Clinical Applications of the Adult Attachment Interview (Book Review)

Author:  Steele, Howard and Miriam Steele
Publisher:  Guilford Press, 2008
Reviewed By:  Katie Fitzpatrick, Vol. XXIX, No. 1, Winter 2009, p. 33

This book provides the reader with detailed yet concise information about the Adult Attachment Interview (AAI) with respect to theory, research, and clinical practice. The contents of the book were contributed by theorists, researchers, and clinicians and written in a way that does not assume that the reader has in-depth knowledge about the measure. At the same time, the book offers plenty of new thought regarding the theory and use of the measure that is useful and stimulating to the reader with AAI experience. As a trained interviewer and coder of the AAI as well as an AAI researcher, I found the book to be a source of the most recent research as well as a great comprehensive review of the AAI scoring and classification system.

The first part of this book provides a solid foundation for understanding the origin and development of the AAI, as well as the scoring and classification system. The disclosure of the details of the system was surprising given that the coding manuals are unpublished and can only be obtained through participation in an AAI training institute. What I found particularly interesting about this section of the book was the authors’ way of taking the reader through the interview protocol at times from the perspective of the interviewer and at other times from the perspective of the interviewee. In this respect, the reader can come to know both the intentions of certain questions and an understanding of the possible meanings of responses to these questions.

The remaining parts of the book offer a variety of clinical applications of the AAI with infant, adolescent, and adult populations and includes research on the treatment efficacy of such applications. Given the depth and breadth of information in this book, I decided to focus on one area of clinical application of the AAI: trauma. Within this section of the book, the perspectives of the contributing authors varied in clinical focus so that some chapters seemed more clinically applicable than others.

In my opinion, the most clinically relevant and experience-near chapter related to trauma work was the chapter entitled “The AAI and Its Contribution to a Therapeutic Intervention Project for Violent, Traumatized, and Suicidal Cases.” It is a highly thoughtful and coherent account of the authors’ use of the AAI in a non-traditional clinical context with difficult to engage, impoverished, and traumatized teenagers in Mexico City. The chapter conveys how useful and therapeutic the measure can be, not just for the interviewee, but for all of the individuals who gain knowledge and understanding from the experience of the interview and the information it brings to light. In this case, a team of psychoanalysts utilized the AAI with at-risk teenage mothers who participated in an outreach program that included a drop-in center run by community art instructors who provided art classes as well as child care and meals. The AAI was used predominantly as a kind of supervisory tool, as information and experience gained from the interviews was shared with the non-clinical instructors in order to help make meaning of their day-to-day interactions with the teens. This understanding of the teens’ attachment relationships, both historically and presently, enabled the instructors to understand their own feelings toward the teens. Subsequently, the instructors became more emotionally accessible to the teens and more tolerant of the sometimes highly intense and explosive interactions. Several case examples are given, which illustrate the nuances in individual responses to the AAI and how they relate to the context of the person’s early attachment-related experiences. The authors articulate how and why each case example fits into a certain attachment classification and how this information enriched their conceptualization of each case.

The chapter on adult attachment and PTSD in women with histories of abuse in childhood seemed to be written more from the perspective of a researcher and coder than of a clinician in that it focused more on the technical aspects of the AAI and the procedure of the study. The authors utilized the AAI to track the treatment outcome for symptoms identified as related to abuse in women ages 18 to 65 with histories of prolonged abuse (physical and/or sexual) during childhood. The study explores possible associations between AAI classification of “unresolved state of mind with respect to abuse” and diagnosis of PTSD. In particular, thinking about the discourse of unresolved speakers in the context of psychological responses to trauma (such as dissociative processes, re-experiencing and avoidance) is a new and interesting contribution of this chapter. Findings of the study suggest that PTSD symptoms, more than dissociative symptoms, predicted unresolved abuse classification. The authors then promote a “PTSD-informed” approach to the treatment of individuals with unresolved histories of abuse, particularly through the use of prolonged exposure techniques. This clinical recommendation lacks a detailed explanation and description of the application. In addition, the benefits of using the AAI and attachment theory in the treatment of individuals with PTSD is unclear.

I reviewed these two chapters within a single section of Clinical Applications of the Adult Attachment Interview in an attempt to convey the variation in what is meant by the term “clinical application.” Given the variation of clinical interests and styles of the contributing authors, some of the papers seemed more readily applicable to clinical work than others that resembled scientific manuscripts. On a similar note, this book reminded me of reading a volume of a psychology journal in that the structure is a compilation of individual papers, some of which are particularly relevant to my clinical work and interests. The common thread throughout the book is, of course, the use of AAI. That being said, there is repetition from one chapter to the next of explanations of the measure. This information could serve as a reiteration or refresher for some readers, but I found it redundant.

Overall, I feel this book is a great resource for orienting clinicians to the Adult Attachment Interview and a good reference for ideas on how to apply the measure once used solely for data collection in clinical settings.

Katie Fitzpatrick
Knoxville, TN

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