Treating Attachment Disorders: From Theory to Therapy (Book Review)

Author:  Brisch, Karl Heinz
Publisher: New York: Guilford Press, 2002
Reviewed By: Cress Forester, Fall 2003, pp. 35-37

From a new viewpoint a familiar landscape can sometimes look very different. (Bowlby, 1969, p. xi)

To suppose that Freud would not have wished to integrate the findings of attachment studies within his psychoanalytic theory is rather like supposing that Galileo would have rejected the discovery of supernovae or black holes (and to reject recent research findings as incompatible with Freud is not unlike rejecting later astronomical findings as incompatible with Galileo). (Hurry, 1998, p.41)

Bowlby’s attachment theory and research, and more recently the elegant works of Main and Stern and their respective associates, has led to a rich and extensive literature. It has influenced the perception and understanding of infants and their development, and parent-infant relations and its effects on later development. Stern (1985) discussed in detail the contrast between the “observed infant” of attachment theory and the “psychoanalytic infant” of traditional psychoanalysis. The latter has been characterized as a restrospective and pathognomic reconstruction based on analyses of adults (Peterfreund, 1978). In contrast, the “observed infant” of attachment theory is based on detailed, elegant, longitudinal studies of infants and parent-infant interactions. These compelling studies have steadily continued to provide a very different view of infant and human development, and of adult patterns of relationship, than that of traditional psychoanalysis. The influence of these studies and ongoing theoretical writing can be found in a variety of psychoanalytic approaches, as Fonagy (2001) describes. Attachment theory has also been used to understand the origin of dissociative disorders (Barach, 1991; Liotti, 1995), and the origin and treatment of serious mental disorders (Allen, 2001). It is puzzling and unfortunate therefore that many psychoanalysts still dismiss or reject attachment theory and research findings, and teach as if neither existed.

Bowlby’s theories arose initially from his clinical experiences with maladjusted children and adolescents who were in residential treatment. He was deeply impressed by the role of relationship loss and deprivation (particularly of the mother) in the origins of maladjustment. Though a combination of clinical practice and careful research driven by his clinical work, he developed a model of psychic development and treatment that addresses the role of life experiences and relationships, particularly the quality of parent-child relationships. Bowlby’s underlying explanatory model relates to a biological drive, present throughout the life cycle, to form attachments as a “secure base” for exploring oneself, the world, and life’s potentials. He developed the construct of “inner working models” —internal representations of relationships formed with early caregivers (although they also can be formed in later relationships)— that influence adjustment, personality and the capacity to form secure relationships throughout life.

A psychiatrist, he was also a member of the British Psychoanalytical Society, was analyzed by Riviere, and became an analyst in 1937. From 1946-1968 he was head of the Tavistock Clinic’s Children’s Department (which he renamed the Department of Children and Parents, in line with his developing theories). He was therefore well placed to test and develop his model and theories through the use of detailed long-term clinical studies and the extensive research studies that he and some of his colleagues undertook. In his commitment to both clinical work and research he was quite unusual (Fonagy, 2001). While he was influenced by other psychoanalytic thinkers, particularly Balint, Fairbairn, Guntrip and Winnicott, and stated that his work had its origin as a variant of object relations theory (Bowlby, 1988), his theories developed independently (Bretherton, 1991). Bowlby was unafraid of exploring and integrating findings and theories from domains outside of psychoanalysis (developmental psychology, cognitive science, systems theory, and ethology) in his search to understand patients and to effectively treat them. Bowlby was also motivated by his experience and research findings to seek to change the way children are understood and treated in schools, hospitals and other settings.

In 1940, Bowlby published a paper that contains many of the core concepts of his theory. Over the next thirty years he wrote numerous articles developing and clarifying his groundbreaking ideas; his first presentation of attachment theory was in 1957 and, undeterred by the disapproving and critical responses this paper evoked in his psychoanalytic community, he published the first of his three major treatises on attachment theory in 1969. Nearly twenty years later in 1988 Bowlby wrote “It is a little unexpected that, whereas attachment theory was formulated by a clinician for use in diagnosis and treatment of emotionally disturbed patients and families, its usage hitherto has been mainly to promote research in developmental psychology.” (p. ix). Fourteen years after this, as Köhler (2002) comments in her Forward to Brisch’s book, despite the vast published literature on attachment research and theory, there is still very little written on clinical applications. It is this dearth that Brisch redresses by describing a selection of cases across the entire age range, in which treatment was informed by attachment theory.

