Attachment Healing in Group Psychotherapy

Grace Bicket

Department of Counseling Psychology, Bastyr University

PS-5410: Theory & Practice: Group Counseling

Dr. Kavita Avula

May 22, 2024

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Attachment Healing in Group Psychotherapy

Attachment styles are salient to psychotherapy as they impact how a person regulates and

processes emotions, their self-perception, relationship patterns and functioning, as well as are

intertwined with experiences of trauma, abuse, and neglect (Tasca, 2014). A person’s attachment

style impacts their therapeutic relationships, therapeutic outcomes, and which interventions may

be effective (Tasca, 2014). Within individual psychotherapy, therapists can provide a secure base

for clients to explore their internal working model of attachment and experience reparative

processes (Cassidy & Shaver, 2016). More recently researchers are exploring the healing and

corrective impacts that group therapy can have on insecure attachment characteristics. This paper

explores and reflects on the impact of group therapy on individuals’ attachment characteristics

and functioning.

Attachment Theory

Attachment theory was developed by John Bowlby and Mary Ainsworth and posits that a

child’s early bonding experiences with their primary caregiver greatly impacts their

psychological development and future relationships (Cassidy & Shaver, 2016). Bowlby and

Ainsworth specifically explored the relationship between mother and child and the biological and

evolutionary mechanisms underlying an infant’s tie to their mother beyond feeding (Cassidy &

Shaver, 2016). A key component of attachment theory is attachment behavior, which are

behaviors such as smiling or crying that predictably increase the child’s closeness to the

caregiver and help them survive and adapt (Tasca, 2014). If the caregiver is responsive and

repairs the bond when there is a strain, the child learns that they can rely on their caregiver as a

secure base for which to interact with their environment and regulate emotions (Cassidy &

Shaver, 2016). When a child’s primary attachment figure is inconsistent, unavailable, neglectful,
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or abusive, the child learns they cannot rely on their caregivers or others (Kinley & Reyno,

2013). Such reactions from caregivers create an internal working model of attachment, called

attachment style, that forms the basis for how a person will interact with the world, process

emotions, regulate distress, and show up in future adult relationships (Tasca et al., 2011).

Attachment Styles

The four attachment styles are secure, anxious, avoidant, and disorganized (Levine &

Heller, 2010). Within the research, the avoidant type is also referred to as detached or dismissive

and avoidant, while the disorganized type is also referred to as fearful avoidant (Yalom &

Leszcz, 2005). A person with a secure attachment has a positive self-view, feels comfortable

with intimacy, trusts their partner, and can reflect upon themselves and others (Levine & Heller,

2010; Tasca, 2014). A person with an anxious attachment will tend to view themselves

negatively, have difficulty trusting, be overly preoccupied with their partner, and up-regulate

their emotions in a maladaptive way (Levine & Heller, 2010; Tasca, 2014). A person with an

avoidant attachment may have a positive or negative view of self, will struggle to reflect on their

own and other’s mental states, be uncomfortable with intimacy and closeness, as well as

maladaptively down-regulate their emotions and struggle to reflect on other’s mental states

(Levine & Heller, 2010; Tasca, 2014). A person with a disorganized attachment will have

characteristics of anxious and avoidant attachment styles, including difficult trusting others,

regulating emotions, and intense fear surrounding intimacy usually stemming from serious abuse

and neglect in childhood (Beeney et al., 2017). Attachment styles usually stay stable across a

person’s lifetime, however in some cases, they can be altered through a significant life event,

traumatic experience, or healed through positive relationships (Waters et al., 2000).

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Bowlby’s Therapeutic Tasks and Therapeutic Factors for Change

Bowlby describes in his 1988 book A Secure Base five therapeutic tasks that therapists

can use to support clients in examining their internal working models of self and attachment

figures (Bowlby, 1988, as cited in Tasca, 2014). These include:

1. Providing a secure base to explore relationships and working models.

2. Encouraging clients to reflect upon relationship patterns and views of individuals

whom they are attached to.

3. Supporting clients to look at their current therapeutic alliance from the context of

attachment working models.

4. Recognize the influence that past relationships with attachment figures have on

their current relationships and view of self.

5. Identify that models of self and others formed due to early attachment

relationships might not be congruent with, or appropriate for their current

relationships.

While Bowlby implicated these tasks for the individual therapist, they apply to the group

therapist and group members and can be achieved through group cohesion, group as early family,

interpersonal learning, and corrective emotional experiences (Yalom & Leszcz, 2005;

Marmarash & Tasca, 2013; Tasca, 2014).

