The child with an avoidant attachment disorder may present as if they are very calm in a distressing situation when in fact their internal experience is quite the opposite. Psychophysiological studies show elevated heart rate and cortisol levels in such individuals when they are stressed by separation or loss of the attachment figure (Spangler & Grossmann, 1993). Over time, the avoidant individual learns to suppress physiological responses related to distress. It doesn’t mean that they don’t feel distress, but it appears that they cannot generate a solution when they feel overwhelmed. As a result, they overregulate their affect to appear as if they are unaffected and are in essence emotionally paralyzed. Hallmarks of the personality of an individual with an avoidant attachment pattern are aversion to physical contact, a brusque, halting, and impersonal relational style, and flat affect which can appear as depression or apathy. Sometimes the adolescent or adult does not remember their childhood and may normalize or overidealize their mother as being “a good mother” when they report early history. However, when probed by the interviewing therapist, the person cannot remember details to support the view of having a good mother. Others with this pattern who develop insight may report having a mother who was verbally and physically rejecting of them, who was intrusive and overly controlling (Sroufe, 1996), or who withdrew emotional support when they needed it. Sadly, the individual with this pattern did not get their needs met as a child and then learn to live as if they have none. Some persons develop a sense of self that they are flawed, helpless, and dependent yet they are isolated from others. Another defense may be to view others as weak and flawed and view themselves with inflated self-esteem. When this occurs, they can be rejecting of others, very controlling, and punitive as a way of distancing from closeness.

There are two types of ambivalent/preoccupied attachment disorders: the angry and the passive types. When this pattern manifests in the angry form, the child seeks connection with significant others, then rejects them and becomes angry and hostile. In the passive type, the child is overwhelmed with their own sense of helplessness and cannot approach others for comfort or intimacy. Even in the presence of a nurturing person, they seem to seek a mother figure who isn’t there. This attachment pattern has been linked with histrionic personality disorder (Schore, 2002). Children with insecure attachment are often dismissive of close relationships and are preoccupied with their own state of mind. Some individuals with this pattern can mirror their own child’s affect, but have no idea what to do with it and quickly feel helpless and overwhelmed. Their own children’s needs can pose a threat to them which sabotages their ability to respond sensitively to them. The end result may be parents and their children who engage more comfortably with the nonhuman world because of their difficulties in interacting sensitively with one another.

When a child has an anxious attachment disorder, they are apt to give and receive mixed emotional messages. Their narratives are tangential and hard to follow. Often they are overly absorbed in their own relationship problems. They tend to be highly vulnerable to distress but can’t come up with solutions to manage it because they are constantly in a state of overwhelm. They hope for closeness from others but fear the loss at the same time.

In children and adults with disorganized attachment, they can be easily flooded by anything that evokes memories of trauma, loss, and abandonment. They can also be triggered by their own child’s distress which can result in dissociated states, overwhelm, or emotional shutdown. Borderline personality disorder is common among this type of attachment disorder. Their behaviors can be quite unusual or bizarre. For instance, one may see the person give a very detailed account of something distressing, then fall suddenly into a long trance-like silence afterward. When this is pointed out to the person, they may rigidly deny the experience.

Children with a history of being dismissed and overlooked by their parents often have difficulty constructing a coherent narrative. They may not be truthful and often have little to say about their attachment history. This is often a by-product of the client experiencing a caregiver who could not attune to their desires, needs, or feelings. Clients with a dismissing history often give brief histories and depend upon the therapist to elicit responses from them.

In contrast, children who have preoccupied attachment disorders are often tangential and hard to follow in a clinical interview. They are intensely troubled and overwhelmed with distress which makes it difficult for them to think about how they feel and to gain insight about their past history. Likewise, children who have an unresolved/disorganized attachment disorder may be unable to stay on-topic when discussing their trauma or loss. There may be lapses in their stories and the child may enter into a dissociated state of mind while reflecting on these difficult past events.

In the therapy process, the therapist should recognize nonverbal communication between themselves and the parents and child. Since all communication is a conversation between one person to another, the therapist should pay careful attention to somatic experiences in their own body that might be communicated by the client. For example, if the therapist feels a sudden choking feeling in her throat that is not commonly experienced, what emotions are being choked off by the client? Or if the therapist suddenly feels sleepy in the session, are they attuning to a feeling of deadness or dissociation in the client? When the therapist perceives emotions of their client, they often feel the emotions themselves.

The techniques described in the Circle of Security Intervention (Powell et al., 2014) are especially helpful in addressing the needs of infants and young children and their caregivers. This intervention focuses on helping the caregiver to build positive intentional responses toward their child while also developing the capacity for reflective functioning to provide regulated parental affect, “good enough” parenting, and a secure attachment base. The Circle of Security Intervention is a 20-week program that emphasizes how to create a holding environment between caregiver and child and to develop safety and security in the relationship to support the child’s exploration. Through psychoeducation and practice, caregivers learn about their child’s affect regulation, how to read and respond to their child’s cues, and how to respond positively when ruptures occur in the relationship.