Brisch’s book, with a Forward by Lotte Köhler and an Afterword by Inge Bretherton, is a translation from the original German edition. Brisch’s presentation of his case material at a convention in Germany came just after the original was published in 1999. His presentation was so well received that all 300 copies of his book at the convention were swiftly taken, and Bretherton was so impressed by his presentation and the book, that she felt an English version would be well received.

Like Bowlby, Brisch is that rare combination of clinician and researcher. As a clinician concerned to give effective help to his patients, he realizes that it is necessary to conduct research to test the usefulness of his psychotherapeutic interventions and the theories that lead to them. As a clinician, he is especially concerned to be involved in research precisely because there has been so little work on the clinical applications of attachment theory. Like Bowlby, Brisch is a psychiatrist and therapist who is unafraid of seeking information from, and cooperation with, professionals from various disciplines “pediatrics, obstetrics, prenatal medicine, psychotherapy psychosomatic medicine, child and adolescent psychiatry” (Brisch, 2002, p. xxiv). Indeed he is enthusiastic and assured in describing collaborations with such colleagues, and comfortable in integrating concepts from various domains of study. He finds it essential to work in this way if he is to help his patients.

His book is certainly worth reading. For those unfamiliar with attachment theory, Brisch provides brief but clear summaries of its core aspects. His detailed, up-to-date descriptions of research on the theory and its applications are written in a style that is rich and human rather than dry and technical. In addition he presents case histories that are absorbing and varied; both the research and clinical work speak clearly to the need and effectiveness of integrating awareness of attachment theory into analytic practice. Indeed, Brisch makes a cogent argument for education in attachment theory and work for providers of any kind of therapy, education, or work with people in residential institutions—including prisons.

For those familiar with attachment theory the book provides a descriptive list of attachment disorders that goes beyond the four usually associated with Ainsworth/Main’s work. There are engaging treatment accounts of both brief and long-term therapies. These accounts are refreshingly peppered with helpful, honest descriptions of the sometimes-raw countertransference feelings that arise with patients. Brisch is humble enough and assured enough that he does not to pretend to be invulnerable to countertransference nor on top of it all the time, and nor does he blame the patient for it. While he describes ways he is able to reflect on and use his countertransference to help the patient, he also reports that this can take quite some time. This openness is reassuring for readers familiar with the vicissitudes of countertransference experiences.

Brisch is also at ease describing some of the major adjustments he makes to the traditional frame, particularly around the timing, length, and location of sessions, adjustments made for thoughtful clinical, theoretical and practical reasons which are in service of the patient and which prove effective. A particular gift in these case histories is Brisch’s frank descriptions of working in the less-than-ideal conditions of clinic and hospital settings, where adaptations frequently have to be made to the therapy for purely administrative or practical reasons. Regarding research, Brisch describes and cites several studies from the Europe which are rarely referred to in American writings

Brisch describes attachment-oriented therapy as a crucial complement to other clinical approaches, and he demonstrates this in his case material. Throughout the text he compares differences in diagnosis and treatment between various psychoanalytic approaches, and refers to areas of congruity between various analytic theories and attachment theory. He makes it quite clear that he does not intend to propose a new metapsychology, nor does he want to start a new school of therapy. Further, as he unequivocally states: “...attachment theory and its therapeutic applications should not be seen as a panacea, nor can attachment theory serve to explain the origins of all symptoms (Brisch, 2002. p. 248), He adds: “Attachment should, however, be seen as a fundamental human motivation that is well documented in the research literature and that is reflected in all therapeutic processes” (2002, p. 248).

The book is divided into five sections, each containing many references to significant papers and books on attachment theory, research and treatment. The first section gives a brief historical introduction to Bowlby and the development of his theory, and a clear and concise description of attachment theory and its core concepts, with a summary of the ways a range of other analysts have addressed “attachment and separation.” The second section gives descriptive summaries of attachment disorders, with numerous references to the research that has supported and helped to form and refine their categorization and understanding. The third section addresses attachment therapy. It begins by reviewing the therapeutic theory underlying attachment treatment and then describes treatment techniques, drawing both from Bowlby’s (1988) recommendations, and Brisch’s own experience and explorations. The fourth section, which represents well over half the text, is devoted to treatment cases from Brisch’s clinical practice. He presents examples of attachment oriented psychotherapy with cases that cover the entire range of the life-cycle from pre-conception, through infancy, childhood, adolescence, adulthood and old age; treatment lengths vary from a few weeks to several years. The fifth section addresses “prospects for further application” of attachment theory. Brisch suggests nine distinct areas where attachment theory could be applied for both the prevention and treatment of attachment disorders.

