Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 23, 142–154 (2016)

Published online in 19 January 2015 Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1943

A Qualitative Exploration of the Use of

Attachment Theory in Adult Psychological
Therapy
Eilish Burke,1* Adam Danquah2 and Katherine Berry1
1
School of Psychological Sciences, The University of Manchester, Manchester, UK
2
Department of Psychological Therapies, Pennine Care NHS Foundation Trust, Stockport, UK

There is a growing interest into how attachment theory can inform psychotherapeutic practice with adults.
This study aimed to explore how a group of therapists with an interest in attachment theory use it in their
work with adult clients. A cross-sectional qualitative design was adopted. Sampling, data collection and
analysis procedures were guided by grounded theory principles. Semi-structured telephone interviews
were conducted with 12 therapists from a variety of training backgrounds. Data were coded and developed
into thematic categories. Six primary themes were identified to describe how attachment theory influenced
the clinical practice of the sample through the following: (i) complementing other therapeutic models; (ii)
providing a framework to understand the development of clients’ mental health problems; (iii) working
with different attachment styles; (iv) thinking about the therapeutic relationship as an attachment relation-
ship; (iv) influencing the different stages of the therapeutic process; and (vi) influencing clinical service de-
sign and delivery. It is concluded that attachment theory can play a significant role in influencing the
practice of therapists and can be usefully adopted to complement therapeutic processes irrespective of
the therapist’s dominant clinical orientation. Further research is needed to explore the views of clinicians
from different theoretical orientations and to investigate the security of the client–therapist attachment
within the context of therapeutic change processes. Copyright © 2015 John Wiley & Sons, Ltd.

Key Practitioner Message:

• Attachment theory may have implications for practice across a range of different types of therapy and may
help therapists to bridge apparent differences between modality-specific formulation and techniques.
• Attachment theory can be used to understand the development of mental health problems. Therapists
should assess and formulate clients’ attachment styles, and these formulations should guide therapeutic
approaches.
• Attachment theory provides a comprehensive framework for facilitating the therapist’s attentiveness to
relational issues and use of the therapeutic relationship as a fulcrum for change.
• The principles of attachment theory can be used to inform all stages of the therapeutic process, as well
as the design and delivery of mental health services.

Keywords: Attachment Theory, Bowlby, Therapy, Secure Base, Adult Mental Health

INTRODUCTION sensitive way, the child will develop a ‘secure’ attachment

style, which enables him or her to become increasingly
Attachment theory proposes that humans have an innate
independent, to manage distress, to build adaptive
attachment behavioural system that compels us to seek
relationships with others and to form a positive self-
proximity to significant others when under threat and that
image. Conversely, if a child’s attachment needs are not
matures into the human capacity to form close and endur-
met, then he or she is left in a state of insecurity and dis-
ing affectional bonds (Bowlby, 1969). In response to early
tress and may go on to develop an ‘anxious’ or ‘avoidant’
experiences, an infant develops mental representations
style or fail to develop a reliable strategy and thus become
or ‘internal working models’ of the world. If a caregiver
‘disorganized’ (Bowlby, 1988; Hesse & Main, 2000). It is
is consistent in meeting a child’s attachment needs in a
hypothesized that insecure attachments become rein-
forced in later relationships, leaving the individual more
*Correspondence to: Eilish Burke, School of Psychological Sciences,
exposed and vulnerable to stress and at a higher risk of
The University of Manchester, Manchester, M13 3PL, UK. developing mental health problems. Significant associa-
E-mail: eilishburke@gmail.com tions have been identified between attachment insecurity

Copyright © 2015 John Wiley & Sons, Ltd.

