TRAUMA
• Child may have different patterns of attachment
with each caregiver
• One secure attachment provides some resilience,
even if another is traumatising, dysregulating
• Later in life …
• Secure and insecure attachment and PTSD
• Unresolved for Loss…

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THE CORE ANXIETY

• Being seen, exposed, judged, criticised, humiliated,
shamed
• Unleashing the longing for connection, intimacy and
acceptance - the “v-word”
• OR being invaded, colonised, so keep others at a distance
• Being abandoned, lost, alone in an unsafe world
• Activating intense attachment needs; clinging,
helplessness, provoking, arguing, enmeshed relationships
• All of the above PLUS being destroyed
• Helplessness, clinging, provoking -> rejecting, attacking…
• -> Intense affect, trauma cycle, self-harm or dissociation

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 SO…

THE AIM OF ATTACHMENT-

ATTACHMENT-
INFORMED PSYCHOTHERAPY IS TO
HELP CLIENTS BUILD SECURITY

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ENTAILS..
• Modifying internal working models:
– feelings about past relationships
– expectations of current and future relations
– relationship with others
– and with oneself
• Replacing entrenched defences – against
abandonment, intimacy or intrusion - with
more mature flexible strategies
• Laying ‘ghosts’ to rest
• This takes time
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SECURE ATTACHMENT
• Develops in optimal relational ecosystem
• The environment also adapts to the new infant
• Attachment needs are recognised, accepted,
responded to
• Infant’s own contributions valued, celebrated
• Support, encouragement, enjoyment

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 WHAT IT LOOKS LIKE
• Values relationships
• Able to be both intimate and separate
• Resilient sense of self, self-esteem
• Balance of left and right-brain capacities
• Comfortable with past and future
• Able to take autonomous decisions and actions
• Able to ask for help without shame
• And reciprocate
• Accepts imperfection in self and others
• No developmental deficits
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Q&A

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BREAK

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 MAKING USE OF THEORY
• “I have never regarded psychotherapy as my
principal role in the psychoanalytic world”
(Bowlby 1985/ 2019)
• Jeremy Holmes, David Wallin …
• Certain models informed by AT, and certain client
groups
• What are we trying to help clients do?
• How can we go about it?
• What are the key ingredients?

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THE BASICS
• Be reliable, consistent (boundaries)
• Interventions underpinned by coherent theory
• Be kind and respectful
• Sensitively attuned, alive and awake
• Be able to think
• Sometimes be surprising
• Have sense of humour
• Willing to challenge client
• Prepared to be self-reflective, especially about
mistakes
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KEY THEMES /AREAS OF FOCUS

1. Meaningful intergenerational narrative
2. Affect regulation
3. Mentalisation / reflective function
4. Mourning
5. Capacity for empathy, compassion for others
6. Self awareness, relationship with self,
compassion for / acceptance of self
7. Internalising a supportive new internal object

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 HOW TO USE THIS MODEL
• Not a linear process
• Development in one area impacts on others
• May need to return to some areas of focus over
time
• Self/supervision
• Assessment
• Reviewing the therapy
• When therapy feels stagnant
• Readiness to end…
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WHERE THERAPY STARTS…

• Each person adapted to unique relational
environment
• Needs a different recipe, proportion of
ingredients
• We are a social species, constantly responding to
current relational environment
• ‘Attachment state of mind’
• BUT – when under duress we revert to our core
pattern of attachment
• ‘Default setting’
• Hunch about core pattern…
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“The gold standard of measuring adult

attachment involves close and detailed
study of the words adults choose to tell
their attachment stories.”

