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First published 2014
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© 2014 Paul Holmes and Steve Farnfield
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Library of Congress Cataloging in Publication Data
The Routledge handbook of attachment :
implications and interventions /
edited by Paul Holmes and Steve Farnfield.—First Edition.
pages cm
1. Attachment behavior. 2. Child psychotherapy.
3. Dependency (Psychology) I. Holmes, Paul, editor of compilation.
II. Farnfield, Steve, editor of compilation.
BF575.A86R684 2014
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This book is dedicated to those professionals
who are the essential players in improving child
welfare and protection, and to our partners who
have supported us and nurtured us during the
long gestation of this book.
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Contents

Notes on contributors ix
Preface xiii
STEVE FARNFIELD AND PAUL HOLMES

1 Introduction 1
STEVE FARNFIELD AND PAUL HOLMES

2 Attachment theory and its uses in child psychotherapy 32

GRAHAM MUSIC

3 Where the child is the concern: working psychotherapeutically

with parents 53
JEREMY HOLMES

4 The marriage of attachment theory and systemic family therapy

practice: an invitation to join the wedding party 65
CHIP CHIMERA

5 Attachment-based interventions: sensitive parenting is the key

to positive parent–child relationships 83
FEMMIE JUFFER, MARIAN J. BAKERMANS-KRANENBURG AND
MARINUS H. VAN IJZENDOORN

6 Attachment-focused therapeutic interventions 104

DANIEL HUGHES

7 Clinical implications of attachment in immigrant communities 117

ELAINE ARNOLD
viii Contents

8 Attachment: a British lawyer’s perspective 132

MARY ANN HARRIS

9 The applications of attachment theory in the ¿eld of adoption

and fostering 147
JEANNE KANIUK

10 Attachment and social work 166

DAVID HOWE

Index 184
Contributors

Elaine Arnold taught social work students (MSW courses) at Goldsmiths College
and Sussex University, UK. She was Director of Training at Nafsiyat Inter-
cultural Therapy Centre, UK. She researched the adverse effects of separation
and loss and sometimes traumatic reunions among some families of African
Caribbean origin, due to immigration from the West Indies to Britain. She is
Director of the Separation Reunion Forum, the aim of which is to raise aware-
ness of the importance of secure early attachment in the life of the individual;
the phenomenon of broken attachments and traumatic reunions is also appli-
cable to children separated through various circumstances and to other groups
in society. Elaine currently lectures at various colleges and voluntary groups on
the Theory of Attachment, Separation and Loss and its applicability to practice
in the caring professions.
Marian J. Bakermans-Kranenburg is Professor at the Centre for Child and
Family Studies, Leiden University, the Netherlands. She is interested in par-
enting and parent–child relationships, with a special focus on neurobiological
processes and the interplay between genetic and environmental factors. Inter-
vention studies and adoption studies as (quasi-) experimental manipulations
of the environment have their natural place in this line of research. She was
awarded the Bowlby-Ainsworth award of the New York Attachment Consor-
tium (2005) and was VIDI (2004) and VICI (2009/2010) laureate of the Neth-
erlands Organization for Scienti¿c Research. She is a Fellow of The Royal
Netherlands Academy of Arts and Sciences and a Fellow of the Association for
Psychological Science, both since 2012.
Chip Chimera is a systemic family psychotherapist and a psychodrama psycho-
therapist. She is the director of the intermediate level of systemic training at
the Institute of Family Therapy. She is also a founder member of the London
Psychodrama Network. For many years Chip has been interested in the integra-
tion of attachment theory into clinical practice and into systemic training. As
course director of Child Focused Practice at IFT she teaches attachment across
the life cycle as an integral part of the training.
x Contributors