Attachment Theory in Adult Therapy
and depression (Bifulco, Moran, Ball, & Bernazzani, 2002),
anxiety (Warren et al., 1997), eating disorder (Broberg
et al., 2001), symptoms of psychosis (Berry, Barrowclough,
& Wearden, 2008) and personality disorder (Brennan &
Shaver, 1998; Fonagy et al., 1996). By contrast, secure at-
tachment is associated with good mental health and may
represent a protective factor against psychological dys-
function (Dieperink, Leskela, Thuras, & Engdahl, 2001;
Mikulincer & Shaver, 2007).
The past decade has seen a growing interest in the rele-
vance of attachment theory to psychological therapy with
adults (Mikulincer, Shaver & Berant, 2013). Bowlby (1977)
proposed the theory as a way ‘to specify therapeutic tech-
nique’ and ‘describe therapeutic process’ (p. 430). He be-
lieved that the therapist’s most important task was to
provide a secure base from which the client may begin
the difficult journey of self-exploration and that a secure
attachment to therapist provided a ‘corrective’ emotional
experience for the client who did not have this in child-
hood (Bowlby, 1988). Evidence of a significant positive as-
sociation between security in the client–therapist
relationship and depth of therapeutic exploration sup-
ports this hypothesis (Mallinckrodt, Gantt & Coble, 1995;
Janzen, Fitzpatrick & Drapeau, 2008). The conceptualiza-
tion of the client–therapist relationship as an attachment
has also been put forward by others (e.g., Holmes, 2001;
Mallinckrodt, 2010; Wallin, 2007). Research indicates that
clients with insecure attachment styles are less likely to
form strong therapeutic alliances; thus, therapists may
need to work harder to establish secure attachments with
such clients (Diener & Monroe, 2011). A recent meta-
analysis reported that clients with secure attachments are
likely to have better therapeutic outcomes, whereas
attachment insecurity is linked to worse outcomes (Levy,
Ellison, Scott, & Bernecker, 2011).
Many therapeutic approaches have lately been influ-
enced by attachment theory. Obegi and Berant (2009)
make a distinction between those that are attachment in-
formed and those that are attachment based. The former
being those who use the theory as a supplementary
framework to conceptualize, assess and treat client prob-
lems but rely on the techniques of established therapies
(e.g., cognitive–analytic therapy; Ryle, 1990), the latter be-
ing those who explicitly use the theory within the struc-
ture of therapy and attempt to demonstrate changes in
attachment as an outcome (e.g., attachment narrative
therapy: Dallos, 2006). There is some evidence that
psychological therapy can result in a movement from
attachment insecurity towards security (Mikulincer,
Shaver & Berant, 2013).
These developments notwithstanding, practitioners of-
ten find it difficult to know exactly how the concepts of at-
tachment can be put to effective use in the clinical setting.
Those who would translate attachment theory into prac-
tice have had to draw inferences from either the mainly
Copyright © 2015 John Wiley & Sons, Ltd.
143
non-clinical adult attachment literature or the compara-
tively sparse and narrowly focused literature on the impli-
cations of attachment theory for single schools of
psychotherapy (Berry, Danquah & Wallin, 2013). One
study explored ways of using attachment theory clinically
indirectly by asking therapists skilled in working with
interpersonal difficulties about how they might work with
hypothetical client vignettes representing interpersonal
styles typically associated with anxious and avoid
attachment. These therapists reported that they would
facilitate change by initially matching a client’s attach-
ment style and thereafter adopting an increasingly non-
complementary stance until an optimal level of ‘therapeu-
tic distance’ was maintained (Daly and Mallinckrodt,
2009). This study usefully but implicitly examined how a
small number of experienced therapists might work with
clients with two particular types of insecure attachment
patterns. We cannot be certain whether the findings de-
scribe how therapists use attachment theory in working
with a wide range of different clients with various demo-
graphic characteristics and developmental histories or
how therapists explicitly draw on attachment theory to in-
fluence other aspects of their therapeutic work. Accord-
ingly, the present study aimed to explicitly ask therapists
who work with adults about their use of attachment the-
ory in all aspects of their clinical work. We specifically
sampled therapists who were likely to have good knowl-
edge of the existing attachment literature and through ex-
perience have found ways of translating these ideas into
practice. It is anticipated that our findings would therefore
inform other clinicians who wish to incorporate the theory
into their practice.
METHOD
Methodological Approach
A qualitative design drawing on grounded theory princi-
ples was chosen to enable the collection of novel and un-
expected data about therapists’ experiences of using
attachment theory in their work and to develop a theory
of how the principles of attachment theory might inform
clinical practice (Charmaz, 2006; Glaser & Strauss, 1967).
The main principles of grounded theory informed partici-
pant sampling, data collection and analysis. Ethics proce-
dures were followed, and the study was approved by
the relevant university ethics committee for research on
human beings.
Sampling
In order to collect different perspectives on the topic, a
sample of therapists with variation in training
Clin. Psychol. Psychother. 23, 142–154 (2016)
144
background, career stage, age and gender was sought.
Criteria for inclusion were that therapists spoke fluent
English, worked with adults and had a stated interest in
attachment theory. Therapists who were known by the
authors to have an interest in attachment theory either
through practice or through publication in the area were
initially identified. They were approached via email from
the first author, which comprised an invitation to take part
in the study, an information sheet explaining the study
aims and procedures and a link to an online consent form.
A total of 18 therapists were contacted in this way, and 10
responded to say they agreed to take part (response
rate = 56%). Those who did not respond to the email were
presumed to have declined, and no reason was sought
for this. After participation, therapists were invited to pass
on the study details to others whom they knew to meet in-
clusion criteria (i.e., snowball sampling), and four addi-
tional participants were recruited in this way. One
interview was cancelled by a participant in advance be-
cause of diary commitments, and another interview with
a therapist located outside the UK could not take place be-
cause of technical difficulties. None of the participants
were personally known to the first author and primary re-
searcher (E. B.), who conducted the interview, prior to in-
terviews taking place.
Participants
The total sample of 12 therapists comprised six women
and six men identified henceforward as Therapists A–L.
Eleven worked in the UK, and one worked in the Republic
of Ireland. Their mean age was 52 years (SD = 10.5 years;
range = 30–66 years). Two had their initial primary train-
ing in nursing, two in clinical social work, four in clinical
psychology and four in psychiatry. Further details on the
sample are given in Table 1.
Reflexivity
In qualitative methodologies, researchers are active
instruments within the research process, and their per-
spectives should be acknowledged given their potential
influence on results (Elliott, Fischer & Rennie, 1999). E. B.
is a woman with an interest in attachment theory in
relation to adult mental health and conducted the research
as part of a taught master’s degree in Psychology at a
university in North West England. The second (A. D.)
and third (K. B.) authors supervised the work. A. D. is a
male clinical psychologist in secondary care adult mental
health, where he works to broaden the application of
attachment theory to assessment and intervention. K. B.
is a female clinical psychologist and a lecturer in clinical
psychology with an interest in attachment theory having
Copyright © 2015 John Wiley & Sons, Ltd.
E. Burke et al.
completed a PhD on the subject. The authors met
regularly to discuss interviews and emerging themes.
Procedure
Interviews took place between January and July 2012. All
were conducted by E. B. over the telephone, a methodol-
ogy used in similar research in the area (Daly &
Mallinckrodt, 2009). E. B. was alone in a private office in
a university campus for 10 interviews and alone at home
for two interviews. Eight participants were alone in a pri-
vate office at work and four were alone at home for the in-
terview. The study was introduced to participants as an
exploration of how therapists use attachment theory in
work with adult clients. The average length of interview
was 48 min (SD = 12 min; range = 23–65 min). Interviews
were recorded and transcribed verbatim by the first
author with identifying information removed.
Interview Topic Guide
An initial topic guide included broad open questions
about therapist’s use of attachment theory in their work
and focussed questions to probe for additional data. The
interviewer was reactive to participants’ responses,
allowing the direction of each interview to be flexible. In
accordance with grounded theory, the topic guide was re-
vised over the course of the study as patterns identified in
the data already collected were then explored in subse-
quent interviews (Charmaz, 2006). For example, while
the early topic guide included questions on all of attach-
ment theory’s theoretical constructs (internal working
models, safe haven and secure base), later interviews fo-
cussed on those areas that had been identified as signifi-
cant from previous interviews (e.g., the secure base). The
final version of the topic guide is included as Appendix
1 in this manuscript.
Analysis
Data were organized using the word processing software
Microsoft Word 2007 (Microsoft Corporation, Redmond,
WA, USA) and the qualitative analysis software QSR
NVIVO9 (QSR International, Melbourne, Australia). In an
initial stage of open coding, the first author coded
transcripts line-by-line, inductively and with a low level
of abstraction from original participant utterances,
endeavouring to construct active codes commencing with
verbs where possible, in order for the analysis to remain
close to participants’ perspectives (Charmaz, 2006). Ana-
lytic notes or ‘memos’ were taken by researchers through-
out the research process; these were records of the
researcher’s ideas about the data as they occurred and in
Clin. Psychol. Psychother. 23, 142–154 (2016)
 Table 1. Participant demographic information

Age Primary Further Theoretical Years in Clients/ Therapeutic

Ppt. Gender (years) Nationality training training orientation Specialism practice week work setting

A M 34 British Clinical Psychoanalysis Psychoanalytic General adult 5 7 Public secondary

psychology mental health, care, community
older adults service
B F 55 Irish Psychiatric Psychoanalysis Psychoanalytic Complex cases 13 2–5 Public secondary
nursing with historical care, community
trauma, BPD service
C F 56 British Psychiatry Psychodynamic Psychodynamic General adult 8 4 Public outpatient
therapy and MBT mental health, psychotherapy
Attachment Theory in Adult Therapy

psychosis and service and

trauma voluntary sector

Copyright © 2015 John Wiley & Sons, Ltd.

