Attachment Based Therapy: Evidence Supported Counseling Practices

By Toni Hoy|Updated April 8, 2022
CheckedMedically Reviewed By Lauren Guilbeault, LMHC

Attachment-Based Therapy Is Critical For Those Who Live With Attachment Disorders

If you think about the many relationships that you have in your life and their importance to your happiness and well-being, you can start to gain a greater understanding of how much our attachments and attachment types influence our lives. For those who live with attachment disorders.

What's Attachment Based Therapy?

Attachment-based therapy encompasses some fairly new, and rather controversial, therapies for treating attachment disorders. Attachment disorders are serious conditions that affect children beginning at a young age. If left untreated, attachment disorders can affect individuals and their relationships for a lifetime.

John Bowlby and Mary Ainsworth were some of the early pioneers on attachment-based therapy. "A Review of General Psychology" survey (2002) ranked Bowlby as the 49th most-cited psychologist of the 20th century.

Research has given us some insight as to some dangerous methods of attachment-based therapy. More importantly, researchers continue to make progress in understanding the types of attachment-based therapies that are beginning to show promising results. However, it’s important to note that attachment-based therapy is still quite controversial, lacking substantial research, and can be dangerous depending on the exact approach used. For example, one attachment-based therapy technique called the rebirthing technique has been entirely banned in Colorado after a ten-year-old girl died due to suffocation. At the very least, significantly more research and understanding is needed before truly utilizing this attachment-based therapy methods.

To date, healing for attachment-based disorders focuses on understanding and strengthening the relationship between a child and his or her primary caregivers.

What Are Attachment Disorders?

Attachment disorders are psychiatric illnesses that develop in very young children as characterized by their inability or difficulty in emotionally attaching to others. The illness is nearly always due to infant or toddler severe neglect or abuse.

Children who lacked early primary caregivers such as those who lived in orphanages, residential centers, or those who had multiple foster care placements, especially where care was abusive or neglectful, often develop attachment disorders. Children who've experienced multiple traumatic losses may also develop attachment-based disorders and could potentially benefit from attachment-based therapy, but, again, more research is needed.

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

  • Severe colic and feeding difficulties
  • Failure to gain weight
  • Detached and unresponsive behavior
  • Difficulty being comforted
  • Preoccupied and defiant behavior
  • Inhibition or hesitancy in social interactions
  • Being too close with strangers

Attachment-based disorders can develop into Reactive Attachment Disorder or Disinhibited Social Engagement Disorder.

What Is Reactive Based Attachment Disorder?

Reactive Attachment Disorder (RAD) is a brain disorder that develops when children have had negative experiences with adults during their early years, and their natural inclination is to disassociate with them. Children living with RAD don't naturally seek out a loving adult when they're stressed, upset, or feeling unregulated. This disorder is based on a child having little or no emotions when they interact with other children, their parents, or other adults. Children living with RAD experience intermittent and unusually strong emotions of unhappiness, irritability, depression, and fear without having the ability to comfort themselves. Chronic symptoms of severe emotional irregularity combined with a history of trauma indicate a diagnosis of RAD.

Attachment-based therapy is one of the most common forms of treatment for RAD. However, it may be beneficial to explore alternative therapeutic treatment paths, as attachment-based therapy for RAD can be rather extreme and is controversial. According to one study focusing on attachment-based therapy for RAD, it is believed that RAD is due to suppressed rage and can be treated through: “…prolonged restraint of the child and exposing the child to noxious stimuli (e.g., tickling, poking, tapping, yelling) until the child's attempts to escape the noxious stimuli have ceased. At that point, the child is given to the caregiver for attachment. Healthy attachment is thought to be able to occur at that point as the child's rage has been released throughout the restraining and noxious stimuli portion of treatment.”

What Is Disinhibited Social Engagement Disorder (DSED)?

A child who is overly friendly with strangers is indicative of Disinhibited Social Engagement Disorder. Such children aren't afraid of meeting people for the first time. They may walk up to them, talk to them, or even hug them. Very young children may be comfortable allowing strange adults to hold them and talk with them, feed them, and play with them.

When these children are put in a situation with strangers, they don't check with their parents or caregivers for assurance and are often willing to go away with someone they don't know at all. This disorder can also be treated by attachment-based therapy, but again, the practices require more research.

Controversy Over Attachment Holding Therapy

In their efforts to heal children from early trauma and attachment disorders, a handful of therapists devised and practiced holding therapy or rebirthing therapies as mentioned above. This was part of early methods of attachment-based therapy.

The premise behind holding therapy was that the way to heal children who weren't able to bond and attach to their parents or primary caregivers was for the caregiver to hold the child tightly so that they'd eventually become comfortable with the sense of touch and hugs.

