What Is Attachment Therapy, And How Does It Work?

By ReGain Editorial Team|Updated April 28, 2022
CheckedMedically Reviewed By Lauren Guilbeault, LMHC

Attachment therapy is a unique therapeutic approach that focuses on thoughts, feelings, behaviors, and interpersonal communication. According to the American Psychological Association, it can help people learn how to express emotions and satisfy impulses in more socially acceptable ways.

Individuals who benefit most from attachment-based therapies are those who have been conditioned to suppress, avoid, or amplify their perspectives. For many, the approach is successful at developing better coping skills and behavior patterns. However, attachment therapy is not a cure-all. Additionally, more research is needed and there’s much controversy surrounding its efficacy compared to other approaches.

What Is Attachment Therapy?

The concise, process-oriented approach that is attachment therapy has transformed individual and family counseling. It’s a therapeutic technique that involves building patient-therapist relationships based on establishing trust and expressing emotions. Therapists thereby examine the connections between each patient’s early childhood experience and their adult persona.

Unpacking the relationship dynamics with caregivers can further help psychologists define and diagnose underlying mental health conditions. Thus, attachment-based therapies aim to construct more support bonds with loved ones despite trauma, neglect, or abuse. The result can include a measurable reduction in depression and anxiety symptoms.

Attachment therapy often focuses on children and adolescents, namely those diagnosed with reactive attachment disorder (RAD). The goal is to provide a safe space for patients to express contempt and rage for the mistreatment in their formative years. This technique can help purge pent-up emotions to reduce confusion, manage impulsive outbursts, and adapt to healthier lifestyles.

It’s important to note, again, that significantly more research is needed on attachment-based therapy methods. In particular, while emotion-based attachment therapies have shown promising and positive results, other attachment therapies like rebirthing therapy and holding therapy can be incredibly dangerous and are very controversial. We’ll explore those specific therapies more in-depth later on in the article.

NOTE: Attachment therapy is commonly used to help children adjust after an adoption or forced separation from their families.

What Is Reactive Attachment Disorder (RAD)?

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Reactive Attachment Disorder, or RAD, is a rare but severe mental health condition. It can arise when an infant or young child doesn’t get the mental, physical, and/or emotional support required for healthy development. The diagnosis involves symptoms of detachment from parents and other caregivers.

RAD is most commonly diagnosed in children and adolescents whose basic needs were frequently neglected. Essentially, their proverbial bowl for comfort, affection, and nurturing was left empty. Due to this, they can struggle to form meaningful, caring, and stable relationships with others as they progress into adulthood. 

Further, children and adolescents diagnosed with reactive attachment disorder may throw tantrums, try to manipulate people, act defiantly, and become argumentative. However, targeted treatment can help. The best treatments for RAD generally include:

  • Individual counseling
  • Family therapies
  • Psychological education
  • Positive interaction training
  • Environmental adjustments

The key to treating reactive attachment disorder is developing a stable, nurturing environment. However, some underlying mental health conditions may need to be addressed before RAD-centered therapies can work. Therefore, emotion-based attachment therapy is often used as a precursor for reactive attachment disorder therapy.  

Diagnosis And Treatment By Attachment Therapists

Treatment in attachment therapy starts with assessment. Patients must be diagnosed with reactive attachment disorder (RAD) and must show severe emotional disturbance. Often, the level of emotional trauma is measured using the Randolph Attachment Disorder Questionnaire.

The Randolph Attachment Disorder Questionnaire (RADQ) is designed to help therapists diagnose attachment disorders earlier. However, it may also be useful in determining conduct disorder, oppositional defiant disorder (ODD), and antisocial behavior disorder. It’s important to note that the RADQ was proven valid in most case studies but did not meet certain research standards to be included in the DSM-IV.

Thus, attachment disorders are more commonly diagnosed through a combination of tests and therapies. Two of the most controversial attachment therapy techniques are called “holding” and “rebirthing.” Neither of these are backed by research, both are incredibly controversial, and both can be dangerous. In fact, rebirthing therapy has resulted in multiple child deaths and has been made illegal in some locations. Here’s a brief overview of them both:

Holding Therapy

This approach involves restricting the patient’s movements to trigger fits of rage. The theory (again, not backed by research) is that this essentially opens a portal into the patient’s mind, allowing them to process thoughts and emotions in real-time. However, it’s controversial because intense cases may involve more invasive tactics, such as:

  • Shouting obscenities
  • Grabbing or groping
  • Shaking or pushing
  • Insulting or belittling
  • Threats of abandonment

Because of its radical approach to emotional processing, many therapists believe holding therapies should only be used in extreme circumstances. Still, there can be several benefits to gentle, focused holding methods, especially when followed by comforting words of encouragement. However, we still recommend utilizing emotion-based attachment therapies rather than holding or rebirthing attachment therapy.

Rebirthing Therapy

Rebirthing therapy for attachment disorder is extremely controversial because of how potentially dangerous it can be. The approach involves unique breathing techniques, or breathwork, to help patients release difficult thoughts and emotions.

In 2001, the technique was banned in Colorado for one year following a lethal incident. However, cases of injury or death are considered rare, and therapists engage enhanced safety protocols to ensure that.

The idea is to help patients experience a rebirth, at which time they can start over and begin forming healthier attachments. But not all attachment therapists subscribe to this approach. Instead, the relatively personalized therapy is reserved for RAD experts and specialists who can conduct each step carefully. Again, many mental health experts do not recommend this form of attachment therapy, as significantly more research is needed to properly evaluate its methods and efficacy.