D M 59 British Clinical Child and family Psychoanalytic, BME groups, 32 25–30 Private practice,
social work therapy, systems refugees, voluntary sector
psychoanalysis CBT intercultural
psychotherapy
E M 53 British Clinical Family therapy, Eclectic, attachment General adult 25 12–15 Public secondary
psychology psychoanalysis informed, mental health, care, voluntary
psychoanalytic complex cases, sector, private
PD practice
F F 66 Swedish Clinical Psychoanalysis Psychoanalytic General adult 22 8 Private practice
social work attachment-informed mental health,
therapy adolescent
mental health
G M 30 British Clinical PhD (attachment Cognitive– General adult 9 months 12 Public secondary
psychology theory), AAI behavioural mental health, care, community
psychosis service
H M 63 British Clinical Family therapy, AAI Systemic Family therapy, 30 2 Voluntary sector
psychology couples therapy,
eating disorders
I F 52 British Psychiatry Psychodynamic Attachment theory, Forensic psychiatry 20 10 Secure psychiatric
therapy, group psychodynamic hospital
therapy, AAI
J M 51 British Psychiatric Psychodrama, group Psychodynamic General adult 13 10–15 Public outpatient
nursing therapy, MBT, AAI mental health; psychotherapy
BPD; PD service
K F 54 British Psychiatry Psychoanalysis, MBT Psychodynamic General adult 30 15 Public outpatient
mental health, BPD, psychotherapy
early childhood service
trauma
L F 53 Irish Psychiatry Psychoanalysis, MBT Psychodynamic, General adult 22 5 Public outpatient
object relations mental health psychotherapy
service

Ppt., participant; M, male; F, female; MBT, mentalization-based therapy; CBT, cognitive–behavioural therapy; AAI, adult attachment interview; PD, personality disorder; BPD, borderline
personality disorder; BME, Black minority ethnic.
145

Clin. Psychol. Psychother. 23, 142–154 (2016)