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 ADULT ATTACHMENT INTERVIEW
• Narrative style and coherence indicates
attachment classification:
– Secure-
Secure-autonomous:
autonomous coherent, appropriate detail,
balanced, high reflective function
– Preoccupied:
Preoccupied overly-detailed, high emotional
content, unreflective, lengthy
– Dismissing:
Dismissing unelaborated, little emotional
language, unreflective, brief
– Unresolved:
Unresolved incoherent at times, sentence
structure breaks down, slippage of tenses etc.
– Cannot Classify:
Classify globally disjointed, incoherent
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ASSESSMENT
• Not only what clients says but how they say it
(AAI)
• How they present themselves and other
people in their life
• Relationship to time
• Attitude to boundaries
• How they engage with the therapist
• Countertransference
• -> Formulation
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VERY BRIEFLY…

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 AVOIDANT / DISMISSING
• Wary of therapy; highly defended
• Narrative lacks detail or emotional language
• Relationship feels tenuous
• Countertransference: bored, disengaged,
uncomfortable, attacked, criticised or critical…
• Focus on developing narrative, fostering curiosity
• Finding self-compassion; accessing emotions,
mourn ‘losses’
• ‘Relocate’ internal critic / bully / saboteur
• Relax boundaries
• Capacity for intimacy
• Spark playfulness, spontaneity, humour, passion
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AMBIVALENT / PREOCCUPIED
• Invests quickly in therapy
• Struggles to contain needs, pushes boundaries
• Overwhelming detail, absence of thinking space
• Countertransference: feeling intruded upon,
coerced, suffocated, “eaten alive”
• Focus on boundaries, developing trust, ability to
wait, self- containment
• Create space to think, make sense of experiences
• See others as separate people with own concerns
• Move on from raging; end mourning
• Support and enjoy new achievements, developing
sense of self
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DISORGANISED / UNRESOLVED
• Those with a history of unresolved trauma and
loss may alternate between “dizzying heights and
terrifying lows”
• They may re-enact trauma through unstable
lifestyle and inability to gauge danger
• They may attack themselves or others as
desperate measures to manage intense affect
• They may dissociate
• Self-medication may be extreme and ultimately
dangerous
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 SO…
• Attendance may be chaotic
• Therapist clung to then rejected, idealised then
denigrated / distrusted
• Narrative disjointed, gaps, inconsistencies
• Focus on structure, routine, containment, grounding,
regulating affect
• SAFETY – from current dangers, self-harm, damaging
self-medication, addictions etc.
• Then as for Preoccupied (or Dismissing)
• BUT talk therapy alone may not be enough, especially
at the start
• More containment and support needed, especially in
times of crisis
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AFFECT REGULATION
• Affect is contagious
• An angry, anxious, depressed or unpredictable
caregiver…
• Affect and the body, nervous system
• Oxytocin, cortisol, endorphins…
• Dismissing individuals are low reactors to cortisol
• And over-regulate emotions
• Those who are Preoccupied are high reactors
• And inflate affect
• Those with unresolved trauma may oscillate between
extremes, and / or dissociate
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AFFECT AND PSYCHOPATHOLOGY

• “As attachment theory has evolved, so the concept of
affect regulation has become increasingly central.”
(Fonagy et al 2002, p.90)
• For Schore, ALL psychopathology has its origins in
difficulty with regulating and managing affect
• Primary dysregulation: psychoses, borderline,
depressive, manic and anxiety states…
• Secondary dysregulation: chemical and behavioural
addictions, self harming behaviours, violence, … all
used to soothe, arouse, modulate and medicate
distressing self-states

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 ACCORDING TO SCHORE:
• Successful therapy changes brain structure
• Also physiology / nervous system
• Better integration of thoughts and feelings
• The therapist soothes, comforts and stimulates the
client’s mood by regulating emotional arousal
• The client can eventually tolerate a broader range and
intensity of emotions - positive and negative -
without becoming overwhelmed
• -> -> greater opportunities for healthy interpersonal
relationships and internal functioning without
becoming dysregulated
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IN THE ROOM
• Notice, name and manage affect in the session
• Therapist’s affect is contagious
• Lift low mood, soothe agitation
• Focus on an experience: “how did you feel … and what
did you do?”
• “How does it feel to talk about X? Or when I said Y?”
“What do you feel in your body?”
• “What do you feel like doing? Can you sit with these
feelings rather than take action?”
• Ensuring client is ‘put back together’ at the end of
sessions
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AFFECT REGULATION/ DISMISSING