In clinical practice Chip has worked as an expert witness in private law high-
conÀict divorce cases and public law care proceedings, using an attachment-
based approach to family assessment and treatment in complex situations. Chip
has a thriving independent practice with individuals, families, couples and
groups. She also offers consultation and training to professionals. She is based
in London and Surrey and can be contacted at [email protected].
Steve Farn¿eld is a Senior Lecturer in Attachment Studies and convenor of the
MSc in Attachment Studies at the University of Roehampton, UK. He is a
social worker and play therapist with over 40 years’ experience in the ¿eld
of child and family welfare, and formerly taught on the Social Work and Post
Qualifying Child Care Programmes at the University of Reading, UK. Steve is
a licensed trainer for the Dynamic-Maturational Model of Attachment Infant
CARE-Index, Preschool Assessment of Attachment and Adult Attachment
Interview developed by Dr Patricia Crittenden. He has also developed a system
for analysing attachment and mentalising using narrative story stems with pre-
school and school-aged children.
Mary Ann Harris has been a member of the Law Society Children Panel for many
years. She came to Britain from the United States in 1969 and initially worked
as a paralegal and then graduated in Law in 1981. She obtained an LL.M (Can-
tab) in Public and International Law from Cambridge University, UK. She then
lectured in the Law Department at Trent Polytechnic, UK, before qualifying as
a solicitor. Since then she has practised in many small and medium sized law
¿rms in Lincolnshire, a City Council and latterly for a ¿rm in London special-
izing in family and children’s law where she became a partner and joint head
of the Family Department.
Her work ranged from probate work, advising on ecclesiastical law, civil
litigation, divorces, and in the last 20 years specialising in the law relating to
children, including adoption law, domestic violence and forced marriages.
She is now retired and lives on a livestock farm in Lincolnshire where she
and her husband breed British Shorthorn cattle.
Jeremy Holmes is a psychiatrist and psychoanalytic psychotherapist. For 35
years he worked as Consultant Psychiatrist and Psychotherapist in the NHS,
providing a district psychotherapy service in North Devon, focusing especially
on people with Borderline Personality Disorder. He was Chair of the Psycho-
therapy Faculty of the Royal College of Psychiatrists 1998–2002. Now par-
tially retired, he has a small private practice; set up and co-runs a Masters
and now Doctoral psychoanalytic psychotherapy training programme at Exeter
University, UK, where he is visiting Professor; and lectures nationally and
internationally. He has written more than 120 papers and book chapters in the
¿eld of Attachment Theory and Psychoanalysis, and 15 books including John
Bowlby and Attachment Theory (Routledge, 1992), and Oxford Textbook of
Psychotherapy (2005, co-edited with Glen Gabbard and Judy Beck). His lat-
est is Exploring in Security: Towards an Attachment-informed Psychoanalytic
 Contributors xi

Psychotherapy (Routledge, 2010). He was recipient of the 2009 New York

Attachment Consortium Bowlby-Ainsworth Founders Award.
Paul Holmes is a Consultant Child and Adolescent Psychiatrist with extensive
clinical experience in community child mental health teams and in specialist
services working with looked-after and adopted children, their families and
their carers. In his private practice he undertook over 500 child psychiatry
assessments for the courts in children’s proceedings where he has used his
expertise in attachment theory to inform his work. He has trained both as a
psychoanalytic and psychodrama psychotherapist and is the author of the Inner
World Outside: Object Relations Theory and Psychodrama and the editor of
three other books on psychodrama.
David Howe is Emeritus Professor in the School of Social Work at the Univer-
sity of East Anglia, Norwich, UK. He has research and writing interests in
emotional development, empathy, developmental attachment theory, and child
abuse and neglect. His most recent books include Child Abuse and Neglect:
Attachment, development and intervention (Palgrave Macmillan, 2005), The
Emotionally Intelligent Social Worker (Palgrave Macmillan, 2008), A Brief
Introduction to Social Work Theory (Palgrave Macmillan, 2009), Attachment
Across the Lifecourse: A brief introduction (Palgrave Macmillan, 2011) and
Empathy: What it is and why it matters (Palgrave Macmillan, 2012).
Daniel Hughes, PhD, is a clinical psychologist with a limited practice near
Philadelphia, PA. He has specialised in the treatment of children who have
experienced abuse and neglect and demonstrate ongoing problems related to
attachment and trauma. This treatment occurs in a family setting and the treat-
ment model has expanded to become a general model of family treatment. He
is engaged throughout the US, Canada, Europe and Australia in conducting
seminars and providing extensive training toward certi¿cation of therapists
in his treatment model, as well as providing ongoing consultation to various
agencies and professionals. Daniel is the author of many books and articles.
These include Building the Bonds of Attachment (2nd ed.) (Jason Aronson,
2006), Attachment-Focused Parenting (W.W. Norton & Co., 2009), Attach-
ment-Focused Family Therapy Workbook (W.W. Norton & Co., 2011) and
Brain-Based Parenting (W.W. Norton & Co., 2012).
Marinus H. van IJzendoorn is a Professor of Child and Family studies at Leiden
University and a Research Professor of Human Development at Erasmus Uni-
versity Rotterdam in the Netherlands. His major research interests include
attachment across the life-span and in various contexts; gene-by-parenting inter-
ventions and differential susceptibility; neural and hormonal concomitants of
parenting and emotional development. He was awarded the Aristotle Prize of
the European Federation of Psychologists Associations (2011), the Bowlby-
Ainsworth Founder Award of the New York Attachment Consortium (2011), an
Honorary Doctorate of the University of Haifa, Israel (2008), the Distinguished
xii Contributors

