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Section 18
Attachment & Boundary Concerns in the Therapeutic Relationship with Abused Adolescents

Question 18 | Test | Table of Contents

Attachment
It is therefore no wonder that 85 per cent of abused boys (and girls) are 'insecurely attached' (Karen 1994) and, as insecurely attached adult men, they come for help defended against forming intimate attachments which are both threatening and longed for. Bowlby (1969) saw attachment as a biological, instinctive bond with the caregiver. Remaining close to the caregiver is important for survival - the parent needs to be a 'secure base' from which the child goes out into the world. The child develops what Bowlby (1973) called 'an internal working model' that forms the basis of his personality. This model is created by the child, over time, in response to his repeated experiences in attempting to form attachments. The model is cognitively formed in the child's mind in response to questions about himself such as 'Am I worthy of support or not?' and about the caregiver 'Can I rely on this person to provide the care I want or not?' The model guides the child's future relationships with others and his attitude to self. The child learns to interact in predictable ways that are shaped by his expectations of his caregiver (Friedrich 1995).

So a child is securely or insecurely attached. A securely attached child has been able to develop an internal working model from his experience of having caregivers that have been consistent, supportive in times of distress and attuned to his needs. Insecure attachments generally fall into three categories; resistant/ambivalent, avoidant and disorganized (Alexander 1992). Insecurely attached children have usually experienced caregivers as inconsistent, not attuned to their needs and unable to soothe them in times of distress.

Resistant/avoidant children behave in ways that indicate they want and seek out contact from caregivers, while at the same time behaving with angry resistance. Such children can seem to be clingy and needy while at the same time creating distance by their behaviour from the very person they seek to be closer to. Caregivers often respond to such children by seeking care from the child rather than vice versa.

Avoidant children often appear to snub or avoid their caregivers. They become guarded in their interactions with others as a result of having caregivers who were emotionally unavailable, who disliked any sign of the child's need for them and who encouraged them to become independent before they were developmentally ready.

Disorganized attachment is seen in children who do not consistently demonstrate any pattern of attachment but may flip from one to the other. This seems to be related to the fact that the caregiver is both the source of the child's distress and the child's comforter. This pattern can be seen in children who have been abused by someone such as Stephen and Mike's grandfather who, while severely abusing them, also gave them a sense of importance, pleasure and being cared about. As described in their story Gramps was a frequent carer of the boys - taking them on holiday, spending time with them and generally paying a great deal of attention to them. Their own father, Gramps's son, was unapproachable, angry and domineering during their childhood, no doubt as a consequence of his own parenting by a father who used children to satisfy his own needs. Gramps had abused several of his own children, as well as his grandchildren.

Specific attachment-related features originating from insecure attachments and frequently found in families where sexual abuse occurs include rejection, role reversal/parentification and fear/unresolved trauma (Friedrich 1995). In forming my relationships with Stephen and Mike I was very conscious of all three aspects. My belief is that the problems experienced by both men stemmed from their early experiences within a sexually abusive family and the 'internal working model' they had developed throughout their childhood and adolescence, which was still in operation for them as adults. By providing them with a relationship of warm acceptance, empathic understanding and respect they have an opportunity for growth and healing. In providing a different kind of relationship, which may not fit their perceptions or expectations of what relationships are, I can make a difference to their experience of self in relationship with another.

So an alliance is formed between us when we agree to work together. A successful alliance depends upon how well I can create a therapeutic space characterized by safety. Stephen's first contact with me emphasized his lack of safety and his need to be able to trust himself to another human being in order to repair the damage caused by his early life. He wrote of the need for confidentiality as part of that safety and the need for somebody who could empathize with him in his distress - his fear of judgment, rejection and exposure all came through his words: 'I.. .feel your empathy coming through, and that I could talk to you. . . talking to just anyone (is) very frightening. . .I feel as if I could trust you.'

Mike described his need for safety and the lengths he went to in order to maintain his anonymity; 'I still remember how risky it felt to be standing at those bookshelves, and how I travelled to other towns to be anonymous enough...'
- Etherington, Kim, Narrative Approaches to Working with Adult Male Survivors of Sexual Abuse, Jessica Kingsley Publishers London, 2000.

Personal Reflection Exercise #4
The preceding section contained information about attachment in the therapeutic relationship. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Attachment security as an outcome and predictor of response
to trauma-focused cognitive-behavioral therapy among maltreated
children with posttraumatic stress: A pilot study

- Allen, B., & Brown, M. P. (2023). Attachment security as an outcome and predictor of response to trauma-focused cognitive-behavioral therapy among maltreated children with posttraumatic stress: A pilot study. Clinical child psychology and psychiatry, 28(3), 1080–1091. https://doi.org/10.1177/13591045221144588


Peer-Reviewed Journal Article References:
Hébert, M., Daspe, M.-È., & Cyr, M. (2018). An analysis of avoidant and approach coping as mediators of the relationship between paternal and maternal attachment security and outcomes in child victims of sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 10(4), 402–410.

Sætren, S. S., Augusti, E.-M., & Hafstad, G. S. (2021). Affective inhibitory control and risk for internalizing problems in adolescents exposed to child maltreatment: A population-based study. Journal of Abnormal Psychology, 130(2), 113–125.

Shevlin, M., Murphy, S., Elklit, A., Murphy, J., & Hyland, P. (2018). Typologies of child sexual abuse: An analysis of multiple abuse acts among a large sample of Danish treatment-seeking survivors of childhood sexual abuse. Psychological Trauma: Theory, Research, Practice, and Policy, 10(3), 263–269.

Sousa, C., Mason, W. A., Herrenkohl, T. I., Prince, D., Herrenkohl, R. C., & Russo, M. J. (2018). Direct and indirect effects of child abuse and environmental stress: A lifecourse perspective on adversity and depressive symptoms. American Journal of Orthopsychiatry, 88(2), 180–188.

QUESTION 18
What are the three categories of insecure attachments with abused adolescents? To select and enter your answer go to Test.

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