The first task, which is to create a secure base, is achieved in group therapy via group

cohesion (Tasca, 2014; Yalom & Leszcz, 2005). In particular, the more members feel a sense of

belonging and can rely on the group, like a caregiver, the more trusting members will feel and be

able to take risks (Marmarosh & Tasca, 2013). Group cohesion creates a foundation for which
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members can tolerate and explore strong emotions and is especially important for those with

anxious attachments to make progress (Tasca et al., 2006).

Through the group as a social microcosm and recapitulation of the early family, clients

can witness relationship patterns in the here and now which can give insight to their attachments

outside of group (Tasca, 2014). The group therapist can also support members to reflect upon

their working model and how it is impacting their therapeutic alliance, by providing a safe space

to explore their relationship in group (Tasca, 2014). As group resembles family dynamics and

can bring up early negative family experiences, the group therapist can support members to

examine these relationships in the here and now and provide a space to interact differently than

they might have with their family (Tasca, 2014). The member can then recognize that past

relationships with attachment figures are influencing their current interactions and modify their

behavior to be adapted to the scenario (Yalom & Leszcz, 2005; Tasca, 2014).

Another group therapeutic factor that Yalom and Leszcz (2005) identify which has been

linked to attachment theory is interpersonal learning. Group members might experience scenarios

and interactions that trigger previous negative experiences, however in the safe context of the

group with a supportive therapist, there is the opportunity for a corrective emotional experience

(Yalom & Lezcz, 2005; Tasca, 2014). During this, the member can be present in their body,

reflect, and adaptively respond to the scenario (Yalom & Leszcz, 2005; Tasca, 2014).

Interpersonal learning in group therapy supports Bowlby’s therapeutic task five which helps a

member understand that their previous working model does not align with their current self,

environment, and functioning (Tasca, 2014).

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Therapist, Member and Group Characteristics

It is important to note that the characteristics of the therapist, individual members, and the

values and norms of the group itself are determinants of success. One of the roles of the group

therapist is to match members to a group based on the potential for growth, positive bonds, and

corrective emotional experiences. A factor that supports attachment healing is the presence of a

securely attached partner or other, such as the therapist and other members (Levine & Heller,

2010). As such, the therapist must be incredibly sensitive to managing interactions in a way that

addresses transference and gently brings it into the space to work with. The therapist can serve to

guide individuals, however the group dynamic needs to be conducive to acceptance, bonding,

and compassion. Preparation for a group assists in creating a group dynamic, as does creating

group norms, boundaries, goals, and expectations (Yalom & Leszcz, 2005). Lastly, anxiously

attached individuals may benefit from different group contexts and interventions than avoidantly

attached individuals, and the therapist needs to be aware of the attachment challenges at play and

how to approach them without re-traumatizing or targeting members (Tasca, 2014).

Current Research

With the aforementioned factors in mind, the subsequent sections of this paper will

review experimental studies that evaluate if group therapy interventions can improve insecure

attachment characteristics and functioning in group members.

Attachment Insecurity and Binge Eating Disorder Treatment Group

A study conducted by Maxwell and colleagues in 2014 explored the impact of group

psychodynamic interpersonal psychotherapy (GPIP) on attachment insecurity at Ottawa College.

The researchers explored if attachment changes remained posttreatment, as well as if reduction in

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attachment anxiety improved symptoms of binge eating disorder (BED), depression, and

interpersonal problems (Maxwell et al., 2014). Their study consisted of 102 (n=102) women who

met criteria for BED, ages 31-52. Almost 90% of participants were White (n=91), around half

were married or lived with a partner (n=49), and ~78% (n=80) had attended college or university

(Maxwell et al., 2014). Participants were included in the study if they were able to speak and

read English and were overweight and were excluded for factors such as engaging in

compensatory behaviors, having a bipolar or psychotic disorder, recent substance abuse, or were

pregnant or planning to become pregnant within 1 year (Maxwell et al., 2014).

Participants for this study underwent pre-treatment measures and attended a pre-group

prep session before engaging in 16 weeks of group therapy (Maxwell et al., 2014). Each group

consisted of 5-10 members and underwent 90-minute sessions weekly (Maxwell et al., 2014).

Participants completed the Attachment Style Questionnaire (ASQ; Feeney, Noller, & Hanrahan,

1994) and were assigned to groups based on high or low attachment anxiety (Maxwell et al.,

2014). These scores were re-evaluated post-treatment, 6 months after, and 12 months after

treatment (Maxwell et al., 2014). Researchers also assessed interpersonal problems, depressive

symptoms, and binge eating using other measures (Maxwell et al., 2014).