It is also important for the therapist to be aware of enactments of early experiences that might occur within the therapist–client relationship. These are usually expressions of unconscious vulnerabilities of the client. Who is the therapist to the parent and child and who are they to each other? For example, a parent may complain that the therapist is too nurturing and wish for them to be stoic to protect them from emotional loss and to distance themselves from closeness toward the therapist.

The following strategies can be used in treatment to develop better attachment capacities and awareness of current and past relationships.

The CCA focuses on improving the child’s developmental capacities within the context of the parent–child relationship or other significant relationships. Relevant stages of emotional development outlined by Greenspan (1989,  1997) are used to help guide this process. These stages include: engagement and disengagement with objects and children; organized, intentional signaling and communication on verbal and gestural levels; representational elaboration of shared meanings; and symbolic differentiation of affective-thematic experiences. Constitutional problems of the child, such as high irritability, sensory hypersensitivities, inattention, and other problems of self-regulation are addressed by modifying the environment, selection of activity or interactive medium, and highlighting ways of modifying nonverbal or verbal communications so that they are better processed by the child. Insights gained about the parent’s relationship with their child and issues from their own past are addressed as they pertain to fostering healthy attachment patterns and regulatory capacities.

Others have applied principles of infant psychotherapy to the sensorimotor phase of development as well (Ostrov, Dowling, Wesner, & Johnson, 1982; Mahrer, Levinson, & Fine, 1976). Wesner, Dowling, and Johnson (1982) have described an approach that is similar to Greenspan’s “floor time” which they term “Watch, Wait, and Wonder.” In this approach, the infant initiates all interactions and the parent seeks to discover what it is that his or her child is seeking and needing from them and the environment. In this process, the parent may become attuned to her child’s constitutional and emotional needs, how her child wishes to communicate and interact, as well as the quality of the parent–child relationship. Helping the parent to recognize their projective identifications with their child is considered an important aspect of the treatment process. The WWW approach has been used successfully with mentally retarded and developmentally delayed children (Mahoney, 1988; Mahoney & Powell, 1988). It has also been used as a method to focus on unresolved relational conflicts of the mother involving the mother’s projective identification with her infant (Muir, 1992).

In CCA, the caregiver is taught to engage in daily 15–20 minute sessions of focused, nonjudgmental attention with their child. The child is the initiator of all play and the parent is the interested observer and facilitator, elaborating and expanding upon the child’s own activity in whatever way the child seeks or needs from the parent (e.g., to imitate, admire, or facilitate). If the child is older, the parent and child decide together on a mutually rewarding context for the activity (e.g., making a craft together, walking and talking, writing poetry and sharing it, and so on). The goal is for the parent to learn to be nonintrusive and nondirective in his or her interactions with the child or other child. It is useful for the caregiver to be instructed to “watch, wait, and wonder” what the child is seeking and needing from them, then to respond accordingly (Wesner et al., 1982).

During therapy sessions, CCA may be practiced for 20 minutes with a caregiver and their child, followed by a discussion between therapist and parent about the process. The caregiver may be asked what they observed about themselves and the child, and what it was like for them to interact in a nonjudgmental way. The therapist’s role is supportive while seeking to help clarify and reflect on the parent’s responses to the child and what the other child’s behaviors might serve for them. This process is important in order to address how a parent might have adapted to the child’s regulatory problems and to help the parent and child become more aware of how their cues might be perceived by others. Parental stress, depression, feelings of incompetence or displeasure with the relationship, connections with the past (e.g., how parented), feelings elicited by the child’s behavior, and family dynamics may be topics that emerge.

Unlike skills training or cognitive–behavioral approaches, CCA is a process-oriented model rather than a technique to be mastered. Some people need considerable help to allow others to take the lead in interactions or, the reverse, becoming active enough in the interaction to be reciprocal. The underpinnings of this approach lie in the view that interactions between children whether they are leisure activities, play, affectionate gestures, nonverbal communication, or a conversation is the medium emotional connections are made.

While we talked, I noticed that Kelly showed no interest in her mother. Occasionally she would look up at mother, but because Megan was either crying or seemed self-absorbed, Kelly kept on playing with toys as if she were alone in the room. I was surprised that Kelly didn’t approach me either. This made me think that Kelly might have been depressed or that she had learned that she didn’t get her needs met from people because they didn’t respond back. I was careful not to woo Kelly because I wanted to strengthen the bond between mother and child.

Megan continued her story. “It’s difficult for me to be separate from others without rejecting them. I do this to my friends and my own mom. I like it when Kelly comes to me and wants to climb on my lap, but whenever she’s mouthing toys or looking at something, I feel left out and rejected.”