International Contributions to Child Development award of the Society for

Research in Child Development (2007), and the Spinoza Prize awarded by the
Netherlands Organization for Scienti¿c Research (2004). He is a Fellow of the
Royal Netherlands Academy of Arts and Sciences (elected in 1998).
Femmie Juffer is Professor of Adoption Studies at the Centre for Child and
Family Centre, Leiden University, the Netherlands. She is interested in the
life-long consequences of adoption and foster care, children’s resilience and
recovery from adversity, sensitive parenting, and effects of attachment-based
early childhood interventions for families. Together with colleagues she is
involved in several longitudinal and meta-analytic studies of adopted children
and in studies testing the effectiveness of the attachment-based intervention
developed at Leiden University: the Video-feedback Intervention to promote
Positive Parenting (VIPP). For her efforts to translate science into practice she
was awarded the Piet Vroon Prize in 2004 and a royal decoration of Of¿cer in
the Order of Orange-Nassau in 2010.
Jeanne Kaniuk is Managing Director of Coram’s Adoption Services, based in
London, UK, which has developed since her appointment as Head of Service in
1980. She has a long-standing interest in the needs of children who cannot remain
in their birth families, and was involved in the longitudinal adoption attach-
ment research study undertaken by Great Ormond Street Hospital, the Anna
Freud Centre and Coram (Kaniuk et al. in Adoption and Fostering, 2004, 28.2,
pp. 61–67). She was also instrumental in developing Coram’s concurrent planning
project, which is now in its 15th year. In 2006 Jeanne set up Coram’s adoption
partnership with LB Harrow, the ¿rst such partnership between a local authority
and a voluntary adoption agency in the UK, aimed at ensuring improved adop-
tion outcomes for Harrow’s children. This partnership has now been replicated in
other local authorities including Cambridgeshire, Kent and LB Redbridge.
Graham Music is Consultant Child and Adolescent Psychotherapist at the Tavis-
tock and Portman Clinics and an adult psychotherapist in private practice. His
publications include Nurturing Natures, Attachment and Children’s Emo-
tional, Sociocultural and Brain Development (Psychology Press, 2011) and
Affect and Emotion (Icon Books, 2001). He has a particular interest in explor-
ing the interface between developmental ¿ndings and clinical work. Formerly
Associate Clinical Director in the Tavistock Child and Family Department, he
has worked therapeutically with maltreated children for over two decades, has
managed a range of services concerned with the aftermath of child maltreat-
ment and neglect and organised community-based therapy services, particu-
larly in schools and in GP practices alongside health visitors. He has recently
been working at the Portman clinic with forensic cases. He organises training
for therapists in the Child and Adolescent Mental Health Services (CAMHS),
leads on teaching on attachment, the brain and child development, and teaches
and supervises on the Tavistock Child Psychotherapy Training and other psy-
chotherapy training programmes in Britain and abroad.
Preface