Along the same lines, therapists developed "rebirthing" strategies based on concepts that were intended to simulate the process of being reborn. The concept was for the child to essentially go back in time and re-experience the feelings of warmth, care, and closeness that they should have received as infants and toddlers.

Both methods based on holding and rebirthing resulted in several child deaths. These practices were quickly banned by 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 Psychology Association. These organizations have all published warnings regarding these types of harmful treatments, which are no longer used in attachment-based therapy treatments.

Evidence Based Attachment Therapy

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder are serious clinical conditions, and their treatments are not yet well-researched.

What we do know is that individuals who are seeking effective treatment for these disorders need to request a comprehensive psychiatric assessment and individualized treatment plan for attachment-based therapy treatment by a qualified mental health professional.

The best attachment-based therapy treatments for children living with attachment-based disorders involves treating their parents and other family members as well because the premise behind the child's healing requires developing and strengthening relationships between the child and their parents and siblings. Parents should expect an ongoing collaboration between the family and the treatment team during attachment-based therapy to increase the likelihood of a successful outcome.

There are currently no evidence-based therapies for attachment-based disorders because researchers haven't yet had the time or funding for repeat studies or longitudinal studies. Based on information from the California Evidence-Based Clearing House for Child Welfare, the best we have at this time is two programs with a Scientific Rating of 3, which means they are categorized as Promising Research Evidence. Those programs are Child-Parent Relationship Therapy and Dyadic Developmental Psychotherapy (DDP). Let's take a closer look at each one of them.

Child-Parent Relationship Based Therapy

Attachment-Based Therapy Is Critical For Those Who Live With Attachment Disorders

Child-Parent Relationship Therapy (CPRT) is an attachment-based therapy that works best for children aged 3-8 who live with behavioral, social, and attachment disorders. This treatment is play-therapy based and is a systemic intervention that is based on attachment principles, Child-Centered Play Therapy (CCPT), and interpersonal neurobiology.

The central idea behind CPRT is that it's essential for a child's well-being to have a secure relationship with a primary caregiver. This is a two-part attachment-based therapy treatment through which children can learn to count on their parents to meet their basic life needs of love, acceptance, safety, security, food, and shelter. At the same time, parents learn skills that help them respond to their children in ways that establish or enhance feelings of secure attachment with their children. With this form of attachment-based therapy, parents learn how to respond to the child's needs as opposed to 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 family members
  • Improve child/parent communication
  • Develop problem-solving strategies within the family
  • Increase affection and enjoyment in relationships
  • Increase parental empathy and acceptance
  • Improve 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 in an appropriate way
  • Encourage children to express and regulate their emotions in appropriate ways

Therapists may work with children and their parents in a variety of settings including hospitals, clinics, schools, community centers, and the family's home. This form of attachment-based therapy is significantly less controversial than rebirthing or holding attachment-based therapy.

Dyadic Developmental Psychotherapy (DDP)

Dyadic Developmental Psychotherapy is an attachment-based therapy with a target population of families with children or adolescents aged 5-17. Children who live with attachment disorders and trauma who meet the DSM-V criteria for Reactive Attachment Disorder, trauma-related diagnoses, and those who meet the clinical criteria for Complex Trauma, which is also known as Developmental Trauma Disorder, are typically good candidates for DDP based treatment.

DDP is a type of attachment-based therapy that was designed to treat children who experienced neglect, abuse, and multiple home or foster care placements. The concept is that when a child's early experiences of attachment to their primary caregivers are abusive, neglectful, or inconsistent, they don't have the opportunity to experience the reciprocal, dyadic relationship that is necessary for healthy development. The benefit of a foster or adoptive home with healthy parenting styles may help a child to overcome past abusive or neglectful relationships by encouraging them to trust and engage with the new caregiver. The most traumatized children have greater difficulty in bonding with their new parents, and DDP can enhance their ability to accept being parented.

DDP is grounded in a foundation of playfulness, acceptance, curiosity, and empathy. DDP practices never involve coercion, threat, intimidation, or the use of power to force a child into submission and are instead based on healthy practices.

The goals of DDP for children include:

  • Helping children 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 are:

  • To be more attuned with the child
  • To reflect more deeply on their responses to their child
  • To approach their child with attachment-facilitating techniques
  • To become more sensitive

Three other programs are developing as attachment-based therapies. They are not rated at this time because not enough studies have been completed to consider them as evidence based. These attachment-based therapy techniques include:

  1. Corrective Attachment Therapy
  2. Healing Hearts Camp
  3. Trust-Based Relational Intervention Therapeutic Camp

In the quest to heal children from issues related to trauma and attachment, new attachment-based therapy methodologies have been emerging over the last decade. Evidence-based practices are emerging as trust-based, relationship-centered interventions which have not proven to be dangerous or harmful to children.

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