• Help client become familiar with feelings, name them,
amplify them – develop right-brain capacities
• Slow down, create space for memories, needs,
feelings, relating
• Countertransference: picking up client’s disavowed
feelings
• Anti-depressive experiences: anger and joy
• Loosen grip of controlling tendencies, liberate
spontaneity, unselfconscious enjoyment, playfulness
• Role of shared humour: “humour and playfulness –
[give] the patient a sense of vitality” (Holmes 2010:77)
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 AFFECT REGULATION / PREOCCUPIED
• Down-regulate emotions
• Create space for thought – left-brain capacities
• “When was the first time you felt like this?”
• “What other situations make you feel this way?”
• Look for patterns
• “What are you trying to achieve? Is it working?”
• “What might happen if you behaved differently when
you are angry / upset / anxious etc.?”
• Promote self-containment, increase self awareness

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AFFECT REGULATION / UNRESOLVED

• Focus on safety
• Therapist must be highly attuned, sensitive to client’s
affective state
• Window of tolerance, titration
• Steer away from overstimulation
• Find ways to soothe, step back, encourage client to
develop observing ego
• Therapist’s presence, calmness, aliveness, tone of
voice and modulation, eye focus and body language…

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AND…
• Carefully manage endings of sessions and breaks
• Clients must be helped to regulate intense or difficult
emotions without acting out
• Attachment-based psychotherapy does not prescribe
specific techniques
• Help client develop techniques or strategies
• Mindfulness, exercise, journal writing, animals, art,
gardening, supportive others…
• Anticipate potentially disturbing / dysregulating
events
• If necessary, consider medication
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 Q&A

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LUNCH

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RELATIONSHIP TO TIME
• Narratives link experiences across time
• Generally, those with dismissing pattern of
attachment shun the past
• Those who are preoccupied get stuck in the
past, unable to see the bigger picture
• Those with unresolved trauma are easily
triggered by memories, may dissociate and
have gaps in their self-narratives

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 INTERGENERATIONAL NARRATIVE
• Therapeutic value of story-telling
• Connecting with personal, cultural and social history
• Bereavement work and beyond
• Developing a coherent, meaningful, plausible self-
narrative
• Curiosity
• ‘Who am I? Where do I come from?’
• Identity, perspective
• ‘Postmodern truth’
• Davoine and Gaudillière: therapy needs to address three
generations

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IDENTITY
• Who was my mother? And my father?
• What were their childhood experiences?
• Genograms
• Time-lines
• Genetic testing?
• Adoption…
• Family secrets
• Interviewing family
and ‘witnesses’
• Restitution
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THE THERAPIST’S ROLE

• Dismissing clients need help elaborating, giving detail,
becoming curious, imagining
• Preoccupied clients need help editing, detaching from
own experiences to take in bigger picture
• Unresolved clients need help to tell their stories
without becoming overwhelmed, sequencing, putting
experiences in order

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 EXERCISE
• Describe the family you were born into
• What was the influence of class, culture, religion,
history?
• What kind of parenting do you imagine your own
parents received at the beginning of their lives? Why?
• What experiences may have shaped their
personalities?
• If you were adopted soon after birth, you may need
to think about two ‘early environments’…

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OR…
• What do you know of the relationship between your
parents before you were conceived?
• How do you imagine they related to each other
during pregnancy? Why?
• What do you imagine were the fantasies,
expectations, hopes and fears each parent attached
to you before conception and during pregnancy?
Why?
• What support would your mother have had?
• What stresses?....