146
addition to the line-by-line codes formed the basis of the
data analysis. The most significant and frequently
occurring concepts in the line-by-line codes and memos
were then used to sift through and interpret all of the data
in order to develop higher order thematic categories. Data
collection and analysis were performed in parallel,
enabling thematic categories identified in initial transcripts
to be explored in subsequent interviews. This iterative
process was followed until a point when, after 12
interviews, it was deemed that a point of thematic satura-
tion had been reached, whereby no new theories or
sub-theories were evident.
Quality and Rigour
A number of measures were put in place to enhance the
validity and reliability of the analysis. Each participant
was sent a copy of their line-by-line coded transcript
and invited to ‘member check’ codes to ensure they
did not misrepresent their intended meaning. Four par-
ticipants contacted the researcher with a total of six mi-
nor changes comprising three code clarifications, one
amendment to a participant’s weekly caseload, one tran-
scription error and one formatting error. The process of
analysis and emerging themes were reflected upon
within regular supervision meetings in addition to dis-
cussion meetings with an academic peer of the first
author who was enrolled in the same master’s degree
course and who was engaged in other qualitative re-
search supervised by K. B. These reflections informed
subsequent analyses and interviews. In addition, a re-
flective diary was kept throughout the research process
and used to record field notes, research decisions and
concerns about biases and implications. This reflective
diary was referenced during data analysis to help ensure
Table 2. Primary themes and subthemes
Theme
1. Complementing other
therapeutic approaches
2. Providing a framework to understand
the development of mental health problems
3. Working with different attachment styles
4. The therapeutic relationship as an
attachment relationship
5. Influencing the different stages of the
therapeutic process
6. Influencing service design and delivery
Copyright © 2015 John Wiley & Sons, Ltd.
E. Burke et al.
that an authentic account of the data was being
developed (Lincoln & Guba, 1985).
RESULTS
Overview of the Influence of Attachment Theory
The majority of therapists cited attachment theory as a
major influence; however, most said that they did not
see themselves as using concrete applications of the the-
ory: ‘I don’t use a sort of direct application’ (Therapist
L). Rather, it was a more holistic influence or ‘informing
paradigm’ (Therapist B). Some commented that the influ-
ence of the theory on their practice had ‘become more
formalised’ (Therapist J) through training in specific ap-
proaches such as mentalization-based therapy (MBT;
Bateman & Fonagy, 2003) or the adult attachment inter-
view (AAI) (George, Kaplan & Main, 1985).
Themes
Six primary themes and 13 subordinate themes were iden-
tified in the data (Table 2). The following section presents
a description of themes and subthemes with illustrative
quotations.
Complementing Other Therapeutic Approaches
Therapists reported using attachment theory to comple-
ment other modalities and ways of working with clients:
‘I use it in combination with systemic approaches’ (Thera-
pist H). The necessity of a specific ‘brand’ of attachment
therapy was questioned since fundamentally ‘all therapy
Subtheme
1.1. Building upon the classic psychoanalytic model
1.2. Bridging psychodynamic and cognitive–behavioural approaches
2.1. An alternative to the diagnostic model
2.2. Sharing the framework with clients and colleagues
3.1. Assessing client attachment styles
3.2. Adapting to client attachment styles
3.3. Therapist attachment styles and countertransference reactions
4.1. Providing a secure base
4.2. The client–therapist attachment as the active ingredient of change
5.1. Engaging clients
5.2. Formulating client problems
5.3. Dealing with boundaries
5.4. Breaks and endings
5.5. Evaluating outcomes
Clin. Psychol. Psychother. 23, 142–154 (2016)
Attachment Theory in Adult Therapy
is attachment based, just you’re either blind to it or you’re
not’ (Therapist E).
Building upon the Classic Psychoanalytic Model
Therapists interpreted the current interest in attachment
theory as a return to psychoanalytic concepts. However,
a marked advantage of attachment theory was said to be
its strong and growing evidence base, and this enabled
therapists to support its influence on their practice:
…I can wave my attachment handbook at people and say
‘If you don’t believe me, read that’… (Therapist J).
Bridging Psychodynamic and Cognitive–Behavioural
Approaches
Attachment theory was said to link psychodynamic and
cognitive–behavioural models. Therapists reported that
the complexity of psychodynamic approaches was often
mistrusted within services, and that attachment theory
can provide a common ground jointly acceptable to those
coming from psychodynamic and cognitive–behavioural
perspectives:
…there’s a lot of suspicion about psychodynamic
thinking and so if you were talking to somebody who
was very firmly in a CBT camp for instance, I think
you’ve got more common ground if you’re talking […]
in an attachment-based language… (Therapist C)
Providing a Framework to Understand the
Development of Mental Health Problems
Therapists spoke about how attachment theory provides a
useful framework to understand how clients develop the
mental health problems they seek help for in therapy.
An Alternative to the Diagnostic Model
This framework was seen as an alternative to the domi-
nant biomedical model of mental illness. It was said to of-
fer a better explanation for how clients develop mental
health problems and to open up the possibility of therapy
for clients with diagnoses, such as personality disorder
and psychosis, that are commonly ‘pushed by the way-
side’ in favour of ‘highly medicalised’ treatments (Thera-
pist A):
…if you re-frame personality disorders as disorders of
affect regulation, arousal regulation and interpersonal
representations then […] personality disorders arguably
Copyright © 2015 John Wiley & Sons, Ltd.
147
are the adult manifestation of early childhood
insecurity… (Therapist I)
At the same time, therapists expressed worry about at-
tachment styles being used in a reductive, ‘Black and
White way’ (Therapist G). One expressed concern that
the language of attachment theory could be ‘slightly pejo-
rative’, that labels such as ‘dismissing attachment’ and
‘preoccupied attachment’ may serve to pathologize clients
and that the theory risks being a ‘deficit model’ of mental
health (Therapist H), perhaps no more helpful than the
biomedical model itself. This person recommended con-
ceptualizing attachment styles as understandable coping
strategies rather than ‘dysfunctions’ and of the impor-
tance of using therapy to reflect upon times when clients’
behaviours are discrepant with underlying attachment
insecurity.
Sharing the Framework with Clients and Colleagues
An attachment framework of mental health was widely
reported to be accessible for clients:
…it’s a very accessible way for people to understand how
childhood experience affects the way they relate to people
in the here and now as an adult… (Therapist I)
Therapists also spoke about educating colleagues about
attachment theory so as to improve their clinical under-
standing and care. Knowing about attachment theory
was said to help staff make sense of client’s behaviour
and of their own emotional response to clients:
…the staff can begin to understand em their own feeling
in relation to those patients… (Therapist J)
Working with Different Attachment Styles
Therapists reported that they found attachment style con-
cepts useful in their work. While some preferred the broad
dimension of security versus insecurity, others preferred
to use more nuanced categories.
Assessing Client Attachment Styles
Formal assessment of attachment style was uncommon in
the sample. Instead, therapists spoke about assessing at-
tachment style ‘loosely’ (Therapist D) or ‘dynamically’
(Therapist E), i.e., from ‘gut feel’ and interpersonal im-
pressions in the client–therapist relationship: ‘you would
pick up a lot just from the way people greet you in the
waiting room’ (Therapist F). Other ways to informally as-
sess client attachment style reported included taking a
Clin. Psychol. Psychother. 23, 142–154 (2016)
148
detailed history of client relationships, especially in early
childhood, and examining case notes, files, letters and
referral information.
One therapist expressed doubts about whether it was
‘clinically wise’ (Therapist G) to formally/psychome
trically assess client attachment style, and doubt was cast
on the usefulness of attachment self-report measures in a
clinical context. However, a different therapist, working
in a long-stay forensic psychiatric hospital, said that for-
mal assessment was important since ‘this impacted on
how the client will behave in relation to staff and it is
therefore helpful to find that out from the get-go’
(Therapist I).
While many of the therapists in the sample were trained
in the AAI, none reported using it regularly because the
work (including transcription) involved is off-putting:
‘just so incredibly time consuming’ (Therapist J).
Nevertheless, the AAI influenced therapists in other ways,
e.g., in how they paid attention to the coherence of client
narratives and in how they looked out for AAI ‘markers’
such as idealization during assessments and in therapy
more generally.
Adapting to Client Attachment Styles
Therapists spoke about the need to adapt themselves to
their clients’ styles both at a micro-level ‘episode by epi-
sode within the therapeutic session’ (Therapist G) and at