During group psychotherapy, therapists used GPIP which combines psychodynamic,

interpersonal and group psychotherapies and describes BED as a maladaptive coping response to

challenging feelings which are brought on by interpersonal conflict and unmet attachment needs

(Maxwell et al., 2014). The researchers found that up to 12 months after treatment ended,

attachment anxiety and attachment avoidance were significantly decreased, with the most change

occurring from pre-to-post-treatment (Maxwell et al., 2014). The researchers also indicated that

changes in attachment anxiety and attachment avoidance scores were related to changes in their
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interpersonal problems scores (Maxwell et al., 2014). This study supports the idea that group

therapy can be a factor for promoting lasting change in attachment insecurity characteristics such

as anxiety and avoidance (Maxwell et al., 2014). Key to these changes is interpersonal

functioning, which is promoted through the concept of interpersonal learning, as well as affect

regulation, which can be modeled by group therapist’s and members (Maxwell et al., 2014;

Marmarosh & Tasca, 2013).

Group Mentalization and DBT Impact on Attachment Styles, Mentalization, & Social

Cognition in Borderline Personality Disorder

A randomized controlled trial conducted by Khabir and colleagues (2021) investigated

the impacts of a mentalization-based treatment (MBT) and dialectical behavior therapy (DBT) on

individuals with borderline personality disorder. Specifically, they looked at how MBT and DBT

could influence attachment style, social cognition, and mentalization (Khabir et al., 2021). In

people with borderline personality disorder, an insecure attachment style (typically anxious or

disorganized) influences their ability to understand their own and other people’s mental states

and use that knowledge to interact accordingly in social situations (Khabir et al., 2021).

This study was a single-blind, randomized controlled trial including 36 participants

(n=36) diagnosed with BPD living in Shiraz, Iran (Khabir et al., 2021). Participants were aged

18-27, were 69.44% female (n=25) and 30.56% male (n=11), with around 86% of participants

having at least a bachelor’s degree (n=31) (Khabir et al., 2021). Participants were divided

equally into a DBT, MBT and control group, and completed multiple questionnaires to evaluate

attachment, reflective function, social cognition, anxiety, and depression (Khabir et al., 2021).

The group therapy format was based on Marsha Linehan’s DBT guidelines (1993) and Bateman

and Fonagan’s MBT Guidelines (2016).

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The study results indicated that both MBT and DBT were effective at improving avoidant

and disorganized attachment styles as well as mentalization and social cognition in participants,

however MBT was more effective (Khabir et al., 2021). Consequently, changes made from pre-

test to post-test in avoidant and ambivalent attachment styles were not maintained in the follow-

up (Khabir et al., 2021). Improvement in social cognition and MBT was more stable than DBT

from pre-test to follow-up (Khabir et al., 2021). These results indicate that using mentalization

based processes in group therapy when working with individuals with BPD can be an effective

intervention for making changes to attachment style, social cognition, and mentalization, all key

components of functioning for BPD (Khabir et al., 2021).

Narrative Therapy Impacts on Attachment Styles and Inferiority in Married Women Who

Experienced Infidelity

In 2022, researchers Ghaffari and colleagues conducted a quasi-experimental study on the

impacts of narrative group therapy on married women who had or were experiencing marital

infidelity. They explored how a narrative therapy group would affect feelings of inferiority and

attachment style using a pre-test post-test design and a control group (Ghaffari et al., 2022). The

study consisted of 40 women (n=40), aged 20-40, who had at least a diploma, had been living

with their partner for at least 3 years, and resided in Mashhad, Iran (Ghaffari et al., 2022). Group

narrative therapy was conducted at a counseling center over the course of 7 weeks during 90-

minute sessions (Ghaffari et al., 2022). To gather their infidelity and attachment scores,

participants took Hazan and Shaver’s Adult Attachment Questionnaire (1987) and Eysenck’s

Inferiority Questionnaire (1972) before and after treatment (Ghaffari et al., 2022).