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WHY THIS HELPS

• Making sense of unique relational ecosystem we
adapted to
• Caregivers were people in their own right (Anagnostaki
& Zaharia, 2022)
• -> Understanding, perspective, compassion
• Having a coherent self-narrative is containing
• Integrates past and present, and looks to the future
• “Why do you think your parents behaved as they
did?”
• From fragile sense of self to “this is who I am…” “this
is where I came from..”
• No longer threatened by others, open to / interested
in difference
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 PROTECTIVE FACTOR
• An individual’s ability to think about his or her
childhood and make sense of it has an impact
on:
– relationships with his or her own children
– adult intimate relationships
– relationship with him or herself

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MENTALISATION
• The ability to reflect on and make sense of
thoughts, feelings and impulses in oneself and
others
• Helps us understand, empathise, predict
• Adjust behaviour accordingly
• Intense affect “throws us into non-mentalising
mode”
• But mentalising helps us contain ourselves, not
act impulsively
• So helps us regulate our affect (Schwarzer et al,
2021)

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DEVELOPMENT OF MENTALISATION
• When caregivers’ behavior is consistent
• Not oblique or frightening
• Infant can begin to predict responses
• Then to sense what motivates caregiver
• To ‘make sense’ of attachment figure’s mind
• And make links between own experiences, feelings and
reactions
• Move from concrete thinking to psychologically-minded
• Caregivers can help by explaining what motivates their
behaviour

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 • “If I drop an egg it breaks”
• “If I drop an egg my dad
shouts”
• “If I drop an egg dad gets
angry”
• “If I drop an egg dad thinks I did it on purpose”
• “If I drop an egg and my dad gets angry it
might be because he lost his job and he’s
worried about money…”
• “Or because he grew up in a place where food
was scarce so that taught him not waste it….”
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• Through making sense of parent’s mind, the

child learns to make sense of his / her own

“This ability … underlies the capacities for affect

regulation, impulse control, self-monitoring,
and the experience of self-agency – the
building blocks of the self”
(Fonagy, Gergely et al. 2002, p.25)

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BUT…
• Deprived of attachment figure’s coherent mind we
cannot make sense of our own
• We misread cues, cannot predict or anticipate
responses, may become paranoid…
• Poor capacity to mentalise is found in the
narratives of people with diagnosed personality
disorders
• And, to lesser degree, those with insecure
patterns of attachment

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 DISTORTED MENTALISING
• Without good reflective functioning the sense we
make of the world is skewed
• We see what we expect to see
• Or coerce others to behave as we expect
• Self-fulfilling prophesy
• Or we project a dangerous, envious, cruel, dys-
regulating internal object onto others
• -> Feel persecuted, paranoid
• We can all be ‘thrown into a non-mentalising stance’
when stressed
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SECURE-AUTONOMOUS
“The secure infant feels safe in making attributions of
mental states to account for the behaviour of the
parent”
(Fonagy &Target, 1998, p.20)
“The person who is free to evaluate attachments is
able to assimilate and think about her own past
experiences in relationships, even when these have
been unsatisfactory. She has mental space to relate
to her own relations with others. She can reflect on
her own feelings and impulses and can forgive and
tolerate her own shortcomings”
(Hobson 2004, p.178 - 179)
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DISMISSING
“The avoidant child shuns the mental states of the
other”
(Fonagy & Target ibid.)
“The person who is dismissing towards attachment-
related experiences, the stiff-upper-lip type of
individual, seems to have a constrained and in
some ways impoverished relation to her own past.
Much emotion seems to have been repressed or
dealt with in other ways that make it unavailable
for thought.”
(Hobson ibid.)
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 PREOCCUPIED
“The resistant child focuses on his own state of distress
to the exclusion of close intersubjective exchanges, or
finds it difficult to distinguish between different
people’s internal states”
(Fonagy & Target, ibid.)
“The person who is enmeshed appears to have been
unable to accomplish a full separation from her early
caregivers… the lack of space to think seems to result
from overwhelming and highly ambivalent feelings
crowding in and taking charge of thought.”
(Hobson ibid.)
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DISORGANISED
“Infants with disorganized attachment may
represent a special category: hypervigilant of the
caregiver’s behaviour, they use all cues available
and may be acutely sensitized to intentional
states, and thus may be more ready to construct a
mentalized account of the caregiver’s behaviour.”

