PSYCHOANALYTIC INQUIRY

2017, VOL. 37, NO. 5, 284–297

https://doi.org/10.1080/07351690.2017.1322420

Attachment Theory and Research and Clinical Work

Morris N. Eagle, Ph.D.

ABSTRACT
In considering the contributions of attachment theory and research to individual
psychotherapy with adults—the focus of this article—the starting point is the
therapist’s role as a secure base from which the patient can safely engage in self-
exploration. I discuss the barriers to the patient’s ability to subjectively experi-
ence the therapist as a secure base and the necessary therapeutic ingredients for
these barriers to be attenuated. I also discuss the nature of therapeutic action
from the perspective of a therapeutic approach informed by attachment theory
and research. And finally, there is some discussion devoted to the contributions
of attachment theory and research to an understanding of psychopathology.

Introduction
When our editor, Paul Renn, invited me to contribute an article to this issue, he noted that in his
experience in presenting seminars and workshops, “many practitioners are at something of a loss when
it comes to actually using attachment theory in their clinical work.” I assume that Renn was referring
mainly to psychotherapy with adults. In my view, starting with being at something of a loss is just
where practitioners should be in considering the question of how to use attachment theory in one’s
clinical work. It has the virtue of opening the question of precisely how attachment theory and research
can contribute to one’s understanding and clinical work. Posing the question to oneself seems to me
preferable to the alternatives of either foreclosure through assuming that there is a specific and
identifiable approach called attachment-based psychotherapy that one can adopt or, at the other end,
largely neglecting attachment theory and research in one’s clinical work.
In my 2013 book, Attachment and Psychoanalysis: Theory, Research and Practice (Eagle, 2013), I
argued, following Slade (1999, p. 577), that whereas attachment theory and research may inform
clinical practice, it is not at all clear that there is a delineated attachment-based therapeutic approach
with adults in the sense of specific therapeutic techniques and interventions that are directly linked
to or prescribed by attachment theory and research. (See Holmes, this issue, who writes: “it would be
a mistake to try to define specific attachment techniques that mark it out as different in kind from
other psychodynamic modalities,” p. 312). This is so, despite the spate of journal articles and books
on so-called attachment-based psychotherapy. I tried to demonstrate that what is frequently pro-
vided in these books and articles as attachment-based psychotherapy are essentially attachment
theory labels and discourse for familiar therapeutic interventions that, for the most part, have
been described and formulated in nonattachment theory terms.
Rather than proposing still another school of psychotherapy—psychotherapistshave more than
enough schools’ and do not need another one—the most useful way, I believe, to look at the role of
attachment theory and research in clinical work is to try to identify the relevant research findings
and formulations of attachment theory that can enhance the field’s understanding of the develop-
ment and the effectiveness of extant therapeutic approaches. This was, I believe, Bowlby’s position.
As Costello (2013, p. 178) noted,

CONTACT Morris N. Eagle, Ph.D. meagle100@aol.com 4351 Redwood Avenue, #1, Marina Del Rey, CA 90292.
Copyright © Melvin Bornstein, Joseph Lichtenberg, Donald Silver
 ATTACHMENT THEORY AND RESEARCH AND CLINICAL WORK 285

Particularly during the last 10 years of his life, he noted and wrote about therapeutic approaches that he thought
were consistent with his own understanding of what troubled patients in their lives (Bowlby, 1980, 1988). The listing
of the therapies he thought could work with an attachment theory framework included cognitive and behavioral
therapies; interpersonal and object-relational psychotherapy; self-psychology; short-term, brief, and time-limited
therapies; bereavement and trauma therapies; social work; and infant-parent psychotherapies.1

Although all clinicians have some theoretical orientation, which is useful for providing a framework
for one’s thinking, approaching clinical situations with too fixed a pre-set theoretical lens, including an
attachment theory lens, carries the risk of imposing one’s views on the clinical material. Although
admittedly difficult, I think it is important to try to achieve a balance between making use of one’s
theoretical orientation and, at the same time, being open to what the patient presents. I have seen too
many instances in which, for example, classical analysts always found evidence of the primacy of the
Oedipus complex in all patients, self psychologists always saw evidence of the primacy of self-defects,
and so on. I do not think it would be useful to continue this pattern so that one now always finds
evidence of the primacy of attachment issues by virtue of now wearing an attachment theory lens (see
Peterfreund, 1983, for a discussion of stereotyped vs. heuristic approaches to psychotherpy).
Although there is little doubt that attachment issues constitute a central aspect of psychological life,
the centrality of the attachment system does not automatically translate to an attachment-based
therapeutic approach, just as the centrality of sexuality in psychological life does not automatically
translate to a sexuality-based therapeutic approach. What a recognition of the importance of the
attachment system does suggest are: (1) that whatever one’s therapeutic orientation, the vicissitudes of
attachment needs should not be overlooked, minimized, or reduced to issues of other motivational
systems; and (2) that attachment issues are likely to be played out in the therapeutic situation,
particularly in the relationship between patient and therapist. Just as Freud’s identification of the
importance of sexuality led him to recognize the role of sexual wishes and fantasies in the transference,
so similarly, recognition of the importance of attachment should sensitize all therapists to the role of
attachment in the therapeutic relationship. My point here is not to minimize the importance, or even
the centrality, of the attachment system, but to suggest that however important it is, it is not the only
motivational system that influences development and psychological functioning (see Liotti, this issue).
The challenge is to try to understand the ways in which the attachment system interacts with these
different motivational systems in influencing psychological development and functioning.
Attachment theory and research have provided a framework not only for individual psychotherapy
with adults, but also for therapeutic work with couples (e.g., Johnson, 2008), adolescents (e.g., Kobak
et al., 2015; Moretti et al., 2015), families (e.g., Ewing, Diamond, and Levy, 2015), and most extensively
with infant-mother dyads, where, in contrast to work with other groups, therapeutic interventions are
more directly linked to attachment theory and research (e.g., see Berlin, 2005). For example, enhancing
maternal responsiveness as a therapeutic process goal for the purpose of achieving the outcome goal of
greater infant security of attachment flows relatively directly from attachment theory and research.
However, my focus in this article is on individual psychotherapy with adults.