This is a very well-structured book, the sequencing of material is well thought out and effective, and the book is written in a style and language that makes the content comfortable to read and accessible. At times the clarity of writing appears to have been achieved by over-generalizing and oversimplifying concepts whose richness and usefulness lies in their details. This is particularly evident in section two when Brisch summarizes other analysts’ understanding of the concepts of attachment and loss, and in section four when he compares and contrasts attachment theory and practice with other analytic theories and approaches.

In some places, notably unfortunately, in some of the earlier cases in section four, his descriptions are sketchy and barely give the reader enough content to be able to understand, think about, or use the material. For a reader familiar with attachment theory this is disappointing and frustrating; one can imagine that for readers who are not familiar with attachment theory this could also be baffling. Such places give the reader an impression of a paragraph written in haste, perhaps impatiently. As an example, Brisch often refers in a general way to having used “attachment theory” to guide his thinking or treatment. It would be more useful to be told which aspect of this multi-dimensional theory he is using, and how it applies–which he does in the later case-discussions.

These would be serious flaws had this book been intended for analysts as a casebook or as an in-depth review of attachment theory and its applications. But this is not that kind of book. Brisch only intended to write “a selective snapshot of the state of research in this area, my own thinking, and my current perspective on the topic” (2002, p. xxvi). This is a very modest description of his book, especially given the breadth of topics within attachment theory that he covers in his “snapshot”: historical, theoretical, comparative, clinical casework, research, and prospective suggestions.

Brisch has been convinced by clinical experience and by the extensive research on attachment, that education in attachment principles and theory can make a profound difference to parents and children, adult patients in therapy and institutions, schools and education, and to society at large. He wants to share an understanding of attachment theory with providers in a range settings and occupations: teachers, nurses, physicians, institutional administrators, parents, families, social workers, as well as therapists. He writes in such a way so as to be accessible to a wide range of readers. In this context, and particularly since the remainder of the case-material is so descriptive, thought-provoking and practical, the flaws while disappointing are less problematic.

This is a useful, unpretentious, and eminently readable book. The theory, research, and case material addressed in it are crucial to consider for those interested in reflective, honest, and effective clinical practice. Attachment theory and therapy challenge some traditional analytical concepts, but it was not the first or only challenge; it is one of the few theories that has repeated, repeatable, and multi-cultural research findings in support of its concepts. Attachment theory is changing the face of parent-infant, child, family, and adult therapy, and it is changing the way development and adult behavior are understood. It is to be hoped that Brisch will write more about his experience of therapy informed by attachment theory.

Allen, J. G. (2001). Traumatic relationships and serious mental disorders. New York: Wiley and Sons.
Barach, P. M. (1991). Multiple personality disorder as an attachment disorder. Dissociation, , 117-123.
Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. London: Basic Books.
Bretherton, I. (1991). The roots and growing points of attachment theory. In: C. Murray Parkes, J. Stevenson-Hinde, and P. Marris (Eds.) Attachment across the life cycle. (Ch. 1, pp. 9-32) London: Routledge
Fonagy, P. (2001). Attachment theory and psychoanalysis. New York: The Other Press
Hurry, A. (1998). Psychoanalysis and developmental therapy. In: A. Hurry (Ed.) Psychoanalysis and developmental therapy #3, (Ch. 2, pp. 33-73). London: Karnac Books.
Liotti, G. (1995). Disorganization of attachment as a model ofr understanding dissociative psychopathology. In J. Solomon and C. George (Eds.) Attachment disorganization (pp. 291-317) New York: Guilford.
Peterfreund, E. (1978). Some critical comments on psychoanalytic conceptualizations of infancy. International Journal of Psychoanalysis, 59, 427-441.
Stern, D. (1985) The interpersonal world of the infant. New York: Basic Books

Cress Forester is a licensed psychologist in private practice in San Francisco. She also provides psychotherapy and supervision at Richmond Area MultiServices. She specializes in working with adults with disrupted early attachment, trauma, and dissociative states.

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