This volume is a companion to The Routledge Handbook of Attachment: Theory

(Holmes & Farn¿eld 2014) and The Routledge Handbook of Attachment: Assess-
ment (Farn¿eld & Holmes 2014).
We have both had a long-standing professional interest in child welfare, child
protection and therapeutic services: Paul Holmes as a child psychiatrist and adult
psychotherapist, Steve Farn¿eld as a social worker, play therapist and university
lecturer. Like many professionals involved in these ¿elds, in recent years we have
become increasingly interested in using attachment theory and the associated evi-
dence-based assessments, presented in these books, to underpin our work as thera-
pists, supervisors and (for Paul Holmes) as an expert witness in children’s legal
proceedings. These three books were designed to cover the areas of expertise we
draw on in this work.
Attachment theory and assessments can be used to assist in making decisions
about the possible therapeutic and social interventions that might assist families
and children. These may be either based on attachment theory and assessments
(i.e. they are logical, evidence-based, developments arising from theory) or attach-
ment-informed, in which existing therapeutic modalities or social interventions
incorporate concepts and knowledge from attachment theory and research.
Attachment strategies, ¿rst developed in infancy to assist in gaining protection
from danger, may later in life no longer assist the individual in the way they once
did. Indeed, they can subsequently be counterproductive to the formation of close,
trusting and secure relationships. Change can occur, through therapy or through
other life experiences, but this is a complex process which can take time.
The authors in this book consider therapeutic, social and legal steps that can
assist in this journey, from individual psychotherapy to, for a child, a change of
carer through fostering or adoption. However, the reorganisation of strategies
towards security or balance can be actually hard, particularly when a child or adult
has been traumatised by abuse or loss. In such cases professionals have to decide if
the problems are better worked through or worked around (Moran et al. 2008).
That said, all the chapters in this book consider interventions that offer the pos-
sibility of growth and change.
xiv Preface

References
Farnfield, S. & Holmes, P. (eds) (2014) The Routledge Handbook of Attachment: Assess-
ment, London and New York: Routledge.
Holmes, P. & Farnfield, S. (eds) (2014) The Routledge Handbook of Attachment: Theory,
London and New York: Routledge.
Moran, G., Bailey, H. N., Gleason, K., DeOliveira, C. A. & Pederson, D. R. (2008) ‘Explor-
ing the mind behind unresolved attachment: Lessons from and of attachment-based inter-
ventions with infants and their traumatized mothers’, in H. Steele & M. Steele (eds),
Clinical Applications of the Adult Attachment Interview (pp. 371–398), New York: The
Guilford Press.
Chapter 1

Introduction
Steve Farnfield and Paul Holmes

A great deal of work needs doing before we can be confident which disorders
of attachment and care-giving behaviour are treatable by psychotherapy and
which not and, if treatable, which of various methods is to be preferred.
(Bowlby 1979/2005: 171)

John Bowlby, the founding father of attachment theory and research, trained both
as a psychiatrist and as a psychoanalyst. His early seminal book Child Care and
the Growth of Love (1953) grew out of a report he wrote for the World Health
Organization commissioned to study the needs of ‘children who are orphaned
or separated from their families for other reasons and need care in foster homes,
institutions or other types of group care’ (Bowlby 1953: 7).
Bowlby’s interest in developing a research-based understanding of the con-
sequences of childhood trauma, loss and separation was always linked to con-
sideration of effective and logical therapeutic interventions. He struggled with
his own personal psychoanalytic heritage and always intended his contribution as
‘an up-to-date version of psychoanalytic object relations theory, compatible with
contemporary ethology and evolution theory, supported by research, and helpful
to clinicians in understanding and treating child and adult patients’ (Ainsworth &
Bowlby 1991: 9).
Clinical applications of his theory were slow to materialise and more has been
achieved since his death, at the age of 83 in 1990, than during his lifetime. It is
impossible to provide a comprehensive over view in a book of this length on all
the implications and treatments associated with issues of attachment. However,
the authors contributing to this volume open windows onto the wide range of
therapies and interventions which use attachment theory and/or research to inform
their practice.

Attachment theory
This book does not aim to provide a detailed account of attachment theory but a
brief summary may be useful.
2 Steve Farnfield and Paul Holmes

Attachment is ¿rst and foremost a relational theory. It has given us a way of

describing what we do when we are anxious and how we use past experience to
make predictions about what is most likely to keep us safe in the future. Bowlby
described this information as being stored as Internal Working Models (Bowlby
1973/1985; Bretherton 2005) whereas Crittenden uses the term Dispositional Rep-
resentations (Crittenden & Landini 2011). These memories of attachment-based
experiences are not things we have in our heads so much as the sum of expecta-
tions of future situations, especially those involving danger, developed in interac-
tion with attachment ¿gures in the past.
The consequences of this process for an individual infant were neatly cap-
tured by Mary Ainsworth and her work on the Strange Situation procedure
(SSP) (Ainsworth et al. 1978) which explored an infant’s responses to a brief
separation from their mother. Ainsworth’s analysis of these observations pro-
vided the ABC notation on which much of the subsequent empirical work has
been based.