The secure base function of the therapist

A fundamental starting point in assessing the contribution of attachment theory and research to
individual psychotherapy with adults is Bowlby’s (1988) idea that, paralleling the caregiver’s role as a
secure base for the child’s exploration is the therapist’s role as a secure base for the patient’s self-
exploration. As Bowlby (1988) put it, one of the main functions of the therapist “is to provide the
patient with a secure base from which he can explore the various unhappy and painful aspects of his
life, past and present, many of which he finds it difficult or perhaps impossible to think about and
reconsider without a trusted companion to provide support, encouragement, sympathy, and, on
occasion, guidance” (p. 138).
1
Costello (2013) makes these comments despite the fact that the title of his book is Attachment-Based Psychotherapy.
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In the context of attachment theory, the primary function of the secure base is to facilitate the child’s
exploration with relative safety and without undue discomfort and anxiety. Such exploration, in turn,
enables the child to develop skills and competencies necessary to function adequately in a complex
physical and social world, that is, to become a well-functioning and competent adult. Although terms
such as secure base and security of attachment have taken on extended meanings, the aforementioned
brief account of the secure base concept captures, I believe, what Bowlby intended as the core of
attachment theory and also reflects the deep links of attachment theory to ethology and evolutionary
theory. The very term secure base conveys the meaning of a base from which one can leave and to
which one can return when one goes off on an exploratory journey that carries unknowns and risks.
Knowing that a secure base is available is what makes a reasonably safe exploration possible.
The importance of the attachment system for the development of competence has been noted by
Fonagy et al. (1995), who has proposed that a primary function of the early attachment bond lies in
its constituting a ground for the development of what he refers to as an interpersonal interpretive
mechanism, that is, the development of social skills and understanding that enables one to function
adequately in a social and relational context.
From the perspective of attachment theory, an important aspect of secure attachment, the essence
of which is the confident expectation in the availability of one’s attachment figure, lies in the safety
and support it provides for exploration. Although perhaps less apparent, this is as true for the adult
as for the child. The differences between the two consist in (1) the expectation that the adult has
internalized a secure base and (2) the nature of exploration. With regard to the latter, the emphasis is
now on self-exploration. When Bowlby (1988) described the therapist’s role as a secure base from
which the patient can explore aspects of his or her life, he, of course, has expanded the concept of
exploration to the adult context and is now referring to self-exploration. This seems obvious and yet
has important implications.
Bowlby’s emphasis on exploration and the secure base function of the attachment figure (including
the therapist) is derived from a fundamental, evolutionary-based idea that in the animal kingdom, if
the offspring are to survive, they need to acquire knowledge of the world and skills that are the result of
exploratory activity. Hence, the importance of the secure base functions of the attachment figure is
directly linked to its vital role in facilitating the exploratory activity necessary to develop competencies,
which, in turn, are necessary for survival in a complex physical and social world. In short, Bowlby’s
emphasis on exploration and the therapist as a secure base for the facilitation of exploration reflects his
general developmental perspective, now applied to the therapeutic situation.