“We suggest that in such children mentalization

may be evident, but it does not have the effective
role of self organization that characterizes
securely attached children.”
(Fonagy & Target, 1998, p.20-21)
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THERAPEUTIC IMPLICATIONS
• A vital aspect of effective therapy is helping the client
understand how minds work
• Therapy is a ‘school for mentalising’ (Holmes)
• We help clients observe their own internal worlds
• Make connections between current and past events
• Encourage them to recognise that other people are
equally influenced by their own experiences

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 ENGAGING THE CLIENT’S MIND
• Deconstruct distressing events that occurred
outside therapy
• “What was going on for you?” “Take me through
your feelings and thoughts..” “What triggered
this?” “What does it remind you of?”
• “How do you think the other person experienced
you? What might have been going on for him?”
• “If he was here now, how do you think he would
describe what happened? Why?”

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USING THE THERAPEUTIC

RELATIONSHIP
• Deconstruct events that happen in the room
• “I noticed you react to something. What is
happening?”
• “How did you feel when I said… ?”
• “What did I say or do that triggered that
reaction?”
• “What do you imagine I was thinking or feeling?”
• “What do you think I was trying to do?”

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SHARING MINDS
• It is vital the client discovers how the therapist makes
sense of the world
• We need to share our minds
• “I have a theory about this – what do you think?”
• “When people tell me about x, I often wonder about
y…”
• “This may not make sense to you but humour me –
let’s consider the possibility that…”
• “I may not be right but this is how I see it. Does that
make sense to you?
• “What do you imagine I would say about this?”
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 THE GOOD NEWS…
• Earning security confers some advantages over those
who have always taken it for granted
• Cassell research: from BPD to earned security
• “Mentalization may circumvent the need to repeat
our own past in our relationships with our children”
(Fonagy et al, 2000, p.251)
• And thus, “The association between parental
reflective function and child security is strongest when
there is adversity in the mother’s history” (Bateman &
Fonagy, 2004, p.76) - and she has received
psychotherapy

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Q&A

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BREAK

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 LAYING GHOSTS TO REST

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MOURNING
• There is no therapy without mourning
• “Pain is the agent of change” (Samuel)
• Bowlby places strong emphasis on mourning as
vital to healing - “Nature’s cure for psychic pain”
• Loss creates a hole that changes our environment
• We need to redefine ourselves, adapt to this new
ecosystem in order to move on
• That is painful and takes time; meanwhile the
world is unfamiliar, feels unsafe
• And defences are constructed
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COLIN MURRAY PARKES

Phases of:
• Numbness
• Yearning\pining\searching – and angry protest
• Disorganisation and despair
• Reorganisation

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 WORDEN’S FOUR TASKS OF
MOURNING

1. Accept reality of the loss

2. Work through pain of grief
3. Adjust to life without the deceased (or what has
been lost)
4. Emotionally relocate the deceased and move on
(find a new perspective on the past)

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INDEFINABLE ‘LOSS’
• Loss through separation, divorce or death may be
easier to grieve
• Absence - of love, trust, intimacy, safety is harder
to identify
• Developmental deficits
• For many, the absence of what was needed is
downplayed (defended against)
• For others, the wound remains raw always
(resistance to healing, letting go)

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THE ELUSIVE
• “The infant [is] born as an imaginative person
expecting life in affectionate company” (Trevarthen)
• Grieving for what was needed but has never been
• Compassion for self as a child, surviving without
security, love, intimacy, affection, encouragement,
support, containment…
• The need to engage in grief work, allow the pain - and
eventually let the process come to an end
• ‘Relocating the lost object’ – the longed-for attuned
caregiver
• Or the absent object – and giving up hope…
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 CHRONIC GRIEF
• Lost attachment figure is clung to, often with anger
or self-punishment
• Full acceptance of loss is blocked
• Relationship prior to loss / death often ambivalent
• Chronic grief keeps the ‘lost object’ alive in the
internal world
• Preoccupied people more prone to chronic grief
• Frequent ‘losses’ of attachment figure due to
inconsistent caregiving
• They have no faith in their ability to survive alone
• Fear of losing the ‘object inside’

