Evidence-based attachment therapy methods

Disclaimer: This article discusses only ethical and healthy forms of attachment-based therapy. The recommended or suggested methods do not refer to controversial methods like rebirthing or holding therapy under the guise of "attachment therapy." These methods can be dangerous and manipulative and may not adhere to ethical standards outlined by the American Psychological Association (APA). An ethical and professional therapist shouldn't risk the health or safety of clients. If you have an ethical concern with a therapist, please report them to your state licensing board. 

Considering the relationships in your life and their impact on your happiness and well-being, you may start to understand how much human attachments can influence behavior. Healthy attachment can be essential for the development of meaningful relationships. Creating healthy and secure attachments can be challenging for those with attachment disorders or an insecure attachment style. However, a form of therapy called attachment therapy may benefit those struggling with relationships and connections.

Attachment-based counseling: An overview 

Attachment-based psychotherapy is a process-oriented therapy that focuses on rebuilding trust and a supportive relationship between a child and their caregivers using attachment therapy techniques. This attachment-based treatment may also be a form of trauma-based therapy for adults struggling with attachment style concerns, such as disorganized attachment or adult attachment patterns.

Attachment Styles

Attachment relationships begin when a child is born. In early development, when infants or young children do not have their emotional or physical needs met by caregivers, they may lack a secure base and feeling of overall safety. This can affect their attachment style and connections to others throughout childhood and adulthood. A secure early attachment is often necessary for building a supportive foundation and developing meaningful connections and positive interactions with others. Attachment parenting during childhood establishes the basis for secure relationships and independence as adults.

A person with negative or inadequate early attachment experiences may struggle to express emotions healthily or have secure relationships with romantic partners. Healthy attachment behaviors can be essential for human development and physical relationships. In these cases, attachment therapy may benefit individuals looking to develop a secure attachment.

Attachment-focused therapy often takes the form of family therapy, addressing attachment wounds and involving family in the healing process. It may also be offered as individual psychotherapy for adults struggling with attachment style concerns. Attachment-based family therapy focuses on repairing family relationships and may help families figure out why a strong early attachment did not form. 

In this process, the therapist helps the client, often young adults or adolescents, through individual and family sessions. They address the obstacles stemming from insecure or negative early attachment experiences. In some cases, they may support the family in processing early life adverse connections and rebuilding or encouraging attachment security. If successful, the client and family may develop better communication, express their emotions more freely, and create meaningful bonds or connections.

What are attachment disorders?

Attachment disorders are mental health conditions that may develop in young children, characterized by an inability or difficulty emotionally attaching to others. These conditions are often connected to severe neglect or abuse.

If you are facing or witnessing abuse of any kind, the National Domestic Violence Hotline is available 24/7 for support. Call 1-800-799-SAFE (7233) or text "START" to 88788. You can also use the online chat. If you're a teen or child experiencing or witnessing abuse of any kind from a family's or caregiver, reach out to the Child Help Hotline at 1-800-422-4453 or use the online chat feature.

Children who lacked early primary caregivers, such as those who lived in orphanages, residential centers, or multiple foster care placements, may develop attachment disorders. Those who've experienced multiple traumatic losses may also develop attachment-based disorders and may benefit from attachment-based therapy. 

According to the American Academy of Child and Adolescent Psychiatry, symptoms of attachment-based disorders may appear within the first year of life. They may persist or exacerbate as the child gets older.

Symptoms of attachment-based disorders

Attachment-based disorders include reactive attachment disorder (RAD) or disinhibited social engagement disorder (DSED). Both diagnoses can only be made in childhood. Adults experiencing attachment concerns may be experiencing an insecure attachment style.

What is reactive attachment disorder?

RAD is a mental health condition that often develops when children have had adverse experiences with adults or caregivers during their early years. In these cases, the children may dissociate from their caregivers. Children living with RAD may not naturally seek out a loving adult when stressed, upset, or scared. The child may experience little to no emotions when interacting with children, their parents, or adults. 

Children living with RAD may experience intermittent and intense emotions of unhappiness, irritability, depression, and fear while struggling to comfort themselves. Chronic symptoms of severe emotional irregularity combined with a history of trauma can indicate a diagnosis of RAD. This condition can only be diagnosed in children. However, it may be associated with an avoidant or anxious-avoidant attachment style in adults. 

