TIFT #32 Attached, A Book for Therapists

tift Oct 12, 2021


One of my best summer reads was Amir Levine and Rachel Heller’s 2010 classic, Attached. Maybe I should be embarrassed for coming to the party late and even more from learning about it via my patient’s dating coach, but this book, aimed at a popular audience, goes beyond Bowlby’s basic concepts in ways that are important in everyday clinical work. I’ll draw out a few of their most enlightening ideas.

First, thoughts on the importance of good concepts

An important principle for teaching, and for building theories that are actually helpful, is how you cut the pie. Life is messy but it has natural “cleavage planes.” These are ways of categorizing and conceptualizing that seem in harmony with nature. One of my favorite and most useful examples, one that is still little recognized in our field, is the difference between values and other mental contents. Values and their close cousins, attitudes, ideals, and prohibitions, are the internalized principles that govern judgments, and those judgments are the source of the unique (cortically generated) emotions of pride, shame, and guilt. Unlike other mental contents, we feel pride in our values. That is not the case with, for example, likes and dislikes. I don’t feel proud of liking peanut butter, but I feel pride in my values. Clinically this is important for many reasons, but the most important is that inappropriate shame and guilt don’t change permanently until the values underlying them are changed. The other critical difference is that values are clinically hard to change. When we identify faulty values, such as those internalized in trauma through identification with the aggressor (in this case, the perpetrator), we can know immediately that the work will be challenging. We will need to use all available tools to bring about changes. This is an example of a distinction that is natural and very helpful in doing therapy. Enough of my ranting, but the reason for bringing it up is that the distinctions and categories raised by Levine and Heller are particularly useful in understanding relationship dynamics.

Attachment style is a highly useful way of describing adults

The Gottman Institute says something essentially equivalent with the concept of distancers and pursuers. Reading Attachment., I realized that distancers have the avoidant attachment style and pursuers have the anxious attachment style. The Gottmans' concept is quite useful for couple therapists, but what I find so compelling about the attachment-based ideas of secure, insecure, and avoidant adult attachment is that these categories connect naturally with our fundamental nature as social beings. The Gottmans emphasize that men tend to seek more distance and that women do the opposite, but, to me, far more helpful is realizing that the majority in the general population are secure, including many men and many women, and are therefore, neither distancers nor pursuers. The attachment concept also makes it clear that men can be anxious and women can be avoidant. In this way, I think that Levine and Heller give us a more flexible and accurate way of looking at characteristics that are important to all therapists in that relationship problems are central to every aspect of our work.

There’s more. The author's thesis fits the definition of a good theory. This arises from the wonderful definition of theory that appears on a Google Search, quoted from Oxford Languages:  Theory is “a supposition or a system of ideas intended to explain something, especially one based on general principles independent of the thing to be explained [My italics].” Attachment theory gives us just that, a principle relatively independent of and larger than the thing being explained, that is, how couples pursue and distance. This is another reason why the concept is so compelling.

But adult attachment is not the same as Bowlby’s infant attachment

One of the important take-homes for the therapist is that adult attachment patterns run parallel to the ones identified in the “strange situation” at around age one to two, but are not identical. In fact, childhood patterns have some lasting power, but the book emphasizes how childhood patterns can and often do fade or change over time and that adult patterns can also change under the influence of clear and calming communications by a partner with a secure attachment style. The authors further cite evidence that even infant attachment styles have a strong genetic component and are only partially influenced by parental behavior.

Important for clinicians is to realize that adult attachment styles can be influenced by developmental factors and stresses other than those of early infancy. For example, one patient shows avoidant characteristics that are probably related to  experience later in childhood and beyond with a highly intrusive mother.

“Activating strategies” of anxiously attached individuals

Another great clinical trove of observations is the authors’ identification of strategies (these are EMPs, entrenched maladaptive patterns) used by anxious people to heighten the need to pursue. Examples are, “Believing this is your only chance for love,” obsessing constantly about the avoidant partner, and indirect communication or “game playing.” There are others as well, and pointing them out to clients can be a very helpful way to lead them to modify behavior. In fact, this book is a great one for bibliotherapy.

Details of “deactivating” strategies of avoidant people

The mirror image of activating strategies are the ones used by avoidant individuals to gain distance. Here, the book’s list is even more extensive and clinically astute. People with an avoidant pattern rationalize that they are "not ready to commit." They find it difficult to say “I love you.” They keep looking for the one ideal mate, thus muting their attachment to the current one. And they may choose someone with whom a long term future is impossible. There are more, but I'll leave it to the authors to describe them.

How change happens

Finally the book is rich in ideas about how to bring about change. It follows the pattern that spouse, therapist, and patient need first to be consciously aware of what’s going on. Why is consciousness so important? This is where having a clear and natural conceptual framework is so useful. It is much easier to hold onto what needs to change when the concepts are sharp, well defined, and follow what seem to be the cleavage planes of nature. Without that clarity, it is too easy to slip back into old patterns, failing to notice what is being lost. The nonconscious problem solver is very good at returning to status quo. In this way, consciousness serves the function of planting a stake in the ground that won’t move, but continues to signal the need for new patterns of appraisal and behavior.

The change process on which the book is built goes from gaining awareness to the next step, behavior change, which then leads to unexpected and surprising results. I hope the reader recognizes here the creation of conditions for memory reconsolidation. The mismatch generates “prediction error,” where the expected meets its surprising antidote in the classic structure of the Corrective Emotional Experience.


In short, this is not one to miss, and a useful resource for clients as well.


Jeffery Smith MD


Photo by Gus Moretta on Unsplash.

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