The patient’s ability to experience the therapist as a secure base

In effect, Bowlby was proposing that the therapist serves as an attachment figure for the patient.
And, indeed, there is evidence that this is the case (e.g., Parish and Eagle, 2003; Mallinckrodt, Porter,
and Kivligham, 2005). However, given the patient’s history, the patient’s capacity to experience the
therapist as an attachment figure is precisely a problem that needs to be confronted in the treatment.
As Freud (1912) commented with regard to transference, it is both an impediment to treatment as
well as an arena in which the treatment will be played out. As I have noted elsewhere (Eagle, 2013),
one would expect that the insecurely attached patient, will, at least early in the treatment, experience
the therapist in accord with the expectations and representations that constitute an insecure
attachment pattern; that is, one can expect that the patient will not necessarily be especially able
to experience the therapist as a secure base.
Were the patient able, right from the start, to experience the therapist as a secure base—or safe
haven—that much less therapeutic work would need to be done. Bowlby (1988) was, of course, aware
that “the patient will import [into the therapeutic relationship] all those perceptions, constructions,
and expectations of how an attachment figure is likely to feel and behave towards him that his
working model of parents and self-dictate” (p. 138). It will be recognized that Bowlby is essentially
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describing transference, but he does not pursue the issue of how the patient’s constructions and
expectations are to be addressed.
What follows from these realities is that although necessary, it may not be sufficient for the
therapist to simply behave as a secure base. Much of the therapeutic work will need to be taken up
with dealing with the barriers that stand in the way of the patient subjectively experiencing the
therapist as a secure base. Indeed, one can view as a central therapeutic process goal an enhancement
of the patient’s capacity to experience the therapist as a secure base; and as a central outcome goal,
the generalization of that capacity to significant others outside the treatment situation.
From a traditional psychoanalytic perspective, what I have been describing bears a strong family
resemblance to transference and defense analysis. However—and here is where an attachment theory
perspective makes a significant contribution—the aim of examining the patient-therapist relationship is not
to uncover presumed infantile wishes toward the therapist or to identify the patient’s distortions, but to
truly understand the factors that make it difficult for the patient to experience the therapist as a secure base.
From an attachment theory perspective, a central factor that influences the patient’s response to
the therapist, including the barriers to experiencing the therapist as a secure base, is his or her
internal working model (IWM), which includes the patient’s representation of self, as well as
representations and expectations in regard to his or her attachment figure. As noted earlier, and
as Bowlby (1988) noted, a working assumption of a psychotherapeutic approach informed by
attachment theory is that insofar as the therapist is experienced as an attachment figure, at least to
a goodly degree, he or she will be experienced by the patient in terms of the latter’s IWM. This is
implicit in Bowlby’s (1988) comment that “the patient will import … all those perceptions,
constructions, and expectations of how an attachment figure will feel and behave towards him
that his working model of parents and self-dictate” (p. 138).
A critical question, then, is: How does one alter the internal model with which the patient comes to
treatment and which, according to Bowlby (1980), is relatively resistant to change? One confronts
something of a dilemma in addressing this question. One the one hand, as Alexander and French
(1946) maintained, new experiences (“corrective emotional experiences” [p. 66]) are necessary for
preexisting structures to change. On the other hand, as Bowlby (1988) recognized, the patient tends to
assimilate new experiences to preexisting structures, the consequence of which is that the new experi-
ences are not subjectively experienced as new, but rather are often construed as confirmations of
preexisting expectations and beliefs. Complicating the dilemma further is the fact that the patient
tends to elicit from others, including the therapist, the very reactions that serve to further confirm his
or her preexisting internal working model. (See Wachtel, 2014, for a discussion of cycle psychodynamics)
I am reminded of a poignant study by Jacobson and Wille (1986), which found that in a group
situation, although insecurely attached toddlers make as many social overtures as securely attached
children, they get rejected significantly more frequently. It is clear that the insecurely attached
toddlers are emitting some behavioral cues that trigger the very behaviors in other children that
tend to confirm their preexisting internal working model. A similar interaction may occur in the
therapeutic situation, where the therapist’s behaviors may be just the reaction the patient pulls for
(Strupp and Binder, 1984) and which, therefore, tend to confirm the patient’s working model. This
may also occur simply as a function of what the nature of the patient’s character and pathology
elicits in the therapist by virtue of the latter’s conflicts, anxieties, character structure, and attachment
pattern. For example, Dozier, Cue, and Barnett (1994) have reported that avoidant therapists and
patients tend to collude in their mutual avoidance of certain topics that are fraught for both of them.
It should be clear from the previous discussion that the barriers to altering the patient’s
maladaptive internal working model include not only the ways in which the patient’s pre-existing
structures serve to maintain sameness, but also the ways in which the therapist’s preexisting
structures and the interactions between the patient and therapist also serve to maintain sameness.
In the language of psychoanalytic theory, this is equivalent to stating that it is both counter-
transference as well as transference and the choreography between the two that are implicated in
the maintenance as well as the possibility of change in the patient’s working model.
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In view of these considerations, how are changes in the patient’s working model brought about in
the treatment situation? Of course, this is at least partly equivalent to asking about the nature of
therapeutic action. Various answers to this question have been provided. Some examples include, as
noted, Alexander and French’s (1946) proposal that “corrective emotional experiences” (p. 66) serve
to extinguish maladaptive expectations and replace them with more adaptive ones; Kohut’s (1984)
idea that repeated experiences of “optimal frustration” (which is essentially equivalent to good
enough rather than perfect understanding) lead to accretions in psychic structure through a process
of “transmuting internalization” (pp. 70–71); Strachey’s (1934) suggestion that through identification
with the nonjudgmental and accepting therapist the harshness of the patient’s superego, experienced
as guilt and self-condemnation, is softened; the hypothesis of Control-Mastery theory (Weiss and
Sampson, 1986; Silberschatz, 2005) that the therapist’s behavior disconfirms the patient’s “uncon-
scious pathogenic beliefs” (p. 7); and, of course, the claim of traditional psychoanalytic theory that
enhanced self-awareness, insight, and self-understanding are the key agents of therapeutic change.
Bowlby’s (1988) answer to this question essentially identifies two factors. I address the first factor
by looking at how attachment theory responds to the question of how the caregiver gets to be
experienced as a secure base by the child. Attachment theory identifies two basic functions of the