Attachment-based therapy is a common form of treatment for RAD. However, exploring alternative therapeutic treatment paths may be beneficial, as attachment-based therapy for RAD may be considered controversial. 

What is disinhibited social engagement disorder (DSED)?

DSED is often characterized by overly friendly behavior, a lack of boundaries, difficulty accepting boundaries, and abandonment anxiety. Children experiencing this condition may walk up to strangers, ask for affection from others, or hug people without consent. They may be comfortable allowing strange adults to hold, talk, feed, and play with them.

When these children are put in a situation with strangers, they might not check with their parents or caregivers for assurance, which could be dangerous if an adult asks them to leave with them. Often, DSED develops from trauma or a lack of needs being met. 

Controversy over attachment holding therapy

Holding therapy and rebirthing therapy are two forms of controversial and unethical treatment methods for attachment disorders in children that often focus on a parent's urge to reconnect with a child through traumatic and non-consensual practices. These practices are no longer legal. If you find a therapist practicing these, report them to their state licensing board. 

In holding therapy, some providers may have believed that children who couldn't bond and attach to their parents or primary caregiver would benefit from being held by that caregiver or another adult until they became comfortable with the sense of touch and hugs. However, this practice was done without physical consent from the child, and the parent or caregiver partaking in the therapy may have caused more harm if the child's trauma stemmed from emotional or physical abuse from that caregiver. 

Therapists and non-licensed providers also practiced unethical and harmful "rebirthing" strategies based on concepts intended to "simulate the process of being reborn." The concept in the development of this treatment was for a child to go back in time and "re-experience" feelings of warmth, care, and closeness that they may not have received as infants and toddlers. In these therapies, parents and therapists may have held down, forcibly tied up, or restrained children. 

Holding and rebirthing therapies resulted in several child deaths. State legislatures and professional organizations such as the American Academy of Child and Adolescent Psychiatry, the American Professional Society on the Abuse of Children, the American Psychiatric Association, and the American Psychological Association banned these practices. These organizations have all published warnings regarding these harmful treatments, which are no longer used in attachment-based therapy. Today, attachment-based therapy does not refer to these practices and instead focuses on other forms of therapy like trauma-based talk therapy or cognitive-behavioral therapy based on attachment. 

Evidence-based forms of attachment therapy

RAD and DSED are mental health conditions that form in childhood, and various treatment methods may offer support. Individuals seeking effective treatment for these disorders may request a comprehensive psychiatric assessment and individualized treatment plan for attachment-based therapy by a qualified mental health professional.

Attachment-based therapy may sometimes be practiced in a family setting. However, as attachment disorders are often based on childhood abuse and trauma, involving parents who may have caused attachment concerns in a child may be counterproductive. It may be more effective for a child to attend individual therapy with a therapist educated in childhood trauma and attachment styles. 

Based on information from the California Evidence-Based Clearing House for Child Welfare, two attachment-based therapies for children have been approved with a scientific rating of three, which means they are categorized as "promising research evidence." These programs include child-parent relationship therapy (CPRT) and dyadic developmental psychotherapy (DDP). 

Adults might benefit from attachment-based therapy focused on treating insecure attachment styles or healing from trauma. A few of these therapies include: 

• Rapid eye movement desensitization reprocessing therapy (EMDR) 
• Internal family systems therapy (IFS) 
• Dialectical behavior therapy (DBT)
• Emotionally-focused therapy
• Trauma-focused cognitive-behavioral therapy (CBT) 

Studies also indicate a strong possibility that insecure attachment styles can change with education, resources, and therapeutic support. 

Child-parent relationship based therapy

CPRT is an attachment-based therapy developed for children aged three to eight living with behavioral, social, and attachment disorders. This treatment is play-therapy-based and is a systemic intervention based on attachment principles, child-centered play therapy (CCPT), and interpersonal neurobiology.

The central idea behind CPRT is that a child's well-being needs to have a secure relationship with a primary caregiver. This treatment is a two-part attachment-based therapy through which children can learn to count on their parents to meet their basic life needs of love, acceptance, safety, security, food, and shelter. 