• Type A Carers of infants in Type A are predictably rejecting of ‘unneces-

sary’ signals of attachment from their child and tend to be protective but not
comforting. Consequently the infant inhibits the display of anxiety; tries to
¿t in with the expectations of the outside world; takes responsibility for what
happens; and ¿nds intimacy in close relationships makes her defensive. Type
A uses cognition as a source of information, i.e. there is a reliance on cause
and effect at the expense of arousing feelings such as anger or desire for a
cuddle.
• Type B Carers of infants in Type B are predictably protective and comfort-
ing and attuned to their child’s needs. The infant comes to learn that the ex-
pression of arousing negative feelings can lead to resolution of problems after
which attachment-seeking behaviour can be terminated and he can go back to
exploration. Children and adults in Type B develop a high level of emotional
literacy.
• Type C Carers of infants in Type C are inconsistently available to meet
their infant’s needs and may reinforce behaviour in the infant that they say
they do not want, for example smiling approvingly when telling the child off
for doing something ‘wrong’. Life in Type C is never clear: the child’s feel-
ings and own perspective are a better guide to how he should proceed than
the perspective of other people. He uses affective logic to solve relationship
problems and force others to feel what he feels; ¿nding the right distance in
close relationships is a problem.

One starting point – two theories of attachment

Not all infants and children assessed in the early SSP samples ¿tted into one of
these three types. Scrutiny of anomalous examples led to a divergence of theory
by two of Ainsworth’s students, Mary Main and Patricia Crittenden. Main and
 Introduction 3

her colleagues developed a fourth category, disorganised-disorientated (Main &

Solomon 1986), setting in motion the development of the ABC + D model of
attachment. Crittenden interpreted the same data in a different way: as alternating
A and C strategies and then early signs of more complex A and C strategies which
she was later to describe in the Dynamic-Maturational Model (DMM) of attach-
ment (Crittenden 1985, 1995), which integrates all types of strategic attachment
behaviour under the three broad headings of A, B or C.

Other related theories

Neither the ABC + D or DMM model offers a phenomenology of attachment.
Yet it is the feeling of being insecurely attached, and how this affects other peo-
ple, which may bring people to therapy and interest professionals when trying to
understand individuals or families.
Object Relations Theory (ORT) provides one way of trying to give subjec-
tive meaning to the internal processes that underpin Bowlby’s ‘inner working
model’ of the world or, to use different language, Crittenden’s ‘dispositional rep-
resentations’. Concepts such as splitting or projective identi¿cation are useful in
explaining not just the internal defences employed in the Type A and C strategies
but also their effect on other people. ORT can Àesh out the meaning attachment
strategies have for speci¿c individuals and the impact on their relationships. It
is thus of considerable clinical use in attachment-informed treatments with both
adults and children (Holmes 1992; Steele & Steele 2008a; Steele et al. 2007;
Fonagy 2001).
The work of Peter Fonagy and colleagues has added the theory of mentalisation
to the classical theories of psychoanalysis and has shifted attention from the clas-
si¿cation of strategies to how people process information. Mentalising refers to
the peculiar human ability to take an intentional stance with regard to our own and
others’ behaviour; our ability to read the minds of other people and think about
our own thought processes. This can happen at a conscious or non-conscious level
and high-level mentalising is associated with secure attachment; the parent–child
relationship is a meeting of minds in which mentalising/secure attachment in the
parent is transmitted to the child (Fonagy et al. 2004; Allen et al. 2008).

What are ‘attachment-based’ interventions?