a macro-level such as when managing staffing and
caseloads, endeavouring to match clients and therapists
based upon attachment style. Irrespective of their own
attachment style, a therapist’s ability to flexibly respond
to clients was highlighted as key:
…the therapist actually has to be able to be to attune
themselves to the client’s needs […] they have to do the
opposite mirroring… (Therapist B)
For more anxious clients, therapists reported that the fo-
cus is to ‘bring them back into more reflective, cognitive
mode’ (Therapist G). Techniques mentioned to achieve
this included introducing more pauses and structure into
the conversation; drawing causal connections between
events using timelines, family trees and genograms; and
sculpting with objects ‘ways of kind of just slowing the
stuff down’ (Therapist H). For more avoidant clients, the
focus was said to be to ‘introduce affect and emotion’
(Therapist G). Techniques mentioned included the naming
of emotions in the room, the therapist speaking about his
or her own emotions, and re-enactment of scenes from the
client’s past. Therapists spoke about introducing emotions
into the therapy sensitively so that clients are not
overwhelmed: ‘kind of pace that, sort of go gently with
that’ (Therapist H).
Copyright © 2015 John Wiley & Sons, Ltd.
E. Burke et al.
Therapist Attachment Style and Countertransference
Reactions
Therapists reported being mindful of how their own at-
tachment style might influence relationships with clients:
…that feeling that all the person needs is just to be looked
after properly, eh, you know, that’s my attachment,
over-assiduous caring… (Therapist K)
Burnout was spoken about as a risk for therapists with
‘compulsive’ caregiving tendencies. So too was the poten-
tial for therapists to unconsciously present their own at-
tachment style to clients as a ‘healthy way of being in
the world’ (Therapist H). Therapists spoke about how a
client’s attachment style could pull them into behaving
in a way that is complementary, but likely counterproduc-
tive to the goals of therapy, e.g., a therapist becoming
overly dominant when working with anxious clients
‘and sort of completely try to control people’ (Therapist
E). Vigilance is required to recognize these types of coun-
tertransference reactions:
…I really do have to be quite careful about that and I am
careful about that in therapy… (Therapist B)
Undergoing their own therapy was mentioned as a way
therapists could mitigate against unhelpful countertrans-
ference reactions. Some reported having performed the
AAI for themselves; one therapist recommended this as
‘something all therapists could helpfully do’ (Therapist
H).
The Therapeutic Relationship as an Attachment
Relationship
All of the therapists interviewed believed themselves to be
attachment figures for their clients. Some spoke about the
bi-directional nature of this attachment and about how
demonstrating an emotional attachment to the client is
necessary for therapeutic progress:
…if people feel like they’re talking to someone who is not
going to get involved or emotionally attached they won’t
really get anywhere… (Therapist E)
Providing a Secure Base
Providing a secure base for clients was described as a ‘fun-
damental pre-requisite’ (Therapist H) for therapy, en-
abling exploratory work to proceed. Therapists stated
that it was important not to resolve distress precipitated
by this exploratory work on a client’s behalf, but instead
to maintain a secure base by showing the client that they
Clin. Psychol. Psychother. 23, 142–154 (2016)
Attachment Theory in Adult Therapy
are able to tolerate and withstand ‘the very turbulent
feelings within them, the horrible thoughts, the shame’
(Therapist A). The core conditions of psychological
therapy (i.e., good listening skills, empathy, reliability,
consistency and ability to maintain boundaries) were said
to go a long way towards establishing a secure base. Of
these core conditions, reliability and consistency were
highlighted as particularly important:
…reliability, consistency, of me as the therapist and of the
setting and the frame and boundaries… (Therapist B)
The Client–Therapist Attachment as the Active
Ingredient of Change
The therapeutic relationship was spoken about as ‘the
specific factor’ (Therapist E) and the active agent of
change. The therapist’s role is to provide the experience
of a secure attachment relationship:
…you want to give them an alternative experience of
somebody who […] is able to hold them and be with them
and sit with them and not react the way they are used to
being reacted to… (Therapist F)
Irrespective of modality, a secure client–therapist
attachment was said to be critical for therapeutic progress;
specific techniques were ‘in addition’ to this (Therapist J).
By responding to client attachment needs in a sensitive
way, the therapist is ‘undoing damage, emotional damage
[…] so someone can actually develop’ (Therapist E).
Influencing the Different Stages of the Therapeutic
Process
Therapists spoke about how attachment theory influences
them throughout key stages of therapy as outlined next.
Engaging Clients
Therapists reported that clients with poor attachment
histories often have difficulty starting therapy, being
initially ‘quite insecure and uncomfortable’ (Therapist I).
Avoidant clients were described as particularly
challenging to engage, and therapists noted the
importance of not giving up if they failed to show up for
appointments. Therapist K described how, using an
attachment theory perspective, she now felt it appropriate
to ‘actively pursue’ clients who miss appointments,
although she would have considered this ‘a complete
no-no’ when she had previously worked in a
psychoanalytic mode.
Copyright © 2015 John Wiley & Sons, Ltd.
149
Formulating Client Problems
Therapists spoke about how they drew on attachment
theory in formulation, although the extent of its influence
varied. One therapist reported how he would ‘weave in
an awareness’ of attachment theory to a standard
cognitive behavioural therapy (CBT) formulation particu-
larly in relation to how early relationships may be a source
of vulnerability, strength and resilience (Therapist G).
Another spoke about putting attachments at the centre
of formulations:
…I start to formulate now in terms of that person in
relation to their significant others […] and their family
of origin in particular… (Therapist A)
Therapist H described his attachment-influenced
formulation for intergenerational effects:
…look at the parents’ own attachment histories […] and
what they brought to their couples’ relationship and then
what they brought to their parenting… (Therapist H)
Dealing with Boundaries
While some therapists preferred firm boundaries, others
said flexibility was necessary to make progress: ‘you don’t
try to be rigid and stiff’ (Therapist E). A number of
therapists outlined the need to be emotionally responsive
and relate to clients on a human level. Human warmth is
a therapeutic tool, which needs to be used judiciously:
‘in quite a deliberate, careful, attuned way and a
measured way and considered way’ (Therapist B). It was
acknowledged that emotional over-involvement has the
potential to negatively impact clients with attachment
difficulties:
…in the early days I certainly fell into that of getting too
you know too involved and not being aware of how
sensitive patients’ attachment processes were and I, I
think to their detriment unfortunately… (Therapist K)
Breaks and Endings
Therapists reported paying close attention to breaks and
endings, using them as an opportunity to explore clients’
current feelings about separation and linking this with
their history:
…try to link it to the fact that I’m going to be gone and
what that is like for them and what experience they have
in the past of people disappearing and maybe not coming
back or any fears they might have and bring it into
consciousness… (Therapist F)
Clin. Psychol. Psychother. 23, 142–154 (2016)
150
They described making efforts to manage breaks sensi-
tively, such as by informing clients of their holiday leave
well in advance. Therapist D described his use of the
telephone to ‘top up’ one client who lived remotely and
to ensure another client was managing anxiety in between
sessions:
…I don’t allow people to have the white knuckle
experience of the separation and the fear you know…
(Therapist D)
Therapists reported spending a significant amount of
time preparing clients for the end of therapy ‘so they feel
that they’re not being abandoned’ (Therapist J). Therapist
E was critical of brief therapy models, which set an end
date in advance since he felt this resulted in insecurely
attached clients not participating fully in therapy because
‘they’re protecting themselves from the ending before
they even start’ and instead advocated working open-
endedly and allowing clients to decide when to end
therapy. Endings can be managed successfully by helping
clients to build secure attachments outside of the thera-
peutic relationship: ‘one’s hope is that you promote their
capacity to form other attachments outside of therapy’
(Therapist E). One therapist said that he ‘put a session in
the bank’ (Therapist H) so that clients are reassured they
can come back again in the future if needed.
Evaluating Outcomes
Although many of the therapists in the sample spoke
about keeping attachment theory in mind when evaluat-
ing client progress, none formally measured attachment
status post-therapy. Therapist A said that an attachment-
informed approach meant his evaluations extended ‘much
more widely […] looking beyond the kind of self-report
measures’. Others said that changes in clients’ relation-
ships, including the client–therapist relationship, were
