This book, "Attachment Disturbances in Adults: Treatment for Comprehensive Repair," is a major breakthrough in treatment.

It should be required reading by every mental health clinician and provider as a basis of treatment. If it were, there would be more positive treatment results for a wide variety of mental health issues. 

Research and Background on Attachment

Dr. Brown and Dr. Elliott along with the following contributing authors:

 Paula Morgan-Johnson, LICSW
Paula Sacks, LICSW
Caroline R. Baltzer, Ph.D.
James Hickey, Psy.D.
Andrea Cole, Ph.D.
Jan Bloom, Ph.D.
Deidre Fay, LICSW

have provided a comprehensive, step by step review of the literature and cross-cultural research on the topic of attachment. They begin with the history of attachment, how it develops in key developmental stages from infancy to teenage years, the role of the caregiver, and the key figures of the field, John Bowlby and Mary Ainsworth. In the history portion, there is a clear and concise explanation of secure attachment and disorganized attachment. In addition, they provide information about The Dynamic-Maturational Model of Attachment, as well as the generational model of how attachment issues are passed down through one generation to another.

In this section of the book, there is extensive research into the concept of internal representation, object relations (introduced by Margaret Mahler), and self-regulation. From this background information emerges a precise understanding of attachment and the emerging self.

Assessment

This book provides you with four distinct categories of Adult Attachment Types:

Secure Attachment
Dismissing Attachment
Anxious Attachment
Disorganized Attachment

Dr. Brown and Dr. Elliot provide in-depth research studies for each of the above Attachment types, along with the work of Mary Ainsworth in the method of Assessment of Attachment of the Strange Situation procedure.

There is also an overview of the Adult Attachment Interview (AAI) and how this is a valuable tool in assessing attachment issues and classifying specific attachment types.

Attachment and Psychopathology

This section of the book covers extensive research into the following psychopathology as it relates to attachment issues:

1) Attachment: Emotional, Distress, and Psychiatric Distress

          A) Attachment and Anxiety Disorder

          B) Attachment and Affective Disorder

          C) Attachment and Bipolar Disorder- this includes Schizophrenia

2) Attachment and Somatic Symptoms Disorders, Factitious Disorders and Malingering.

          A) Somatic Disorders

          B) Factitious Disorders

          C) Malingering Disorders

3) Traumatic -Related Disorder

          A) Attachment and Dissociative Disorders

          B) Depersonalization/Derealization Disorder (DRD)

          C) Dissociative Identity Disorder (DID)

4) Attachment and Addictions

          A) Alcoholism and Substance Abuse

          B) Eating Disorders

5) Attachment and Personality Disorders

          A) Borderline Personality Disorder (BPD)

          B) Conduct Disorder and Antisocial Personality

Finishing this section of the book is probably one of most disturbing research studies; The Orphanage Study: Attachment and Complex Trauma. This study clearly shows how the various attachment types effected how the children coped with severe trauma by priests that were child abusers and were sent to manage this orphanage in New Orleans. To read that innocent children were put into this orphanage because of domestic abuse and violence, only to have caregivers that were child abusers, is beyond criminal. It was clear that the attachment type was a defining indication of how the children coped with such severe trauma.

Treatment of Attachment Disturbances

The best part about this section is that it presents each treatment with the honor and dignity that it deserves. It starts with Bowlby’s attachment-based psychotherapy, and then moves to psychoanalytic approaches.  

Other approaches include attachment based psychotherapy, dynamics-maturational model integrative treatment, and targeting dysfunctional attachment representation and internal working models. The latter approach deals with working independently of transference.

Elgan Baker’s approach works with the imagery of the good enough therapist with the patient.

The work of Bowlby, Ainsworth, and Mahler has been the base of attachment theory and treatment approaches. The focus of the therapeutic alliance and soothing holding environment has been stable in attachment treatment.

This book provides an in-depth explanation of newer methods of attachment-informed treatment, such as schema therapy for patients with personality disorders and Accelerated Experiential Dynamics Psychotherapy (AEDP), whereas other books have omitted to only promote their own theory or approaches. 

In addition to these methods are the following:

Metacognitive attachment-informed psychotherapies, which include Mentalization Based Treatment (MBT), the modular approach to metacognitive development.
Beyond mentalizing and the representational self is Mindfulness and transcendence of self. From this approach evolved a Consensus -Based Model for Attachment Treatment. This was developed by Brent Mallinckrodt in 2009.

From these various methods emerged the comprehensive treatment of Attachment Disturbances developed by Dr. Brown and Dr. Elliot, entitled the Three Pillars. The next part of the their book focuses on the explanation of the Three Pillars, then a comprehensive, step-by-step explanation of how to use this treatment approach with each attachment type. 

Three Pillars of Comprehensive Attachment Treatment

The three pillars include the following:

Pillar 1:  The Ideal Parent Figure (IPF) Protocol.
Pillar 2:  Fostering a range of Metacognitive Skills.
Pillar 3:  Fostering collaborative nonverbal and verbal behavior.

The first pillar, involving the ideal parent figure, includes the following essentials:

1) Felt secure/protection

2) Feeling seen and known/attunement

3) Felt comfort/soothing and reassurance

4) Feeling valued/expressed delight

5) Felt support for best self/unconditional support and encouragement

All of these are included in an attachment-based imagery over the course of treatment.

The second pillar fosters a range of metacognitive skills such as the following:

1) Being aware of yourself; the sense of self and of others.

2) Monitoring the accuracy of your state of mind.

3) Recognizing how the past has shaped the present and your own experience.

4) Taking a wider perspective of yourself and your life.

5) Recognition of interdependence.

There are many more aspects of this pillar that authors provide to you.

The third pillar integrates the previous two pillars into collaborative imagery and metacognitive development.

The following chapters provide a step by step approach, along with actual transcripts of sessions to show the reader how to use the Three Pillars with each specific attachment type. There are over 400 pages of information providing the novice to the seasoned mental health clinician with valuable information and training.  

What is unique about this book is that even though it is clearly designed for the education of a mental health provider, a person with attachment issues can also benefit from the information in this book.

Conclusion

If you are a mental health provider or a person struggling in your own therapy, my analogy is that you cannot fix the upstairs until you fix the foundation of the house, which is the core attachment issue. This book provides the history of attachment and its various therapies, as well as a new revolutionary and comprehensive Three Pillar approach that will change your life and allow the healing to occur.  This book is a must read.

Copyright ©) Dr. Diane Roberts Stoler, E.D. 2016

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