Writing on clinical work with adults, Obegi and Berant (2009) make the useful dis-
tinction between attachment-informed and attachment-based psychotherapy. The
former refers to the use of attachment theory and research to aid with assessment,
formulation and aspects of treatment but with a reliance on established therapeu-
tic modalities in terms of approach and technique. The latter attachment-based
therapies make explicit use of attachment theory as a conceptual and operational
framework for intervention and use validated assessment procedures to establish
whether changes in attachment behaviour or representations of behaviour have
4 Steve Farnfield and Paul Holmes

occurred following a particular treatment. At a minimum this requires pre/post

research designs and at best randomised controlled clinical trials.
The ¿rst reaction to reading the above might be that we should be striving for
attachment-based interventions that meet the demand for evidenced-based prac-
tice. Certainly if increasing attachment security in our clients is the primary aim of
our treatment then we should be able to give an account of our success. However,
the progress in establishing formally attachment-based interventions is patchy at
best. This is partly due to both the dif¿culty and the cost of mounting studies of
effectiveness. But, a more central reason is that, as Music observes in Chapter 2,
attachment theory and research cannot provide a whole theory about therapeutic
work.

Do we need specific attachment-based treatments?

The chapters in this book are a testament to the likely balance between attach-
ment-informed and attachment-based interventions in present clinical practice. In
our opinion only one chapter (Juffer and colleagues in Chapter 5) describes a for-
mal attachment-based intervention, while all the others are attachment-informed.
In the other chapters the authors have used their training as therapists and their
professional experiences to integrate the concepts of attachment into their work
using their clinical judgement and creativity rather than following ‘evidence-
based’ procedures. However, we would hope that therapeutic interventions that
are ‘felt to work’ will result in the establishment of proper evidence-based outcome
studies.
A prominent view, and one that we share, has been that attachment theory
should be used to inform the use of existing interventions rather than create new
ones (see Slade 1999: 577). The authors in this book discuss a number of therapeu-
tic and social interventions informed by attachment studies in this way.

‘Holding therapy’
Even a cursory search of the internet reveals all manner of ‘attachment therapies’
and cures for ‘attachment disorders’ together with other sites devoted to people
complaining that they have suffered at the hands of intrusive and abusive thera-
pists. These sites are reminders of an issue that came to a head in professional
circles around 2005 regarding ‘therapy’ which included enforced holding and eye
contact to recon¿gure the social brain of traumatised children. This produced an
outcry in professional circles (e.g. BAAF 2006; Chaf¿n et al. 2006; Prior & Glaser
2006). Our impression is that in this country the use of overt holding and other
forms of enforced ‘therapy’ has now abated or indeed ceased.
‘Holding’ was certainly the antithesis of a ‘secure base’ and it also reminds us
that psycho-social therapies are not neutral; if they can bene¿t people then they
can also do damage. Doctors and therapists can do harm (Fonagy & Bateman
2006: 1–2).
 Introduction 5

Wheels within wheels: systems within systems

This book considers interventions from a wide perspective, moving from one-to-
one individual psychotherapy through family therapy and parent training to the
input of social workers and the interventions of society through legal activity.
Attachment can be conceptualised as an intra-personal, inter-personal and a
social psychological theory which considers different spheres of existence or sys-
tems that all have an interlinked and hierarchical relationship to each other.

System

Genetic That which is inherited but which is open to change after

birth through the epigenetic process.
Biological The nervous, neurobiological, system which grows and adapts
over time from infancy consequent upon life experiences.
Intra-personal The individual’s psychology.
Inter-personal The dynamics of families and close relationships with other
people.
Cultural The dynamics between people in the local community and
national and international relationships.
(adapted from Holmes 1989: 244 and Holmes 1992: 20)

To take a very brief, simple, example:

Inter-personal system The difficulties caused by a distressed and angry act-

ing-out teenager will impact on those closest to him
in a way that might be assisted by family therapy.
Intra-personal system But the stresses in the home might make both the boy
and his mother depressed and have an impact on the
family. Individual psychotherapy or even antidepres-
sant medication might help.
Social system Likewise a change in any one system (say the family)
may impact on the boy’s peers and teachers at school.
Should this lad’s behaviour cross certain social and
cultural boundaries he may become involved with
social services and even the police and the criminal
justice system.

Family systems theory describes how a change in any person in the family will
impact on all the constituent parts of that system (Marvin 2003). This process will
also result in changes in the other systems in the hierarchy. If the family therapy is
successful the boy’s mother might become less depressed (which some would see
as a change in her nervous/biological system). Further pressure could be taken off
the school and social services systems and, indeed, the police.