Attachment Disturbances: Major Breakthrough in Treatment
Book Review on “Attachment Disturbances in Adults: Treatment for Comprehensive Repair”
By Daniel P. Brown and David S. Elliott
Over the course of the past year, Norton Publishing has asked me to review several books for them and I have done so with great honor and pleasure. However, this book was slightly different.
Before I go into the background of how I came to review this book, I am going to present the conclusion: This book is a major breakthrough in treatment. It should be required reading by every mental health clinician and provider as a basis of treatment. If it was, we would have more positive treatment results for a wide variety of mental health issues.
Book Review Background
Now I will go into the background about reviewing this book, and then provide you with an in-depth over-view of one of the most significant books to have been written in decades. I first met Dr. Daniel Brown over 40 years ago. He was among several people: Erika Fromm, Elgan Baker, Cory Hammond and Eugene Isotti, who provided me with extensive training in the field of hypnosis. In 1987, several of my hypnosis scripts were published in Cory Hammond’s book: “Hypnotic Suggestion and Metaphor.”
After my stroke/auto accident (see my story) in 1997 I had to prove to the license board that I was able to continue in my field, and I was required to have supervision. Dr. Daniel Brown was one of two supervisors for me, for which I will always be grateful. Since that time, I have taken several more courses and continued our relationship. This past July there was another continuing education course down on Cape Cod. When I saw Dr. Brown was offering one, I quickly registered for it. The week long course was an in-depth overview of the 20 years of research in Attachment Disturbances in adults. When he told me that his new book was being published by Norton Publishing, I asked his permission to review it and present it to you. With Dr. Brown’s blessings, I am honored to present to you, as mentioned above, a major breakthrough in treatment for Attachment Disturbances.
Lay out of Book
The book is divided into 7 separate and distinct parts:
1) An in-depth and comprehensive background on the theory of attachment issues.
2) Assessment methods used for classifying the 4 main forms of attachment issues.
3) An in-depth and comprehensive background on a multitude of treatment approaches for attachment issues, Post Traumatic Stress Disorder (PTSD), and complex trauma.
4) An in-depth and comprehensive understanding of how the various types of attachment issues relate to specific mental health issues, such as somatic disorders, Borderline Personality Disorder (BPD) or Dissociation Identity Disorder (DID). Also an explanation of how the type of attachment issue relates to one’s ability to cope with various forms of trauma and abuse.
5) An in-depth and comprehensive understanding of their 3 Pillar Approach of treatment for Attachment Disturbances.
6) Step by step methods of using the 3 Pillar Approach for each type of attachment issue.
7) Step by step, in-depth methods for self-identity, relationships with others, and enhancing romantic intimacy.
No book that I have ever read has been this comprehensive with research and concise explanation, while also providing step-by-step methods for specific treatment.
I can say this with over 40 years of extensive training in trauma, hypnosis, child development and 7 years of training in personality disorders with the Masterson Institute. The interesting part about reviewing this book was that in the portion devoted to the background research in Attachment Disturbances and treatment methods, I have had the honor and privilege of knowing and being trained by many of the noted authors, such as Dr. Elgan Baker, Dr. Jerome Kagan and Dr. Bessil van der Kolk.
Research and Background on Attachment
Dr. Brown and Dr. Elliott and their contributing colleagues:
Paula Morgan-Johnson, LICSW
Paula Sacks, LICSW
Caroline R. Baltzer, Ph.D.
James Hickey, Psy.D.
Andrea Cole, Ph.D.
Jan Bloom, Ph.D.
Deidre Fay, LICSW
have provided a comprehensive, step by step review of the literature and cross-cultural research on this topic. They begin with the history of attachment, how it develops in key developmental stages from infancy to teenage years, the role of the caregiver, and the key figures of the field, John Bowlby and Mary Ainsworth. In the history portion, there is a clear and concise explanation of secure attachment and disorganized attachment. In addition, they provide information about The Dynamic-Maturational Model of Attachment, as well as the generational model of how attachment issues are passed down through one generation to another.
In this section of the book, there is extensive research into the concept of internal representation, object relations (introduced by Margaret Mahler), and self-regulation. From this background information emerges a precise understanding of attachment and the emerging self.
This book provides you with 4 distinct categories of Adult Attachment Types:
1) Secure Attachment
2) Dismissing Attachment
3) Anxious Attachment
4) Disorganized Attachment
Dr. Brown and Dr. Elliott provide in-depth research studies for each of the above types, along with the work of Mary Ainsworth in the method of Assessment of Attachment of the Strange Situation procedure.
There is also an overview of the Adult Attachment Interview (AAI) and how this is a valuable tool in assessing attachment issues and classifying specific types.
Many theories are based on genetics, trauma, and environment, but miss the core factor: that developing a secure attachment is essential for coping with life. My training in developmental psychology with Jerry Kagan at Tufts University did emphasize heritage and genetics, and I do believe there are hearty people, reactive and sensitive people. However, how the caregiver interacts with the various types eventually can produce any of the Four Attachment. Therefore, even if a child is reactive or has certain developmental issues, it is how the caregiver interacts with that child and how the attachment is formulated.
Attachment and Psychopathology
This section of the book covers extensive research into the following psychopathology as it relates to attachment issues:
1) Attachment: Emotional, Distress, and Psychiatric Distress
A) Attachment and Anxiety Disorder
B) Attachment and Affective Disorder
C) Attachment and Bipolar Disorder- this includes Schizophrenia
2) Attachment and Somatic Symptoms Disorders, Factitious Disorders and Malingering.