I urged Megan to try the CCA. Her reaction was that 15 minutes seemed like an unbearably long time to play with Kelly in this way. I encouraged her to try a little, so we did it for about 5 minutes. Kelly mouthed and banged toys, and climbed up on her mother’s lap. Every time that Megan imitated Kelly, she commented on what Kelly was doing. She appeared to have an amazing capacity to share attention with Kelly around whatever Kelly was doing (i.e., holding and inspecting a toy). Kelly enjoyed the play with her mother and looked up and smiled at her. I was pleased to see how responsive Kelly was to the approach. Megan was able to wait and allow Kelly space to explore what she was interested in doing. It seemed that she could master CCA quite easily, yet I was aware that Megan was completely overwhelmed with the process. She seemed to distance herself every time Kelly mouthed something. I decided to talk through the baby as she played so that Megan could feel the connection with her baby and would not detach from the process.

After we did the play time, we talked more about the process. Megan felt that Kelly knew that she had a “crazy” mother who was a “bad child” because she had used drugs. I asked her what Kelly did to make her think this but she said, “I can tell by the way she looks at me.” She felt abandoned by Kelly whenever she mouthed a toy or became object focused. Megan said that she felt very angry at Kelly for doing this to her. She felt that Kelly was pulling away from her on purpose because she knew that her mother was “sick” or “bad.” I wondered too if Megan resented that Kelly was turning to objects to suck on instead of her mother’s breast and was angry that Kelly was initiating the separation from her mother rather than Megan controlling the separation. Megan constantly projected her feelings and issues on Kelly. Since there were so many projections, I tried to pick a few main themes to focus on, emphasizing the here and now. I selected a few observations that I noticed and asked Megan if she, too, noticed them about Kelly. For example, I said, “Did you notice how Kelly is so good at crawling?” or “Did you see how Kelly can look and play with objects for a long time without losing interest? She seems to have a very good attention span.” I tried to focus on positive things about her developmental competence. If there had been more things showing the connection between the two, those kinds of comments would have been preferable (i.e., “She really smiles when you stroke her hair.”).

I stressed how the CCA would help us to discover what kind of a baby Kelly was going to be and what kind of a mother Megan would become. We talked about how it was an unfolding process and that each week we would learn more about each of them and what their relationship together would be. I emphasized this to give Megan the notion that their relationship was evolving versus the idea that Megan would always be a “crazy mom.” I asked her to try to enter into Kelly’s world and see if she could tune into what Kelly was getting out of the play and her relationship with her.

When we tried a few minutes of the CCA, Megan began to cry again, saying that the intimacy was too much for her to handle. I convinced her to try the play for 3 minutes. I narrated through Kelly, talking for the baby and keeping a connection going between mother and child [i.e., “I like it when you bang toys with me, Mom”; “I love to touch your face” (when Kelly touched mother’s face)]. By talking through Kelly, I emphasized what it might feel like for Kelly to have her mother’s attention and love, focusing on the here and now. I also gave Megan permission to be detached from Kelly when she was feeling upset.

Kelly did a lot of banging on the mirror, mouthing objects, and noticing whenever Megan mouthed or banged objects along with her. Megan often asked Kelly to give her whatever she was holding. By talking through Kelly, I said things like “I’m practicing holding onto my toys, Mom” since Kelly did not seem to want to give up her toy to mom. I had several sets of toys available so that Megan could have her own toys as well. Kelly was much more animated and connected to her mother as they played. Megan also seemed more relaxed and seemed to like it when I kept the connection going by narrating through Kelly.

When we reflected on the play, Megan talked about how hard the past month had been for her in the drug detoxification program, but felt that many conflicts had been resolved in her therapy program and in her work with me. She said that her own mother did not give her any attention as a young child. She related that she sometimes felt disengaged from Kelly and had a hard time maintaining the connection with her. At other times, she felt attached to her and found that she could give attention to Kelly without disconnecting from her. We talked about Kelly’s comfort at moving away, but her need to keep touching base with her mother.

Other issues that came up were planning for discharge from the drug detoxification program. Megan would be returning to her former job and was apprehensive about how that would go. Although there were plans that she would continue services with our program, I suspected that Megan was planning to stop coming.

This session Megan seemed very happy, almost euphoric. She did not make as many projections on Kelly and seemed more grounded in the here and now; however, I was suspicious of her overly happy mood. I reinforced how she was doing some lovely things with Kelly in the play and that Kelly’s progress was because Megan was doing nice mothering. Megan was able to talk with Kelly in a very loving manner, to attune herself to what Kelly was doing, and to wait and respond to her in a contingent manner. Megan seemed more relaxed with me as well. She talked about how she wanted to become a therapist like me some day, which alerted me that she was overidentifying with me. I also wondered if she was trying to turn our relationship into what she had had with her own mother. Megan never trusted her own mother’s feelings toward her and felt a competition with her mother.

Megan spontaneously called me on Kelly’s first birthday to tell me how well Kelly was doing. She called me again a few months later to tell me that she had decided not to have another baby, but to continue to enjoy Kelly, feeling that they were having fun together and she didn’t want to ruin it. She reported that she felt she had learned so much from our sessions together. I was not totally convinced that things were that good, but on the other hand, I did feel that Megan had internalized some good parts of herself as a mother and had learned how to tolerate some level of intimacy with her child. Although the work on this case was unfinished, there was certainly some good benefits to what had happened in the process.