During group, sessions followed a 7-step narrative therapy protocol that worked on

reducing feelings of inferiority (common in insecure attachments) and increasing secure

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attachment by exploring alternative stories and understanding how one’s dominant story has

been influenced by society and past relationships (Ghaffari et al., 2022). The therapist and

members were in a collaborative role, however members held high authority and all opinions

were deemed acceptable and respected—in other words, the therapist gave power to the women

in the relationship by holding space, respecting opinions, and focusing on strengths and goals

that align with their alternative story (Ghaffari et al., 2022). Members were encouraged to accept

their internal psychological experiences and thoughts that came up when communicating with

others in the group (Ghaffari et al., 2022). Additionally, members were encouraged to find

meaning in their interactions within the group, rather than focusing on absent attachment figures

in their marital relationships (Ghaffari et al., 2022). As a result, the researchers found that scores

for anxious attachment, avoidant attachment, and inferiority were decreased, while secure

attachment scores increased post-treatment (p<.05) (Ghaffari et al., 2022). The results from this

study support the research and literature indicating that group therapy can be effective at

improving healthy attachment characteristics (Ghaffari et al., 2022).

Online Group Psychodynamic Psychotherapy: The Effectiveness and Role of Attachment

A study conducted by Wajda and colleagues in 2022 tested how attachment dimensions

of anxiety, avoidance, loneliness, and self-esteem would be impacted by participating in 10

weeks of online group therapy, as well as how participants attachment styles would predict

treatment outcomes. Their study consisted of 22 participants (n=22), 13 women and 9 men, aged

21-65, who had at least secondary schooling, and were receiving psychiatric outpatient care in

Gliwice, Poland (Wajda et al., 2022). This study contained 2 groups of 10 and 12 members that

met for 2.5 hours twice a week for 10 weeks (Wajda et al., 2022). Patients were initially included

in the study based on a diagnosis of neurotic, stress-related, and somatoform disorders, or

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mild/moderate depressive episodes according to the ICD-10 (Wadja et al., 2022). Participants

underwent 2-3 consultation sessions with a psychologist and psychiatrist and were excluded

based on diagnoses of other disorders or factors deeming them unfit or unable to participate in

the online group (Wajda et al., 2022).

For this study the therapists used a psychodynamic and interpersonal style based on

group therapy handbooks from Yalom & Leszcz (2020), Bernard et al., (2008) and Weinberg and

Rolnick (2018) (Wajda et al., 2022). To measure attachment, the researchers used the Experience

in Close Relationships-Revised measure (ECR-R; Brennan et al., 1998), taken at the 1 st and 10th

week, as well as a symptom checklist for neurotic symptoms and measures for loneliness and

self-esteem. Variables were measured before the 1st session, 2 days after the end of therapy, and

6 weeks following (Wajda et al., 2022). Attachment styles of participants were distributed

accordingly: 27% secure (n=6), 23% anxious (n=5), 23% avoidant (n=5), and 27% disorganized

(n=6) (Wajda et al., 2022).

Functions of the therapists in this study were to encourage members to interact freely and

provide feedback to each other, strengthen group cohesion, build a “group observing ego”, create

an atmosphere for corrective experiences, expand client awareness to their defense mechanisms,

interpret transferences, and monitor group principles (Wajda et al., 2022). Consistent with the

psychodynamic/interpersonal approach, the group leader and members focused on relationships

between members, awareness of the internal world, group strength, clinical setting, socio-cultural

environment, and what members participation styles reveal about their interpersonal

relationships (Wajda et al., 2022).

At the end of therapy and follow-up, participants displayed a decrease in anxiety and

avoidance dimensions, with a moderate effect size (Wajda et al., 2022). Participants with a
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secure attachment style showed the most decrease in neurotic symptoms, while participants with

anxious and disorganized attachments showed the most increase in self-esteem (both 18.2%)

(Wadja et al., 2022). The researchers also observed a positive correlation between social phobia

symptoms and attachment anxiety (r=.44) while avoidance correlated negatively with pain

symptoms (r=-.501) (Wadja et al., 2022). Loneliness did not improve after follow-up, which the

authors suspect may be due to online therapy occurring during COVID-19 and losing the bonds

formed during the study thus increasing loneliness. In sum, the study concluded that online group

psychotherapy is effective at reducing anxiety and avoidance attachment characteristics and

increasing self-esteem but is not effective at decreasing loneliness after therapy (Wadja et al.,

2022). Researchers did not find attachment styles to be predictors of overall treatment efficacy

(Wadja et al., 2022).

Drawbacks to the Research

General drawbacks to the research included small sample sizes in 3 of the studies,

homogenous groups, demographic limitations such as gender, age, and schooling level, short

study duration, use of self-report questionnaires instead of the Adult Attachment Interview, as

well as some lack of explanation of the therapeutic processes and follow-up measures (Maxwell

et al., 2014; Khabir et al., 2021; Ghaffari et al., 2022; Wadja et al., 2022). The subsequent

paragraphs discuss drawbacks to the studies at length.