Other Attachment Therapies To Consider

If holding and rebirthing therapies are too controversial, there may be some other options to explore. For example, the therapeutic foster parent technique could be an option. Children with attachment disorder are placed in a foster home where people who are trained in attachment therapy act as parents or caregivers. However, it’s important to note that, again, this particular attachment therapy is considered controversial and could be dangerous if not utilized properly by a professional with significant understanding of both children and the therapy approach, though there is a bit more research behind it than holding or rebirthing therapy.

Adaptive treatment foster care represents one of the most intense attachment therapies there is. It’s a technique that’s similar to bootcamp. Patients are treated using frequent compliance drills to retrain their habits, expectations, relationships, and goals. Meanwhile, therapeutic foster parenting can be combined with other attachment therapy parenting techniques, such as emotion-based techniques, to help foster healthy attachment styles and overall wellbeing.

Parenting Techniques InAttachment Therapy

Although they act as therapeutic foster parents, attachment therapists expect parents to take an active role in treatment. Various parenting methods are revealed to tailor the approach to each child’s needs. Then, the therapists instruct parents on when and how to use said methods safely at home.

Meanwhile, these are the five most commonly taught tactics:

#1. Total Authority

Adults and caregivers practice ultimate authority over the child. Thus, the child gets few if any personal choices. This tactic not only reveals destructive behaviors but also highlights any tendencies that differ from what caregivers deem appropriate.

#2. Withholding Information

As part of the total authority package, withholding information from a child during everyday activities is considered crucial. It produces insecurities and prevents the child from knowing what to expect. Then, they’re left with fewer choices and must follow their caregiver’s lead. This can help induce trust.

#3. Denying Food And Snacks

It may seem harsh but temporarily withholding food and snacks from a child being treated for reactive attachment disorder can work. Some attachment therapists call it “German Shepard Training” because it helps condition behaviors much like the Pavlov’s dog experiment.

#4. Strong Sitting

This attachment therapy involves forcing a child to sit with their legs crossed and arms folded for an extended amount of time. It prevents them from acting on impulse while also encouraging mindfulness or meditation. Thus, strong sitting is often used as a gentle punishment for disobedient behavior and can help children to learn how to ground themselves in the present moment.

#5. Daily Caregiver Sessions

Parents are usually encouraged to combine the other approaches with hour-long caregiver sessions. This is when the parent actively reinforces positive behavior with loving physical contact, sweet treats, and extra attention. However, it’s important that the parent does this at their discretion and never when the child requests it.

Also, keep in mind that there’s still great controversy surrounding this therapeutic method. It may not be ideal for all individuals or families, and it should always be guided by a licensed professional.

Does Science Back Up Attachment Therapy?

Attachment therapy goes by many names. It’s sometimes called “rage reduction therapy” or “the Evergreen model.” There has been some research, but arguably more research is needed on the various forms of attachment therapy to better determine efficacy and best methods.

Meanwhile, caregivers and therapists remain understandably skeptical about the pros and cons. Treatment tactics such as holding, rebirthing, and restraining are understandably controversial.

Is Attachment Therapy Safe?

Many people are rightfully concerned about the safety of attachment therapy methodologies, namely rebirthing. That’s likely because of a widely reported accident in Colorado which prompted a year-long ban on the practice in that state after a ten-year-old girl suffocated during rebirthing therapy. Afterward, CO lawmakers put a permanent ban on attachment therapy rebirthing techniques, as did the state of North Carolina.

However, attachment therapy focused specifically on RAD has been deemed a safe and effective treatment option for RAD and some other attachment disorders. Licensed therapists also understand that there are alternatives for when attachment therapy isn’t appropriate. And on the other side of the coin, there are a handful of psychologists who question the long-term emotional consequences of said therapies.

Determining the safety of attachment-based therapy is subjective to the individual or group. So, be sure to ask your therapist for more details about the pros, cons, and goals.

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The Goals Of Attachment Therapy

The goal of attachment therapy is to help an individual process and express challenging thoughts and emotions. But the ultimate objective is to teach that individual how to develop meaningful connections with others. So, attachment therapy is most commonly used after an individual experiences trauma.

ABFT seeks to develop the child's attachment to their caregivers, even as that child recognizes the importance of their autonomy. The progress is typically accomplished using these four approaches:

Mindful Relationship Reframes

The idea here is to redefine challenging relationships. Mindful relational reframes help shift the focus away from symptoms and back onto rebuilding familial bonds.

Primary Emotional Development

In attachment-based therapy, the emphasis is on the primary emotion. Primary emotions can trigger extreme reactions that may be otherwise misunderstood without therapy.

Satisfy Unmet Attachments

Attachment therapy is designed to help identify unmet attachment needs. Then, therapists can create or provide enriching scenarios and opportunities to address the symptoms of emotional neglect.

Corrective Attachment Experiences

Therapists tap into the natural, biological attachment system if possible. Using a combination of therapeutic methodologies, individuals can learn how to form and maintain healthy attachments.

Because each person is different, counselors may or may not use all of these methodologies.Therapists may also use them out of order or focus on one approach more than another. However, most therapy sessions for attachment disorder are customized to the individual, with talk and play often favored over controversial tactics.

Here is how licensed therapists generally accomplish their goals during attachment therapy sessions:

  • Positive reinforcement
  • Encouraging eye contact
  • Mindful responding
  • Active listening
  • Behavior modeling
  • Redirecting thoughts
  • Accountability
  • Family education

The overarching goal of attachment psychotherapy is to help the individual understand that they’re capable and worthy of forming and maintaining bonds with other people.

How To Get Help For Attachment Disorders

Don’t wait until the symptoms of attachment disorder become unmanageable. Reach out for help as soon as you see the signs. ReGain counselors specialize in childhood and adolescent attachment therapy, so they’re ready to answer any questions you might have and can get started right away.

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