In the therapy, parents may learn skills that help them respond to their children in ways that establish or enhance feelings of secure attachment. With this form of attachment-based therapy, parents may learn how to respond to the child's needs instead of reacting to a child's symptoms. 

The goals of the attachment-based therapy treatment are to:

• Increase trust, security, and closeness between the child, parents, and other families
• Improve child-parent communication
• Develop problem-solving strategies within the family
• Increase affection and enjoyment in relationships
• Increase parental empathy and acceptance
• Improve a parent's ability to attune and respond to children
• Help parents develop realistic limits and expectations
• Boost parents' self-confidence in parenting
• Increase children's ability to express their needs and feelings appropriately
• Encourage children to express and control their emotions appropriately

Attachment therapists may work with children and their parents in various settings, including hospitals, clinics, schools, community centers, and the family's home. A child experiencing abuse or mistreatment from their caregivers may not benefit from this therapy.

Dyadic developmental psychotherapy (DDP)

DDP is an attachment-based therapy with a target population of families with children or adolescents aged ten to 17. Children with attachment disorders and trauma who meet the DSM-5 criteria for RAD, trauma-related diagnoses, and complex trauma (also known as developmental trauma disorder) may be appropriate candidates for DDP-based treatment.

DDP is an attachment-based therapy that treats children who experienced neglect, abuse, or multiple foster care placements. Those who developed this treatment felt that if a child's early experiences of attachment to their primary caregivers were abusive, neglectful, or inconsistent, they would not have the opportunity to experience the reciprocal, dyadic relationship necessary for healthy development. Therefore, family therapy or parent-child interaction may not be beneficial. 

A foster or adoptive home with healthy parenting styles may help a child overcome past abusive or neglectful relationships by encouraging them to trust and engage with the new caregiver. The most traumatized children may have greater difficulty bonding with their new parents, and DDP may help them learn to trust and help new caregivers learn trauma-informed care, fostering, or adoption strategies. Studies show that adoption and foster care can be highly traumatic for a child, so pushing them before they are comfortable may increase this trauma. 

DDP is often grounded in a foundation of playfulness, acceptance, curiosity, and empathy. DDP practices should not involve coercion, threat, intimidation, or using power to force a child into submission. The goals of DDP for children could include the following:

• Helping them develop a more secure pattern of attachment
• Resolving symptoms of trauma
• Strengthening the child's relationship with the primary caregiver

The goals of DDP for parents or primary caregivers can comprise:

• Attuning to the child
• Reflecting more deeply on their responses to their child
• Trauma-informed care 
• Approaching their child with attachment-facilitating techniques
• Empathy 

More attachment-based therapies may be available for children and adults in the future. Evidence-based practices may emerge as trust-based, relationship-centered interventions that have not proven dangerous or harmful to children. Any practice that coerces, abuses, harms, or forces a child into submission to "attachment" can be traumatic and harmful. Report any practitioners suggesting these therapies. 

How to find a therapist

An attachment-based therapist may take the form of any family therapist, practitioner of clinical psychology, psychiatrist, or clinical social worker with an attachment-based approach. These therapists work with many different people and can offer in-person or online sessions. If you are looking specifically for therapists who focus on attachment theory, taking the first step could be searching online for those credentials or asking any therapist about their approaches.

Adults or families with children experiencing attachment issues may also benefit from online platforms. For instance, separated or divorced parents living in different cities can simultaneously attend an online therapy session, which may be more challenging to arrange in face-to-face environments. Additionally, many online therapists are more affordable than in-person ones, and you can choose between phone, video, or live chat sessions with your therapist. 

In addition to online therapy's convenience and ability to match individuals with therapists trained in specific modalities, internet-based counseling has proven effective in supporting adults with attachment disorders. In a 2022 study, researchers hypothesized that teletherapy interventions would reduce participants' anxiety, avoidance, and loneliness scores while increasing self-esteem. Not only did the study's results support their hypotheses, but additional benefits were observed in the effectiveness of teletherapy in reducing social phobia symptoms. 

People seek therapy for many different reasons, if you're interested in discussing attachment concerns with a therapist, consider signing up for a platform like BetterHelp for adults. If you have a teen child aged 13 to 19, they can also sign up for online treatment through a platform like TeenCounseling, as long as they have parental permission or are 18 or 19.