attachment figure that form the circle of security (Marvin et al., 2002), namely, the safe haven and
secure base functions, two sides of the coin of secure attachment. As I have shown what it means to
be a secure base is when, in the course of exploratory activity, the child becomes frightened and
distressed, the attachment figure will be both physically and emotionally available and will be
comforting. And, indeed, there is evidence that in all species studied, the availability of the attach-
ment figure enhances exploratory activity (Rajecki, Lamb, and Obmascher, 1978). In children,
although the physical presence or even a visual presentation or a photograph of mother (Passman
and Erck, 1977; Passman and Longeway, 1982) increases the range of the child’s exploration and
comfort in doing so, mother’s emotional availability does so even more (Sorce and Emde, 1981).
Trust in the availability of the attachment figure is based on the caregiver’s safe haven function,
that is, on the child’s repeated experiences of being comforted by the caregiver when distressed. The
child comes to trust and expect that the caregiver will be available should the child feel distressed in
the future. It is this trusting expectation that constitutes a secure base from which the child can
explore. That is, if the child becomes distressed during exploratory activities, he or she can trust in
the caregiver’s availability based on past frequent safe haven experiences. Thus, exploration is now
an emotionally safer venture. One can hypothesize that a similar process occurs in the therapeutic
situation, namely, that based on trust-enhancing repeated experiences of the therapist’s availability
for comforting during times of distress in which the patient feels held and safe, he or she comes to
experience the therapist as a secure base.
Both for the child and the adult patient, vital questions include: Is it safe to explore? Will you be
available if I become distressed? Control-mastery theorists (e.g., Weiss, Sampson, and their colleagues,
1986; Silberschatz, 2005) have presented evidence that patients present tests to their therapist to
determine whether it is safe to explore warded-off, anxiety-laden material. The tests are essentially
means of determining whether the therapist will behave in the same way as parents did, thus
confirming the patient’s “unconscious pathogenic beliefs” (Silberschatz, 2005, p. 7), or will behave in
a way that disconfirms these beliefs. In effect, the patient is attempting to determine whether condi-
tions of safety will obtain in the treatment situation. Thus, from the perspective of control-mastery
theory, in a trajectory roughly similar to the child’s reactions to the caregiver, the patient’s experience
of the therapist as a secure base is made possible only after he or she feels relatively assured that it is safe
to explore with this therapist. This is the control-mastery theory version of the attachment theory
formulation that the patient needs first to experience the therapist (and the treatment situation) as a
safe haven before he or she can experience the therapist as a secure base from which to explore.
As the Sorce and Emde (1981) study showed, the child’s experience of the attachment figure as a
secure base from which to explore is enhanced when the caregiver is not just physically present, but
also emotionally available. Although not directly linked to exploration, there is evidence that what
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Stechler (2000) referred to as the therapist’s “affective presence” (p. 75) is related to positive
therapeutic outcome. Havas, Svatberg, and Ulvenas (2015) reported that the therapist’s nonverbal
affective attunement to the patient had a significant influence on attachment insecurity at the
termination of treatment. It is also likely—although there is little research in this area—that the
emotional availability of the therapist is experienced by the patient as a sense of being understood, of
being represented and held in the therapist’s mind. Perhaps for the child, too, but certainly for the
adult, a critical element of security of attachment consists not only in a confident expectation that
the attachment figure will be physically available, but also affectively present and that one is
accurately represented and held in the attachment figure’s mind.
Note that in the aforementioned scenario, the importance of the safe haven function lies largely
in its role in allowing the child to experience the attachment figure as a secure base from which to
explore. This brings me to the second factor necessary for altering the patient’s IWM. I think that
it is fair to say that the primacy Bowlby gives to the secure base function derives from its link to
the exploratory system. As noted earlier, the exploratory system, in turn, is essential for the
development of basic skills and competencies necessary to function as an adult in the world. In
short, the secure base function of the attachment figure is the primary one given its role in
allowing the exploratory system to function adequately. From an attachment theory perspective,
the importance of soothing and comforting lies not only in the fact per se that the child feels safer,
but more importantly in the fact that it allows the child to explore without undue anxiety and to
develop essential skills and competencies. The extensive research findings demonstrating that
secure attachment is associated with the greater development of cognitive and social skills provide
support for Bowlby’s position (e,g., Allen et al., 2007; Fingi et al., 2001; Kochanska, 2001; Lyons-
Ruth, 1996; Sroufe et al., 2005a, b).
One of the issues debated in the psychoanalytic literature and implicit in this discussion is the
relative roles of the therapeutic relationship and insight and interpretation in therapeutic outcome.
There are essentially two views with regard to this issue, one emphasizing the therapeutic primacy of
the therapeutic relationship and the other view placing primary emphasis on the therapeutic value of
interpretation and insight. The first view explored early on by Alexander and French (1946), is that
the “corrective emotional experience” provided by the therapist reacting differently than the patient’s
expectations, based on early experiences with parental figures, are sufficient for therapeutic change.
Although, as far as I know, Alexander and French did not refer to extinction of a conditioned
response, implicit in their concept of “corrective emotional experience” (p. 66) is the idea that, over
time, repeated therapist behaviors that are different from the patient’s maladaptive expectations, will
ultimately extinguish these expectations, without explicit interpretation.2
In the second view, associated with traditional psychoanalytic theory, rather than constituting a
separate therapeutic factor itself, the therapeutic relationship is essentially a vehicle for the active
components of interpretation and ensuing insight and self-understanding to operate. Thus, the
unobjectionable positive transference is viewed by Freud (1912) not as necessarily therapeutic in
itself, but primarily insofar as it enhances the patient’s receptivity and acceptance of the analyst’s
interpretations. But it is the latter that is critical for effective therapeutic action. Indeed, therapeutic
improvement that comes about mainly due to the therapeutic relationship is viewed as evanescent
and dismissed as a transference cure.
Bowlby’s (1988) conception of therapeutic actions lies somewhere between Alexander and
French’s view and the more traditional view. On the one hand, he minimized the role of interpreta-
tion and placed primary emphasis on the therapist’s function as a trusted companion (i.e., a secure
base). On the other hand, he diverged from Alexander and French’s view insofar as he does not, so
to speak, place all his bets on the therapeutic relationship and the “corrective emotional experiences”
(p. 66) it provides. Rather, he also emphasized the importance of the patient’s exploration of “the
various unhappy and painful aspects of his life, past and present…” (Bowlby, 1988, p. 138).