Maxwell and colleagues’ 2014 study contained seemingly homogeneous group

characteristics, such as a predominantly White, female, educated, middle-aged and middle-class,

English as first language participants (Maxwell et al., 2014). Thus, this study is not

representative of the general population and group members held high levels of privilege. Their

study also had a wide range for number of group participants (5-10), whereas groups of 7-10
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would have been more appropriate (Maxwell et al., 2014). Furthermore, the study placed

participants into groups based on attachment anxiety levels, which may have limited the

opportunities for experiencing a “secure other” in the group and generalizability to the

population (Maxwell et al., 2014). The study also contained missing data points, and used a

correlational model, which limits the ability to make causal conclusions (Maxwell et al., 2014).

Next, the study conducted by Khabir and colleagues (2021) does not include information

regarding the frequency and duration of the group therapy sessions, so it is difficult to deduce

how long it takes to observe changes in attachment characteristics. Additionally, their sample

was small (n=36), and contained mostly highly educated individuals who likely are of high

socio-economic status, as well as limited age to 18-27 years, which is not widely representative

of the population (Khabir et al., 2021). Other than mentioning that sessions of DBT were based

on Marsha Linehan’s guidelines (1993), and that MBT sessions used Bateman and Fonagy’s

MBT treatment guide (2016), there is no discussion of the therapeutic process or group

members’ interactions with each other (Khabir et al., 2021).

Drawbacks to Ghaffari and colleagues (2022) study include that there is a gender

(women-only) and age (20-40) limitation within the population, making the results difficult to

generalize. The duration of therapy was also short (7-weeks) and not representative of typical

group psychotherapy length (Ghaffari et al., 2022). Furthermore, the study did not conduct a

follow-up assessment to see if results were maintained post-treatment (Ghaffari et al., 2022).

Lastly, limitations to Wadja and colleagues (2022) study include a small sample size

(n=22) with no control group to compare results against. Wadja and colleagues’ (2022) study did

not use randomization to assign groups and relied upon self-report measures. The study also
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noted a need for measuring therapist attachment behaviors in future research to measure the

impact of therapist attachment on participants attachment healing (Wadja et al., 2022).

Conclusion

This paper explores the question, “Can insecure attachment characteristics be improved

in group therapy?”. Based on the research, there is evidence that insecure attachment

characteristics can be improved by participating in group therapies such as traditional

psychodynamic, interpersonal, MBT, DBT, and narrative therapy (i.e., Ghaffari et al., 2022;

Khabir et al., 2021; Maxwell et al., 2014; Wadja et al., 2022). By experiencing group cohesion,

the group and group therapist as a secure base, interpersonal learning, reflecting on self and

others in the group, and affect regulation, individuals can move towards a more secure

attachment (i.e., Ghaffari et al, 2022). The studies reviewed also found that group therapy

improved symptoms associated with their participants functioning such as binge eating disorder

and depression, components of borderline personality disorder such as mentalization and social

cognition, self-esteem, and inferiority (Ghaffari et al., 2022; Khabir et al., 2021; Maxwell et al.,

2014; Wadja et al., 2022). Future research might explore healing attachment in heterogeneous

groups containing individuals with various gender and sexual identities, racial identities, cultural,

and socio-economic backgrounds. Moreover, more groups might employ the Adult Attachment

Interview as a measure and create groups of individuals with mixed attachment styles. Lastly,

research might measure the impacts of therapist attachment style, client-to- therapist attachment,

and therapist directiveness/participation to understand how these variables impact attachment

characteristics in members.
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Author Reflection

In gathering research for this paper, I was surprised at the variety of psychotherapy

techniques employed in the studies. What this tells me is that many forms of group therapy could

likely produce results indicating more secure attachment characteristics. What is most important

is the group therapist creating and maintaining a cohesive group with boundaries and mutual

goals, while providing a secure base. In that, the group therapist holds a lot of power as a role

model and base for attachment healing and must maintain an unbiased role. I was disappointed to

see a lack of representation of people of color in the studies, but this does not surprise me. I was

also surprised that there are few studies exploring attachment healing in group therapy with

children and parents. I came across one mother-son dyad with disorganized attachment (Knafo et

al., 2018) but found no others. Working with children and their families seems like the most

important time to address attachment. Overall, my interest in conducting group therapy has

grown since completing this project, and I am interested in exploring attachment in groups,

within myself and others.

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