useful in evaluating client progress. Functional outcomes
at work and home were also cited: if clients are ‘managing
to stay at work without falling out with everybody’ or if
they are ‘managing their children differently’ (Therapist
K). Therapist E noted that ‘the re-referrals show you that
anyway’, namely that if attachment problems are resolved
through therapy, clients should not need to return for fur-
ther help.
Clinical Service Design and Delivery
Therapists described how attachment theory influences
the design and delivery of clinical services. Reference
was made to service culture; a therapist working in a
MBT-oriented service described how a systemic focus on
mentalization and attachment influences clinical culture:
Copyright © 2015 John Wiley & Sons, Ltd.
E. Burke et al.
…we would be talking to each other using that kind of
conceptual framework and things like are they
mentalizing? not mentalizing? what’s happening to the
attachment?… (Therapist K)
Therapists were critical of services that were ‘attach-
ment blind’, resulting in the design of ‘very unhealthy sys-
tems’ (Therapist E). Insensitive discharge practices, the
frequent rotation of staff and the closure of day hospitals
were used to illustrate how the principles of attachment
theory are commonly ignored within mental health ser-
vices to the detriment of clients.
DISCUSSION
Our findings build on previous research as this is the first
qualitative study to directly explore and provide a poten-
tial theory of how attachment theory can be applied by
therapists working with adult clients (Table 2). The prac-
tice and views of the therapists varied, although there
was agreement on some key areas. Our findings suggest
that attachment theory can complement therapeutic work,
irrespective of the therapist’s main modality. It can pro-
vide therapists with a clinically useful framework to un-
derstand and approach a range of different clients’
problems across the different stages of therapy. Notably,
participants highlighted the importance of the client–
therapist attachment and reported that a key goal was to
establish a secure base within this relationship in order
to facilitate therapeutic change.
All therapists in this study used attachment theory in
addition to other theories and therapeutic approaches.
This finding is in line with a perspective on attachment
theory as one that informs rather than defines clinical in-
tervention and that can be drawn upon by therapists irre-
spective of their theoretical orientation (Slade, 2008).
Using Obegi and Berant’s (2009) typology, it may be said
that these therapists are ‘attachment informed’, rather
than an ‘attachment based’ in their practice. In describing
attachment-informed therapy as a bridge between psy-
choanalytic and cognitive–behavioural approaches, the
therapists in this study are in accord with key authors in
the field (Allen, 2008; Holmes, 1994, 2010; Shaver &
Mikulincer, 2005).
Almost all of the therapists self-identified as having a
psychodynamic or psychoanalytic orientation and were
trained in this approach. Given Bowlby’s roots in psycho-
analysis, perhaps there is a natural affiliation with attach-
ment theory, although it has been noted that there is ‘bad
blood’ between the two theories (Fonagy, 2001). Thera-
pists spoke about how psychoanalytic theory could be
regarded with suspicion within services, whereas attach-
ment theory was more accessible. It is important to high-
light that the majority of the therapists in the sample
Clin. Psychol. Psychother. 23, 142–154 (2016)
Attachment Theory in Adult Therapy
work in the National Health Service (NHS) in the UK and
therefore the culture and policies within this system likely
influence their perspectives. Currently, CBT is recom-
mended as the first-line psychological intervention for
most adult mental health problems in the NHS in accor-
dance with guidance issued by the National Institute for
Health and Clinical Excellence. It may be that attachment-
informed approaches are a way for psychodynamic think-
ing to retain a foothold within CBT-oriented services and
that this may be of particular appeal to this sample.
Whether there are differences between psychodynamically
oriented and non-psychodynamically oriented therapists
in motivations to apply attachment theory to practice and
how they do this is also an important area for further re-
search. Therapists in this sample with different theoretical
backgrounds expressed similar themes, suggesting that mo-
tivations and practice are similar across different modalities.
These issues aside, the strong emphasis on evidence-based
practice within public health services highlights the impor-
tance of developing a solid evidence base for attachment-
informed approaches. Therapists practising privately are
likely to have more flexibility.
Therapists in this study reported that they adopted at-
tachment theory as a framework to understand the psycho-
logical well-being of all of their clients, regardless of
attachment style or diagnosis. This is consistent with the
body of literature linking insecure attachment with a range
of psychological problems. Four of the 12 therapists were
trained in MBT, an intervention that has shown promise in
demonstrating that personality disorder can be successfully
treated through psychological intervention. Therapists
spoke about the potential for an attachment-informed
framework of mental health to encourage psychological in-
tervention with individuals who experience psychosis, an-
other client group who faces barriers to accessing
evidence-based psychological treatment in public mental
health services (Berry & Haddock, 2008). In this way, the ev-
idence and insights offered by attachment theory may help
to open up psychotherapy to a wider range of clients and to
those with more challenging mental health problems. This
is timely given recommendations issued by the World
Health Organization and commitments made by govern-
ments such as the UK for psychological therapies to be of-
fered to people with ‘severe and enduring’ mental health
problems (Department of Health, 2011; WHO, 2010).
Consistent with the views of Bowlby and others
(e.g., Wallin, 2007), therapists in this study described the
client–therapist relationship as an attachment relationship
whose function is to provide a secure base and corrective
experience that foster psychological development (Bowlby,
1977). A recent review found empirical evidence of positive
changes in attachment styles or patterns following range of
different types of psychotherapy (Taylor, Reitzschel,
Danquah & Berry, 2014). However, the active ingredients
of therapy that leads to change still need to be identified.
Copyright © 2015 John Wiley & Sons, Ltd.
151
In the main, therapists rejected a fixed approach to
measurement. Consistent with existing descriptions of
practice, formal assessment of attachment style was un-
common, and therapists relied instead on history-taking
and clinical judgement (Harris, 2004; Shilkret, 2005).
Therapists’ reluctance to formally assess attachment
style related in part to concerns about these being
interpreted in a reductive way. Such concerns have been
criticized as counterproductive by those who feel that
assessment captures clinically significant information
(Slade 2008). The reliance on informal methods of
assessment raises concerns about reliability, especially if
there is then a significant influence on the direction of
treatment.
Adapting clinical approaches and interpersonal styles to
suit client attachments was a key theme identified in this
study. This was reported to require flexibility from thera-
pists across the different stages of therapy, from engaging
clients through to managing endings. Therapists de-
scribed using different techniques depending on client at-
tachment style; notably, they spoke about employing
cognitive techniques with anxious clients while focusing
more on emotions when working with avoidant clients.
It has previously been reported that cognitive therapies
are best suited to anxious clients because they are thought
to deactivate arousal (Daniel, 2006; Purnell, 2010), while
avoidant clients have better outcomes than anxious clients
in more emotionally focussed psychodynamic therapy
(Fonagy et al., 1996). Responding to the attachment needs
of clients is consistent with Bowlby’s (1988) assertion that
effective therapists are those who can flexibly adopt a
stance that is in contrast to the client’s. It also lends sup-
port to models that propose that change occurs through
the regulation of therapeutic distance between client and
therapist (Daly & Mallinckrodt, 2009). Further, context-
sensitive research that details change processes such as
therapist adaptability and therapeutic distance is required
in order to delineate the active ingredients of change
within therapy.
Sensitivity to the attachment needs of adult clients is
required not only from individual therapists but also from
the wider adult mental health system. Reports were given
of services run in a manner contrary to the attachment
needs of clients. Commitment to attachment theory as a
guiding principle in services would demand significant
changes to cultures, structures and systems, for example,
revisiting policies on the closure of day hospitals,
decreasing the reliance on temporary staffing and
increasing investment in psychological therapies. Such
changes are likely to be hugely challenging, although
increasing interest in attachment theory may help to push
the agenda for change. Recent evidence that people with
insecure attachment use services more and incur higher
costs also provides economic support for this argument
(Berry, Roberts, Danquah & Davies, 2014).
Clin. Psychol. Psychother. 23, 142–154 (2016)
152 E. Burke et al.