2
French (1935), in fact, wrote a paper on the relevance of Pavlov’s work for psychoanalysis.
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However, although from Bowlby’s perspective, self-exploration (which implies a search for insight
and self-understanding) is a necessary component of psychotherapy, it does not take place primarily
through the analyst’s interpretations, but rather through the patient’s own struggles. Further, although
such exploration may have been “difficult or perhaps impossible” to do, it is made possible by the
presence of a “trusted companion to provide support, encouragement, sympathy, and on occasion,
guidance” (Bowlby, 1988, p. 138). In other words, the task of exploration is made safer by the
availability of a secure base. Just as the caregiver does not explore for the child, but rather provides a
secure base from which the child can explore safely, so similarly, in Bowlby’s view, it is not the therapist
who engages in exploration (in the form of presumably insight inducing interpretations), but rather,
the patient who carries out the exploration and arrives at his or her own insights.
However, despite minimizing the role of interpretation, Bowlby (1988, p. 138) said that the self-
exploration made possible by the presence of therapist as a secure base and “trusted companion” and
the presumed insights it may lead to are necessary ingredients of psychotherapy. In that regard,
Bowlby’s position is in accord with traditional theory in two interrelated ways: One, it retains the
primacy of self-exploration and insight (even if there are sharp differences regarding the content of the
insight); and two, it views the therapeutic relationship not as a curative factor in itself, but, as Freud
(1912) did, as a vehicle and context for self-exploration. However, Bowlby departed from traditional
theory in his minimizing the primacy of the therapist’s interpretive activity. Bowlby’s position is
similar, in certain respects, to Winnicott’s (e.g., Winnicott, 1965), who also minimizes interpretations
and construes the role of the therapist and of the therapeutic situation in terms of the provision of a
facilitating environment necessary for the facilitation of a “maturational process.”
I think that Bowlby’s eschewal of the role of interpretation is based on his image of the nature of
interpretation in classical theory, characterized by authoritative pronouncements issued from a blank
screen Menschenkenner analyst and directed toward uncovering presumably deeply repressed
instinctual impulses. However, interpretive activity can be understood in a way that blurs the
distinction between the therapeutic effects of the therapeutic relationship and the effects of inter-
pretive interventions.
It seems to me that attachment theory provides a model that dissolves, or at least attenuates, the division
between therapeutic relationship—corrective emotional experiences versus interpretation—insight as
critical therapeutic factors. The obvious response to this dichotomy is: They are both critical. However,
that response is too vague and general and not very useful. The questions that need to be addressed are:
How is each factor useful? And in what ways do these two factors interact synergistically?
One can think of the ideal therapeutic relationship as constituting a circle of security that parallels
the circle of security in the child-caregiver dyad. That is, as discussed earlier, repeated experiences of
the attachment figure as a safe haven when the child is distressed paves the way for experiencing the
attachment figure as a secure base from which to explore. A similar pattern is present in the
therapeutic situation. For the adult patient in psychotherapy to be comforted by the therapist
requires the experience of being understood, being represented and held in the therapist’s mind,
an experience metaphorically paralleling the child being literally held by the caregiver. Repeated
experiences of being understood, then, form the basis for the trust and feelings of safety necessary to
experience the therapist as a secure base from which to explore.
In this formulation, there is no clear distinction between relationship and interpretation. It is not
clear what it would mean to say that the patient feels comforted and understood simply by virtue of
the therapeutic relationship. For, there must be something the therapist does and is that contributes
to the patient feeling understood and comforted. For example, from a self psychology perspective,
what the therapist does is demonstrate, through his or her intervention, including its tone, timing,
and tact, an empathic understanding of the patient. Although Kohut (1984) distinguished between
understanding and explanation, there is no clear division between what Kohut (1984) referred to as
empathic understanding and what others may view as an accurate and empathic interpretation.
Indeed, insofar as an intervention that conveys empathic understanding is not simply a parroting of
the patient, it always contains an interpretive element. An intervention that conveys empathic
 ATTACHMENT THEORY AND RESEARCH AND CLINICAL WORK 291

