The Handbook of Person-Centred Therapy and Mental Health

This is an extract from Chapter 11 by Emma Tickle and Stephen Joseph entitled Using attachment theory in person-centred therapy

The idea for this chapter arose from a recent teaching session with some of our students on a person-centred training course. They had recently started a new placement, working with children and young people, and their supervisor had advised them to familiarise themselves with the work of John Bowlby and attachment theory. We agreed that this was a good idea. Knowing more about attachment theory would give our students a wider perspective that would help them engage in dialogue with other health professionals about the similarities and differences of the person-centred approach. However, as the conversation progressed, it became clear to us that the students were interested in attachment theory because they thought that the person-centred approach was not able to provide a sufficient understanding of developmental processes and how early experiences with a caregiver related to mental health.

The aim of this chapter is to show that Rogers’s personality theory is a developmental theory that is sufficient in its own right, and that attempts to integrate attachment theory are unnecessary and may actually detract from person-centred practice. First, we will describe attachment theory and three types of attachment. Second, we will discuss how these three types of attachment describe experiences that can otherwise be viewed through the lens of person-centred theory and conditions of worth. Third, we will argue that, although the two approaches might describe the same phenomenon, the implications of categorisation are both limiting and inconsistent with the ethics of the person-centred approach. We will show how conditions of worth and attachment styles are essentially theories about the same process, but the terminology is different, and, most importantly, there is a difference in how the theory is put into practice.

Attachment theory
There is general consensus in the counselling and psychotherapy literature that our early childhood experiences of being in relationship with a significant other has an impact on how we relate to self, others and the world around us. Much of the credit for this is due to John Bowlby, who began writing about maternal care and mental health in the 1950s. One of his earliest studies was of the mental health of homeless children in post-Second World War Europe, the results of which came to wider attention in his 1952 book on child care (Bowlby, Fry & Ainsworth, 1953).

Bowlby went on to write what is known as the Loss Trilogy. This was a set of three books published in 1969, 1973 and 1980 respectively, which formed the building blocks for attachment theory, the full synthesis of which was published in 1988 in Bowlby’s book A Secure Base: parent-child attachment and healthy human development. Bowlby’s work highlighted the damage of maternal deprivation. Bowlby argued that attachment to a significant other was both an evolutionary necessity for survival and necessary for psychological wellbeing. Bowlby believed that infants possessed a motivational system programmed to establish secure attachments with a small number of significant others, and that achieving this promoted healthy development.
Bowlby was unequivocal in his view that parental love was vital for healthy psychological development; it was he said, as important as vitamins and proteins for physical health. He argued that the absence of parental love was invariably present in, if not the basis of, psychiatric disorders. He described attachment as an evolutionary behavioural system comprising three elements: the behavioural response to threat (eg. protest, crying); the significant other’s response to these behaviours (eg. soothing), and the ‘psychophysiological state that is the end result of those behaviours’ (eg. a return to calm, feelings of safety) (Holmes, 2001).

One of the most influential contributions to attachment theory was made by Mary Ainsworth and colleagues (1978), who created the Strange Situation test to trigger and then observe this behavioural system in action. It consisted of a standardised laboratory procedure involving the observation of a child in the presence of its parent, followed by separation of the child from the parent, the introduction into the room of a stranger, and finally the reunion of the parent and the child. Children in the experiment were aged between 12 and 18 months old. Observations of the child’s reactions to these led Ainsworth and colleagues to identify the three infant categories of secure, avoidant, and resistant/ambivalent.

Secure attachment
In the Strange Situation test, before separation, a securely-attached child will freely explore their environment with evident curiosity. When separated, they will show signs of missing the parent. They will show a clear preference for the parent over the stranger. When the parent is brought back into the room, they will initiate contact and return to play as before.

Avoidant
The avoidant child appears barely affected by the Strange Situation test. The child displays little distress when the parent leaves the room. Their play is unaffected by the presence or absence of the parent. The child’s approach to the parent is tentative and they are equally well comforted by the stranger.

Resistant or ambivalent
The resistant or ambivalent child clings to the parent, and does not explore the toys. They are preoccupied with the parent and have difficulty finding comfort when reunited, seeking and resisting contact through a show of anger.

How childhood attachment affects adult relationships
It is thought that attachment patterns in childhood have consequences for how we develop relationship skills as adults. According to attachment theory, a person’s attachment style as an adult is shaped by his or her early attachment patterns. Although recent researchers have begun to question this causal link and call for better research on the predictive power of early attachment (Meins, 2017), the idea remains influential among practitioners.

As with infants, it is thought that, as adults, we can be grouped into different attachment styles. Those with a secure attachment style are comfortable being close to others and don’t worry about being abandoned. They have the capacity to be both intimate and autonomous.

In contrast, those who are anxious-avoidant are uncomfortable being close to others; for them, the trade-off is autonomy at the expense of intimacy (Holmes, 2001). They find it difficult to trust others completely and to allow themselves to become dependent. They are nervous when anyone gets too close and may feel uncomfortable when people seek intimacy.Those who are anxious-preoccupied feel that others are reluctant to let them get as close as they would like; for them, autonomy is relinquished for intimacy (Holmes, 2001). They worry that their partner doesn’t really love them or won’t want to stay with them. Their desire for intimacy may frighten people away (Hazan & Shaver, 1987).

Attachment styles are an internal working model for all relationships that provides the lens through which people perceive the world and think about others and themselves. It is thought that a person’s attachment style is evident in how they talk about their lives and what they focus on. It is thought that at least 39 per cent of people are insecurely attached (Meins, 2017).  Ultimately, for those using attachment theory in their therapeutic practice, a person’s attachment style is a guide for whether they are ‘inoculated’ against mental health problems (that is, they are resilient to the assaults and adversities that lead to mental health problems) or vulnerable to developing them.

There has been much further development in using attachment theory in therapy than we have described above, but it is beyond the scope of this chapter to go into the detail. Interested readers are referred to Holmes (2001). What is important for the purpose of this chapter is to note the central idea in attachment theory: that the classification of secure, avoidant or ambivalent attachment patterns or styles provides the basis for psychotherapeutic formulation, whether working with children or with adults.

Attachment style is thought to be an important predictor of how therapy progresses (Gonzalez, 2015). Working with children and young people, the practitioner will take into account their attachment pattern in terms of how best to respond to them. With adults, practitioners will interview their patients in order to discover their attachment style, and will relate to them in specific ways and offer interventions depending on their style. Holmes (2001) uses the metaphor of the boxing ring. The ring itself represents the secure base, but the therapist must be able to move freely around the ring so as not to get cornered. For example, an insecure patient will want to cling on and control the therapist, so the therapist must help the patient trust him/herself. In short, by knowing a person’s attachment style, we know how they are likely to relate to us as therapists, what they need, and what we should do. Attachment theory offers a typological understanding of how experiences in childhood are important in the development of people’s internal working models, and how these relate to mental health problems.

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