Limitations of the Research CONCLUSIONS

As a developmental theory, attachment theory has much
The study has a number of limitations. It is the first work of
to offer therapists in understanding the development of
its kind in the area and employed a small sample of thera-
mental health problems. Evidence for the links between
pists all of whom had a stated interest in attachment theory.
attachment insecurity and mental health difficulties in
It could be argued that this resulted in a bias towards a pos-
adulthood strengthens the rationale for its application to
itive description of how the theory applies to clinical prac-
psychological therapy with adults. As a relational theory,
tice and an over-estimation of its influence. However,
it has much to offer therapists in understanding the
given that the aim of the study was to identify how attach-
therapeutic relationship and therapeutic process. Results
ment theory is currently being used in adult therapy and to
of this study propose that attachment theory can usefully
provide a guide for other practitioners who wish to incorpo-
inform therapists in their work with adults irrespective of
rate the theory in their practice, it was necessary to explore
therapists’ theoretical orientation and of clients’ attach-
this in a sample of therapists with an interest in the theory.
ment patterns or diagnoses. Nevertheless, results are
Future research might examine the limitations of
drawn from a relatively small and homogenous sample
attachment-informed therapies and ways in which the
and should be explored among therapists with more
theory may be less useful relative to other approaches.
diverse theoretical backgrounds. Further empirical work
The sampling strategy may have resulted in a bias to-
is needed to explore change processes in therapy,
wards academically oriented participants whose inter-
particularly concerning attachment security in the
view data may reflect theory more than practice. This
client–therapist relationship.
could be argued to account for what appears to be a high
concordance between the themes identified in the data
and previous findings in the literature. Nevertheless, all Appendix 1: Final version of the interview topic
of the participants were in active clinical practice at the guide
time of interview, and not all of the authors had published
on attachment theory. Similarities between the themes How does attachment theory influence your therapeutic
identified in this study and previous work may be due work with adults?
to the authors’ prior exposure to the literature. In a full If not spontaneously mentioned, ask the following:
grounded theory study, researchers should avoid reading How does attachment theory influence your:
previous work in the field so as to ensure their analysis re-
flect solely their own data, although others argue that this • Assessment
is impractical (Charmaz, 2006). While the authors
attempted to be reflexive about the assumptions brought ○ Do you attempt to classify clients’ attachment styles?
to data collection and analysis, it cannot be ruled out that How?
prior exposure to the literature influenced results. Validity ○ Do you find attachment styles useful in your work?
checks of codes and themes were conducted by the re- How so?
search team members and by a peer researcher, and it is ○ What are the challenges in working with clients with
hoped that these went some way to minimize this. the different styles?
Although all interviews took place by telephone, the loca-
tion of interviews was not consistent and responses may po- • Formulations
tentially been influenced by this. Since E. B., who conducted • Evaluation
the interviews, was not a trained therapist, her ability to dis-
cuss therapeutic processes in depth with participants may Do you believe you as therapists are an attachment fig-
have been limited. Participants may also have responded ure for your clients? How so?
differently to her as a student, rather than as a colleague. Do you think about the idea of ‘secure base’? How do
This may have compromised the richness of the data col- you create a ‘secure base’ in therapy?
lected. This was addressed at the end of each interview by Is there anything else you would like to say or add to
offering participants the opportunity to speak about areas our discussion about how attachment theory influences
that may have not been addressed. Additionally, each your work?
participant was given the chance to check a verbatim
transcript of their interview, which provided them with
the opportunity to expand upon points raised in interviews
if they felt these had not been explored in sufficient depth.
ACKNOWLEDGEMENT
The use of a peer researcher with similar academic
experience and training to ‘sense check’ themes might also The authors wish to thank Karolina Szpak for her input in
be said to enhance the reliability of the analysis. reviewing data coding and themes.