understanding is essentially equivalent to an accurate and empathic interpretation conveyed tactfully

and in a particular tone and manner. At their best, such interventions both enable the patient to feel
understood and to feel represented and held in the therapist’s mind, and also contribute to the
patient’s self-understanding and self-knowledge. Hence, empathic interpretations are both relation-
ship as well as insight-generating factors.
In this context, one can say that in making empathic interpretations that enable the patient to feel
understood and held, the therapist is functioning as a safe haven for the patient. However, insofar as
accurate and empathic interpretations facilitate self-exploration, they also are intrinsic to the secure
base function of the therapist. In particular, they may facilitate reflection on and insight into the nature
of the patient’s internal working model. Thus, from an attachment perspective, empathic interpreta-
tions reflect both the safe haven and secure base functions of the therapist. Furthermore, in this
process, the therapist is not simply a trusted companion who is merely present, but through his or her
interpretive interventions, is an active participant who encourages the patient’s self-exploration.
The aforementioned represents the ideal relationship between the safe haven and secure base functions
of the attachment figure, including the therapist as attachment figure. However, the ideal relationship is not
always the one that prevails, neither in the child-mother nor in the patient-therapist relationship, as a
consequence of the personality characteristics and attachment patterns of both participants, as well as the
nature of the interaction between the two. For example, Bowlby focused on pathogenic scenarios in the
child-mother interactions characterized by loss, separation, and threats of loss and separation, with the
consequence that the child experienced neither a safe haven nor a secure base.
There is also a pathogenic scenario in which the safe haven and secure base functions become
disconnected from each other. Some mothers are emotionally available as a safe haven for soothing
and comforting when the child is distressed, but are not available when the child attempts to explore and
separate. Not only is exploratory activity not supported, but it is actively discouraged, most often due to
the caregiver’s own anxiety and neediness. Hence, although it is true that repeated experiences of the
caregiver as a safe haven, that is, of being comforted and soothed when distressed normally ensures the
experience of the caregiver as a trusted secure base, this is not the case when the caregiver’s comforting
and soothing excludes exploratory activities and attempts at separation. Thus, the safe haven and secure
base functions become disconnected from each other and the circle of security no longer functions.
As Masterson (1986) has observed in his discussion of borderline conditions, the child learns that
the caregiver is available when he or she is distressed and regressed and not available when he or she
attempts to explore and separate. The result is one that the child never experiences the caregiver as a
secure base for exploration; and two, that because there is no opportunity to internalize a secure base
function, exploration and separation are saturated with anxiety and fear.
Do subtle versions of a dissociation between the safe haven and secure base functions occur in the
therapeutic situation? For example, are some therapists supportive when the patient is distressed and
emit subtle cues of anxiety and/or displeasure when the patient makes moves toward separation and
independence, including from the therapist?3 This introduces the issue of how therapist attachment
patterns interact with patient attachment patterns in the therapeutic process. There is evidence that
the therapist’s attachment pattern influences how he or she deals with patient issues. For example,
Dozier, Cue, and Barnett (1994) reported that compared to secure case managers, insecure case
managers tended to become enmeshed with enmeshed/preoccupied patients and to become avoidant
with avoidant/dismissive patients. They also found that, compared to secure therapists, insecure
therapists were more likely to see their enmeshed/preoccupied patients as more needy and depen-
dent and less able to manage their patient’s demands and dependency needs.
There is also evidence that therapists are more likely to respond in the more cognitive way of
interpretation with avoidant/dismissive patients and the more affective way of reflection of feelings
with more enmeshed/preoccupied patients (Hardy et al., 1999; Rubino et al., 2000). As Slade (2008)

3
In the language of Control-Mastery theory, such therapist behaviors would be seen as test failures and as serving to confirm the
patient’s unconscious pathogenic beliefs.
292 M. N. EAGLE

observed, the effective therapist may be better able to move “between these two strategies—some-
times mirroring the patient’s experience … and at other times challenging his or her state of mind”
(p. 268). In her excellent review of “The implications of attachment theory and research for adult
psychotherapy,” Slade (2008) raised the question “of whether a treatment type that is non-
complementary to the patient’s attachment style may be most therapeutic” (p. 770). Citing
Daniel’s (2006) suggestion, Slade asked whether “a more deactivating treatment (such as cognitive-
behavioral therapy) may be more effective for patients who are preoccupied/anxious, whereas hyper-
activating treatments (such as psycho-dynamically oriented psychotherapy) may be more useful for
dismissive/avoidant patients” (p. 770). Daniel’s suggestion is based on the idea that appropriate
therapeutic interventions may consist in eliciting emotions in avoidant/dismissing patients and
constraining emotion in enmeshed/preoccupied patients.