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PREOCCUPIED INDIVIDUALS
• Are stuck at phase of yearning / protest
• Angry protest is unproductive, maintaining enmeshed
relationships with ‘ghosts’
• Grievance rather than grieving
• Defence against accepting reality, irrevocable nature
of loss or deficit, letting go
• Fear of losing internal object that is not firmly
established
• Especially evident when a relationship ends
• Therapy entails mobilising mourning, undoing
resistance
• Helping clients to give up hope

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MASKED GRIEF
• There may be no conscious awareness of loss
or deficit
• Distress is repressed / dissociated
• But may be manifested through physical
symptoms, changes in behaviour etc.
• For Dismissing individuals, repressed
attachment needs may leak out as masking
symptoms
• Shame of feeling vulnerable
• Reinforcing view that relationships are not to
be relied on – or needed
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 DISMISSING INDIVIDUALS
• Defences – against acknowledging loss, feeling
vulnerable, distressed
• Refusal to ‘fall apart’
• Deny or downplay significance of loss or deficit
• If relationships don’t matter they don’t need to
be grieved
• Action, distraction, manic defence
• Impact on immune system -> physical illness as
outlet for grief – and surrogate attachment-
seeking
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THE WORK
• We need to help Dismissing clients recognise
loss / absence/ deficit and its impact
• Engage in grief work, rage, cry, feel vulnerable,
feel compassion for themselves
• We must help Preoccupied clients recognise
that they are stuck in grief, trying to hold onto
the past, keeping someone / something alive
through raging
• They need to accept reality, feel genuine grief,
let go, have faith in themselves, move on
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FOR THOSE WITH HISTORY OF TRAUMA

• A major loss is profoundly dysregulating
• Coping strategies fall apart
• The known world falls apart
• Loss of containment, structure, routine ->
• Major depression, self harm, self-medication
• Rage, violence, persecutory fantasies (Ringel,
2019)
• We need to help them stabilise, keep them safe
• Affect regulation, window of tolerance
90

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 DEFICITS
• Reliable, predictable, SAFE caregiving
• Structure, containment
• Soothing, reassurance, protection
• Play, learning
• Hope, possibility
• Feeling valued
• Capacity to keep self safe…
• Eventually the many losses, absences and deficits
need to be mourned
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UNRESOLVED LOSS
• A major loss can be traumatic, even for someone
secure
• Period of disorganisation / despair
• Deconstructed self / dis-integration
• And eventual reintegration, remaking of the self
• AAI and linguistic markers – slips in discourse,
temporal confusion etc.
• Ability to forgive own failures, have self-
compassion, soothe self, reassure and encourage
self…

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RELATIONSHIP WITH ONESELF

• Capable of complex
relationships with others
• But also with ourselves
• Internal splits and ‘internal
objects’
• “The way we were treated as small children is the way
we treat ourselves the rest of our life. And we often
impose our most agonizing suffering upon ourselves”
(Miller 1983, p.133)
• Moral defence (Fairbairn)
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 ROGUE INTERNAL OBJECTS
• That keep us in check, inhibit us
• Criticise and shame us
• Attack and hurt us
• Cut us off from other people
• Undermine us
• Tell us we are helpless, feeble
• Tell us that other people can’t be trusted
• Tell us we are worthless
• Hidden self harm

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OBSERVING EGO
• Experiencing self / observing self split
• How and when we criticise / undermine / attack /
support / encourage ourselves
• How and when we shut ourselves down, or open
ourselves up
• Multiple motivations: “part of me wants to lash out,
but that’s not who I want to be…”
• The impact of experiences in the ‘outside world’ on
how we relate to ourselves

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HOWEVER…
• Attachment to ‘bad objects’
• Domestic violence, coercive control dynamic
• Cutting person off from others
• Preventing trust, promoting epistemic vigilance
• “No-one ‘out there’ is to be trusted”
• Major obstacle to therapy
• This is intended to keep the individual safe

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 WORKING WITH RESISTANCE
• “Why must you continue to abuse yourself like this? What
have you ever done that deserves such punishment?”
• “I don’t think you feel you’ve done something wrong - I
think you feel you ARE something wrong”
• “Would you say these things to anyone else?”
• “When do you first remember telling yourself that? What
was going on in your life then?”
• “I know you are just trying to stay safe, but this has kept
your life very small. How about you take a risk – just
once?”