Copyright © 2015 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 23, 142–154 (2016)
Attachment Theory in Adult Therapy
REFERENCES
Allen, J. G. (2008). Mentalizing as a conceptual bridge from
psychodynamic to cognitive–behavioural therapies. European
Psychotherapy, 8, 103–121.
Bateman, A. W., & Fonagy, P. (2003). The development of an
attachment-based treatment program for borderline
personality disorder. Bulletin of the Menninger Clinic, 67(3),
187–211. DOI: 10.1521/bumc.67.3.187.23439
Berry, K., Roberts, N., Danquah, A., Davies, L. (2014). An
exploratory study of associations between adult attachment,
health service utilisation and health service costs. Psychosis.
DOI: 10.1080/17522439.2014.899386
Berry, K., Danquah, A. & Wallin, Introduction. In Danquah, A. &
Berry, K. (Eds.). (2013). Attachment theory and adult mental
health: A clinical guide. London: Routledge.
Berry, K., Barrowclough, C., & Wearden, A. (2008). Attachment
theory: A framework for understanding symptoms and
interpersonal relationships in psychosis. Behaviour Research
and Therapy, 46(12), 1275–82. DOI: 10.1016/j.brat.2008.08.009
Berry, K. & Haddock, G. (2008). The implementation of the NICE
guidelines for schizophrenia: Barriers to the implementation of
psychological interventions and recommendations for the
future. Psychology and Psychotherapy: Theory, Research and
Practice, 81, 419–436. DOI: 10.1348/147608308X329540
Bifulco, A., Moran, P. M., Ball, C., & Bernazzani, O. (2002). Adult
attachment style. I: Its relationship to clinical depression. Social
Psychiatry and Psychiatric Epidemiology, 37(2), 50–59. DOI:
10.1007/s127-002-8215-0
Bowlby, J. (1969). Attachment and loss volume 1: Attachment. Lon-
don: Hogarth Press.
Bowlby, J. (1977). The making and breaking of affectional bonds
II. Some principles of psychotherapy. The Fiftieth Maudsley
Lecture (expanded version). British Journal of Psychiatry, 130,
421–431. DOI: 10.1192/bjp.130.5.421
Bowlby, J. (1988). A secure base: Parent–child attachment and healthy
human development. London: Routledge.
Brennan, K. & Shaver, P. (1998) Attachment styles and
personality disorders: Their connections to each other and to
parental divorce, parental death, and perceptions of parental
caregiving. Journal of Personality, 66, 835–878. DOI: 10.1111/
1467-6494.00034
Broberg, A.G., Hjalmers, I., & Nevonen, L. (2001). Eating
disorders, attachment and interpersonal difficulties: A
comparison between 18- to 24-year-old patients and normal
controls. European Eating Disorders Review, 9, 381–396. DOI:
10.1002/erv.421
Charmaz, K. (2006). Constructing grounded theory: A practical guide
through qualitative analysis. London: Sage.
Dallos, R. (2006). Attachment narrative therapy: Integrating systemic,
narrative and attachment approaches. Maidenhead, UK: Open
University Press.
Daly, K. D., & Mallinckrodt, B. (2009). Experienced therapists’
approach to psychotherapy for adults with attachment
avoidance or attachment anxiety. Journal of Counseling
Psychology, 56(4), 549–563. DOI: 10.1037/a0016695
Daniel, S. I. F. (2006). Adult attachment styles and individual
psychotherapy: A review. Clinical Psychology Review, 26,
968–984. DOI: 10.1016/j.cpr.2006.02.001
Department of Health (2011). Talking therapies: A four year plan
of action. A supporting document to No Health Without
Mental Health: A cross-governmental mental health care
strategy for people of all ages (Product No. 402471b). Retrieved
Copyright © 2015 John Wiley & Sons, Ltd.
153
from http://www.dh.gov.uk/en/Publicationsandstatistics/
Publications/PublicationsPolicyAndGuidance/DH_123759
Diener, M. J., & Monroe, J. M. (2011). The relationship between
adult attachment style and therapeutic alliance in individual
psychotherapy: A meta-analytic review. Psychotherapy, 48(3),
237–248. DOI: 10.1037/10022425
Dieperink, M., Leskela, J., Thuras, P., & Engdahl, B. (2001).
Attachment style classification and posttraumatic stress
disorder in former prisoners of war. American Journal of
Orthopsychiatry, 71(3), 374-378. DOI: 10.1037/0002-9432.71.3.374
Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving
guidelines for publication of qualitative research studies in
psychology and related fields. British Journal of Clinical
Psychology, 38(3), 215–229. DOI: 10.1348/014466599162782
Fonagy, P. (2001). Attachment theory and psychoanalysis. New
York: Other Press.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon,
G., et al. (1996). The relation of attachment status, psychiatric
classification, and response to psychotherapy. Journal of
Consulting and Clinical Psychology, 64, 22–31. Retrieved from
http://www.apa.org/pubs/journals/ccp/index.aspx
George, C., Kaplan, N., & Main, M. (1985). Adult attachment
interview (Unpublished manuscript). Berkeley, CA: University
of California.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded the-
ory: Strategies for qualitative research. New York: Aldine.
Harris, T. (2004). Implications of attachment theory for working
in psychoanalytic psychotherapy. International Forum of Psycho-
analysis, 13(3), 147–156. DOI: 10.1080/08037060410018462
Hesse, E., & Main, M. (2000). Disorganized infant, child, and
adult attachment: Collapse in behavioral and attentional strat-
egies. Journal of the American Psychoanalytic Association, 48(4),
1097–127. DOI: 10.1177/00030651000480041101
Holmes, J. (1994). Bowlby—A reappraisal. The Clinical implica-
tions of attachment theory. British Journal of Psychotherapy, 11
(1), 62–76. DOI: 10.1111/j.1752-0118.1994.tb00702.x
Holmes, J. (2001). The search for the secure base: Attachment theory
and psychotherapy. London: Routledge.
Holmes, J. (2010). Exploring in security: Towards an attachment-
informed psychoanalytic psychotherapy. East Sussex: Routledge.
Janzen, J., Fitzpatrick, M., & Drapeau, M. (2008). Processes
involved in client-nominated relationship building incidents:
Client attachment, attachment to therapist, and session impact.
Psychotherapy: Theory, Research, Practice and Training, 45(3),
377–390. 10.1037/a0013310
Levy, K.N., Ellison, W.D., Scott, L.N., & Bernecker, S.L. (2011).
Attachment style. Journal of Clinical Psychology, 67(2), 193–203.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic Inquiry. London:
Sage.
Mallinckrodt, B. (2010). The psychotherapy relationship as attach-
ment: Evidence and implications. Journal of Social and Personal Re-
lationships, 27(2), 262–270. DOI: 10.1177/0265407509360905
Mallinckrodt, B., Gantt, D. L., & Coble, H. M. (1995). Attachment
styles in the psychotherapy relationship: Development of the
Client Attachment to Therapist Scale. Journal of Counseling
Psychology, 42(3), 307–317. DOI: 10.1037//0022-0167.42.3.307
Mikulincer, M., & Shaver, P. R. (2007). Boosting attachment
security to promote mental health, prosocial values, and
inter-group tolerance. Psychological Inquiry, 18(3), 139–156.
DOI: 10.1080/10478400701512646
Mikulincer, M., Shaver, P. R., & Berant, E. (2013). An attachment
perspective on therapeutic process and outcomes. Journal of
Personality. DOI: 10.1111/j.1467-6494.2012.00806.x
Clin. Psychol. Psychother. 23, 142–154 (2016)
154
Obegi, J., & Berant, E. (2009). Attachment theory and research in
clinical work with adults. New York: Guilford.
Purnell, C. (2010). Childhood trauma and adult attachment.
Healthcare Counselling and Psychotherapy Journal, 10(2).
Retrieved from http://www.bacp.co.uk/advertising/divi-
sional%20journals/hcpj.php
Ryle, A. (1990). Cognitive analytic therapy: Active participation in
change. Chichester: Wiley.
Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and
research: Resurrection of the psychodynamic approach to
personality. Journal of Research in Personality, 39(1), 22–45.
DOI: 10.1016/j.jrp.2004.09.002
Shilkret, C. J. (2005). Some clinical applications of attachment
theory in adult psychotherapy. Clinical Social Work Journal,
33(1), 55–68. DOI: 10.1007/s10615-005-2619-z
Slade, A. (2008). The implications of attachment theory and
research for adult psychotherapy: Research and clinical
Copyright © 2015 John Wiley & Sons, Ltd.
E. Burke et al.
perspectives. In J. Cassidy & P. Shaver (Eds.). Handbook of
attachment: Theory, research, and clinical applications (2nd ed.).
New York: Guilford.
Taylor, P., Rietzschel, J., Danquah, A., & Berry, K. (2014). Changes
in attachment representations during psychological therapy.
Psychotherapy Research. DOI: 10.1080/10503307.2014.886791
Wallin, D. (2007). Attachment in psychotherapy. New York: Guilford.
Warren, S. L., Huston, L., Egeland, B., & Sroufe, L. A. (1997).
Child and adolescent anxiety disorders and early attachment.
Journal of the American Academy of Child and Adolescent
Psychiatry, 36(5), 637–44. DOI: 10.1097/00004583-199705000-
00014
World Health Organisation (2010). Mental Health Gap Action
Programme Intervention Guide for mental, neurological and
substance use disorders in non-specialized health settings.
Retrieved from http://www.who.int/mental_health/publica-
tions/mhGAP_intervention_guide/en/index.html
Clin. Psychol. Psychother. 23, 142–154 (2016)
Copyright of Clinical Psychology & Psychotherapy is the property of John Wiley & Sons,
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.