Mentalization and reflective function

I here comment on the relationship between attachment theory and research on reflective function,
mentalization, and mentalization-based therapy (MBT). Bowlby’s (1988) statement that a main
function of the therapist is to provide a secure base for the patient’s self-exploration can be under-
stood in a number of ways. As noted earlier, it does not refer to uncovering repressed infantile
impulses. Rather, as it has been understood and elaborated in the contemporary literature, it refers to
enhancing the patient’s capacity to both reflect on his or her own working model and understand the
circumstances under which they were formed, as well as on the mental states of his or her
attachment figure. As an extension and exploration of Main, Kaplan, and Cassidy’s (1985) move to
the level of representations, the concept of reflective function (RF) came into prominence through the
pioneer work of Fonagy and his colleagues. In one important study, Fonagy, Steele, and Steele (1991)
found that the level of RF in mothers in their third trimester of pregnancy was able to predict what
the attachment status of the as-yet-unborn infant would be at one year of age. There is evidence that
a major proportion of the variance on the AAI is accounted for by level of RF (Fonagy and Target,
1997). Thus, a high level of RF essentially identifies a secure attachment pattern on the AAI, whereas
lower levels of RF essentially identify insecure attachment patterns.
Based on the aforementioned work, Fonagy and his colleagues (e.g., Batement and Fonagy, 2006)
developed the concept of mentalization, as well as mentalization-based therapy (MBT), a core goal of
which is to enhance the patient’s capacity for reflective functioning. Although these concepts and
formulations arose in the context of attachment theory and research, they are relevant to a wide
range of therapeutic approaches.4 As Allen and Fonagy (2006) put it, “Any reasonable and effective
psychotherapy is likely to enhance mentalizing capacity” (p. 19). And, indeed, as noted earlier,
outside the context of attachment theory and research, contemporary ego psychologists such as
Sugarman (e.g., 2006) have essentially redefined a process goal of psychoanalytic treatment not as the
uncovering of repressed impulses, but as helping the patient better understand how his or her mind
works—which is certainly similar to enhancing the capacity for reflective functioning.
As Luyten and Fonagy (2015) have proposed, mentalization is not a unitary process. They identify
different dimensions of mentalizing, including: (a) automatic (unconscious, reflexive, fast) versus
controlled (conscious, verbal, reflective, effortful); (b) internal (a focus on inner mental contents)
versus external (a focus on external features); (c) cognitive (a focus on cognitive features such as
belief, desire, perspective taking) versus affective (affective empathy, more automatic). Thus, one
may automatically attribute intentions to another in a reflexive and affective fashion, which is often
associated with one’s own strong negative affective states. For example, if one feels hurt or ashamed,
a frequent automatic reaction is that the other intended to hurt or shame. This form of mentalization
tends to intensify, rather than regulate, negative affect. Thus, it seems clear that it is not

It should be noted that reflective functioning bears a strong family resemblance to Sterba’s (1934) distinction between “affective
4

experience” and “intellectual contemplation” (p. 121).

 ATTACHMENT THEORY AND RESEARCH AND CLINICAL WORK 293

mentalization of any kind that needs to be enhanced in treatment, but a form of mentalization
inherent in the concept of reflective functioning, that is, the capacity to step back from immersion in
one’s thoughts and feelings and reflect on them; and, similarly, with regard to one’s automatic and
reflexive attributions regarding others’ mental states.
It is worth noting that a goal shared by virtually all infant-mother intervention programs is
enhancement of the mother’s capacity to reflect on both her own mental states and those of her
infant (see Berlin et al., 2005; Eagle, 2013, for a description of such programs). This approach reflects
the joint influence of the psychoanalytically informed concept of “Ghosts in the nursery” (Fraiberg,
Adelson, and Shapiro, 1975) as well as attachment research demonstrating the relationship between
reflective function and secure attachment.
I began this article with a focus on the therapist as a secure base from which the patient can safely
explore. In a sense, a good portion of the article consists of an examination and elaboration of that
idea and the recognition that it cannot be taken for granted as a given. It turns out that the seemingly
simple notions as functioning as a secure base and trusted companion are not at all simple ideas, but
markers for a long complex story. The long story lies largely in the complexities and vicissitudes
involved in the therapist being able to function as a secure base, the barriers to the patient being able
to subjectively experience the therapist as a secure base, and the interaction between the two.