A) Somatic Disorders
B) Factitious Disorders
C) Malingering Disorders
3) Traumatic -Related Disorder
A) Attachment and Dissociative Disorders
B) Depersonalization/Derealization Disorder (DRD)
C) Dissociative Identity Disorder (DID)
4) Attachment and Addictions
A) Alcoholism and Substance Abuse
B) Eating Disorders
5) Attachment and Personality Disorders
A) Borderline Personality Disorder (BPD)
B) Conduct Disorder and Antisocial Personality
Finishing this section of the book is probably one of most disturbing research studies; The Orphanage Study: Attachment and Complex Trauma. This study clearly shows how the various attachment types effected how the children coped with severe trauma by priests that were child abusers and were sent to manage this orphanage in New Orleans. To read that innocent children were put into this orphanage because of domestic abuse and violence, only to have caregivers that were child abusers, is beyond criminal.
Being a trauma specialist in the Boston area, I have treated many individuals who were sexually abused by priests. The movie “Spotlight” was a sharp view of this crisis. Dr. Brown presented this information at the course I took with him on the Cape, yet reading the research and the in-depth accounts brought up intense emotions. It was clear that the attachment type was a defining indication of how the children coped with such severe trauma.
Treatment of Attachment Disturbances
The best part about this section is that it presents each treatment with the honor and dignity that it deserves. It starts with Bowbly’s attachment-based psychotherapy, and then moves to psychoanalytic approaches.
Other approaches include attachment based psychotherapy, dynamics-maturational model integrative treatment, and targeting dysfunctional attachment representation and internal working models. The latter approach deals with working independently of transference.
As mentioned above, I am honored to have studied with many of the authors mentioned in the various approaches, including Elgan Baker. His approach works with the imagery of the good enough therapist with the patient.
The work of Bowbly, Ainsworth, and Mahler has been the base of attachment theory and treatment approaches. The focus of the therapeutic alliance and soothing holding environment has been stable in treatment. For over seven years I was a teacher in the area of special needs. Thus, I come from a teaching coaching model that always embraced a collaborative approach to therapy, which is one of the pillars of Dr. Brown and Dr. Elliott’s treatment methods.
This book provides an in-depth explanation of newer forms of attachment-informed treatment, such as schema therapy for patients with personality disorders, whereas other books have omitted to only promote their own theory or approaches. Another newer method is Accelerated Experiential Dynamics Psychotherapy (AEDP), developed by Diana Fosha.
Along with these approaches, there is Intersubjective-based Treatment; exploratory psychotherapy that is an extension of Bowbly’s work on exploration.
In addition to these methods are the following:
- Metacognitive attachment-informed psychotherapies, which include Mentalization Based Treatment (MBT), the modular approach to metacognitive development.
- Beyond mentalizing and the representational self is Mindfulness and transcendence of self. From this approach evolved a Consensus -Based Model for Attachment Treatment. This was developed by Brent Mallinchrodt in 2009.
From these various methods emerged the comprehensive treatment of Attachment Disturbances developed by Dr. Brown and Dr. Elliott, entitled the Three Pillars. The next part of the their book focuses on the explanation of the Three Pillars, then a comprehensive, step-by-step explanation of how to use this treatment approach with each attachment type.
Three Pillars of Comprehensive Attachment Treatment
The three pillars include the following:
- Pillar 1: The Ideal Parent Figure (IPF) Protocol.
- Pillar 2: Fostering a range of Metacognitive Skills.
- Pillar 3: Fostering collaborative nonverbal and verbal behavior.
The first pillar, involving the ideal parent figure, includes the following essentials:
1) Felt secure/protection
2) Feeling seen and known/attunement
3) Felt comfort/soothing and reassurance
4) Feeling valued/expressed delight
5) Felt support for best self/unconditional support and encouragement
All of these are included in an attachment-based imagery over the course of treatment.
The second pillar fosters a range of metacognitive skills such as the following:
1) Being aware of yourself; the sense of self and of others.
2) Monitoring the accuracy of your state of mind.
3) Recognizing how the past has shaped the present and your own experience.
4) Taking a wider perspective of yourself and your life.
5) Recognition of interdependence.
There are many more aspects of this pillar that authors provide to you.
The third pillar integrates the previous two pillars into collaborative imagery and metacognitive development.
The following chapters provide a step by step approach, along with actual transcripts of sessions to show the reader how to use the Three Pillars with each specific attachment type. There are over 400 pages of information providing the novice to the seasoned mental health clinician with valuable information and training.
What is unique about this book is that even though it is clearly designed for the education of a mental health provider, a person with attachment issues can also benefit from the information in this book.
When I shared the information in this book with my own patients who are dealing with severe trauma, it was quite validating. They too realized that the trauma was only secondary to their attachment issues, and were eager to work with the Three Pillar approach. They have found this approach extremely beneficial to them.
If you are a mental health provider or a person struggling in your own therapy, my analogy is that you cannot fix the upstairs until you fix the foundation of the house, which is the core attachment issue. This book provides the history of attachment and its various therapies, as well as a new revolutionary and comprehensive Three Pillar approach that will change your life and allow the healing to occur.
On the outer cover of the book are reviews of the book stating: “This is extraordinary achievement,” “a book of genius,” “incredibly important volume that makes a stunning contribution to the field.” I totally agree.
This book is a must read!
Copyright© Dr. Diane Roberts Stoler, E.D. 2016