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THERAPIST INTERVENTIONS
• Notice, name and focus on internal voice that is self-
critical, self-shaming, undermining
• Encourage client to notice when critical internal voice is
activated
• What is its purpose?
• Hidden self harm?
• A message to attachment figures?
• An attempt to stay safe?
• Challenge rejection of ‘narcissistic supplies’: “Your partner
said something very appreciative about you – do not
dismiss her feelings about you”

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98

• One aspect of the therapist as ‘secure base’ is active

protection of client from his or her attacks on self
• “STOP IT. I won’t have you saying that about yourself after
all this time in therapy”
• “If someone else treated you like this we would call it
abuse. You could leave. But like many victims of domestic
abuse, you stay attached to the one who is harming you”
• “I know you feel worthless. So what can you do in life to
feel worthy of your own respect?”

99

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 EXERCISE
• Draw a picture of your internal object world
• What are the ‘bad objects’? What qualities do
they have? How do they harm you?
• What are the ‘good objects’? What qualities do
they have? How do they help you?
• Who are the people who contributed to the good
objects? What did each of them supply in terms
of your internal resources?
• What did your parents / primary caregivers
contribute?
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100

NEW ‘INTERNAL OBJECT’

• That encourages, soothes, enlivens, reassures,
believes in and enjoys the self
• Based on experiences with the therapist
• + Positive experiences with friends, family,
colleagues
• + Any good experiences in early life
• + What caregivers tried to offer (though perhaps
they often failed)

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101

THE THERAPIST AS INTERNAL RESOURCE

• “Can you remember when you first told me about
…? What was my reaction?”
• “What do you imagine I would have said if I were
there with you?”
• ”What has been the most important thing I’ve said or
done during your therapy?”
• “When therapy has finished, what will you
remember to help you when times get tough?”
• Transitional objects
• Dreams
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 THE MOST IMPORTANT INGREDIENT
• Internalising a new protective ‘secure object’
• “It’s okay – this has happened before and we dealt
with it”
• “Just breathe…. This time will pass…”
• “Don’t forget to eat…”
• “You always feel like this in January – it’s the
anniversary of xxx dying”
• “That’s enough of giving yourself a hard time. You
haven’t done anything to deserve it.”
• “Come on – I know this is daunting but we can do it”
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KEY THEMES /AREAS OF FOCUS

1. Meaningful intergenerational narrative
2. Affect regulation
3. Mentalisation / reflective function
4. Mourning
5. Capacity for empathy, compassion for others
6. Self awareness, relationship with self,
compassion for / acceptance of self
7. Internalising a supportive new internal object

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SELF/SUPERVISION
• Identify a client where the work feels stuck or
is not going well
• Using the ‘menu of ingredients,’ identify areas
that can be focused on to get the therapy
moving ahead
• Develop specific strategies or interventions

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35
 READINESS TO END
• Reviewing therapy
• Where client was in early stages in terms of
‘ingredients’
• Where now?
• Resources
• Resilience

106

106

Q&A

107

107

ENDING

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36
 KEY THEMES / AREAS OF FOCUS
in Attachment-based psychotherapy

1. Meaningful intergenerational narrative

2. Affect regulation
3. Mentalisation / reflective function
4. Mourning
5. Capacity for empathy, compassion for others
6. Self-awareness, relationship with self, compassion
for / acceptance of self
7. Internalising a supportive new internal object
Linda Cundy

37
APPLYING ATTACHMENT THEORY: Full References
Linda Cundy, April 2023

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