Attachment theory and research and understanding of psychopathology

Although my focus has been on psychotherapy, it is important to note that attachment theory and
research have made enormous contributions to the field’s understanding of psychological function-
ing in critical areas of life and of development, including the development of psychopathology. With
regard to the latter, as Levy et al. (2015) have argued, “Difficulties with attachment are often at the
heart of most [personality disorders]” (p. 197). Although this claim may be somewhat overstated,
there is a good deal of evidence linking at least borderline personality disorder (BPD) to fearful
attachment (i.e., high anxiety and high avoidance), enmeshed/preoccupied attachment, and disorga-
nized attachment. Fear of abandonment is a central feature of both enmeshed/preoccupied attach-
ment, as well as BPD. Early adolescent attachment anxiety predicts risky sexual behavior and
aggression, both characteristic of BPD.
In a longitudinal study, Lyons-Ruth et al. (2013) found that abuse and childhood attachment
disorganization at age 8 predicted BPD and that maternal withdrawal during infancy predicted BPD
symptoms, including suicidality and self-harm. These are merely representative examples of the role of
attachment theory and research in understanding BPD. Indeed, I think it is fair to say that research on
BPD highlights the primacy of attachment issues in at least certain forms of personality disorder.
Attachment and attachment-related research have identified important risk and protective factors,
not only in relation to psychological health and illness, but also in regard to physical health and
illness. There is much evidence, for example, indicating that whereas security of attachment in both
children and adults is associated with positive health outcomes, insecure attachment is associated
with negative health outcomes (e.g., Maunder and Hunter, 2008; Pietromonaco and Powers, 2015).
Furthermore, there are research findings that point to likely processes that mediate the relationship
between attachment patterns and physical health. First, there is an accumulating body of evidence
linking positive social relationships, including positive attachment relationships, to positive health
outcomes, and negative social relationships, including poor parenting, to negative health outcomes
(see Pietromonaco and Powers, 2015, for a very informative review).
Second, one can think of secure attachment as betokening the presence, both in the past and
currently, of more positive social relationships; and insecure and disorganized attachment as
suggesting problematic relationships. Third, there is evidence that childhood adversity (e.g., poverty;
violence) and/or poor parenting (including parental behavior associated with insecure and disorga-
nized attachment) are associated with dysregulation of the hypothalamic-pituitary-adrenal (HPA)
axis, which is centrally involved in response to stress, including release of cortisol (e.g., Gunmar
294 M. N. EAGLE

et al., 1989; Blair et al., 2011). Fourth, insecure attachment in infancy, childhood, and adolescence is
associated with dysregulation in the form of hyper- or hypo-responsiveness of the HPA system
(Bernard and Dozier, 2010; Oskis et al., 2011; Borelli et al., 2014). There is also evidence that infant
disorganized attachment interacts with mother’s depression and contributes to dysregulation in the
infant’s autonomic functioning (Tharner et al., 2013).
Despite the importance of these findings, I introduce a cautionary note. Although early attach-
ment experiences are, indeed, associated with later outcomes, the association is not always especially
robust, nor simple and linear. For one thing, the stability of attachment patterns is, to a significant,
extent, a function of environmental stability. Second, genetic factors interact with early experiences
in influencing the degree to which these early experiences influence later development. There is
evidence that genetic factors render individuals more susceptible to both positive and negative
environmental influences (Belsky and Pluess, 2013; Ellis et al., 2011; Bakermans-Kranenburg and
van Ijzendoorn, 2011). Thus, although early attachment experiences are undoubtedly important,
their degree of influence on later developmental outcomes is a function of their interaction with both
other environmental factors and genetic factors (for an excellent review of these issues, see Luyten
and Fonagy, 2015). Third, instead of thinking of early attachment relationships as a template for later
relationship patterns, as Luyten and Fonagy (2015) suggested, they are more usefully viewed as a
factor that influences the individual’s developmental pathway and that provides a context for social
learning and the acquisition of relational skills and relational trust.
Bringing all this and other evidence together, what emerges, keeping the previous cautionary note
in mind, is the importance of the nature of the early attachment bond, as well as the adult
attachment bond, for the physical and psychological well-being of the infant, child, adolescent,
and adult. At the very least, the overwhelming evidence makes it clear that, just as Bowlby (1980)
stated, attachment issues play a primary role in an individual’s life from birth to old age. It is,
therefore, unquestionable that although other motivational systems also should be attended to,
attachment issues need to play a primary role in any form of psychotherapy. In particular, the
therapeutic situation provides a context for enhancing the patient’s capacity to reflect on and
reevaluate their representations of themselves and of others (e.g., their expectations and implicit
assumptions regarding the other).
Finally, it is worth noting the striking contrast between the relative lack of an evidential base for
central psychoanalytic developmental hypotheses and the considerable evidential basis for central
attachment theory developmental hypotheses. For example, I know of no body of research evidence
supporting the iconic psychoanalytic hypothesis that the way in which the individual resolves the
Oedipus complex is a significant factor in the development of psychopathology or in central psycho-
logical areas in an individual’s life such as the formation of gender identity or the development of
conscience. My point here is that what researchers know about development, including the develop-
ment of psychopathology, should generally correspond to the issues addressed in psychotherapy.

Notes on contributor
Morris N. Eagle, Ph.D., is distinguished Educator-in-Residence, Graduate School of Psychology, California Lutheran
University, Thousand Oaks, California, and Professor Emeritus, Derner Institute for Advanced Psychological Studies,
Adelphi University, Garden City, New York.

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