Running head: ATTACHMENT IN-HOUSE CLINICAL CONUNDRUMS
It Takes A Village: A Call for Engaging Attachment with
Adjunct Disciplines to Clarify “In-House” Clinical Conundrums
Or Dagan & Kristin Bernard
Department of Psychology, Stony Brook University, Stony Brook, NY
*Paper accepted for publication at Attachment & Human Development (ID # RAHD-2020-SE05 R1); 1/19/21
Reference: Dagan, O. & Bernard, K. (in press). It Takes A Village: A Call for Engaging
Attachment with Adjunct Disciplines to Clarify “In-House” Clinical Conundrums.
Attachment & Human Development.
Correspondent author:
Or Dagan, Ph.D.
Department of Psychology, Stony Brook University
Stony Brook, NY, 11794
or.dagan@stonybrook.edu
+1- 646-270-1100
ATTACHMENT IN-HOUSE CLINICAL CONUNDRUMS 2
Abstract
Researchers have long discussed the rich clinical applications of attachment theory. Specifically,
clinicians have been compelled by the idea that insecure attachment may bring about stressful
(real or perceived) interpersonal experiences that increases risk for internalizing symptoms.
However, recent meta-analyses examining the links between attachment representations and
internalizing symptoms have challenged the assumption that insecure attachment, broadly
speaking, is associated with negative mental health outcomes. Rather, findings highlight the
importance of considering insecure attachment subtypes in understanding one’s vulnerability for
internalizing symptoms. Here we expand on this special issue’s target papers and propose that,
despite an increase in citation impact of clinically relevant attachment research, there are still
core theoretical and methodological questions left unanswered. We highlight three clinical
conundrums: (1) hyperactivating, but not deactivating, attachment is linked to increased
internalizing symptoms in adolescence and adulthood; (2) the magnitude of the associations
between insecure attachment subtypes and internalizing symptoms varies depending on the
developmental period; and (3) self-reported, but not narrative-based, deactivating attachment is
associated with increased internalizing symptoms. We call for engagement with adjunct
academic disciplines to elucidate these issues. These clinical conundrums have important ethical
implications regarding how we understand insecure attachment and necessitate close theoretical
and empirical attention before attachment findings can truly inform clinical practice.
Keywords: Clinical, insecure attachment, internalizing symptoms
ATTACHMENT IN-HOUSE CLINICAL CONUNDRUMS 3
It Takes A Village: A Call for Engaging Attachment with
Adjunct Disciplines to Clarify “In-House” Clinical Conundrums
Since its development, attachment theorists have considered attachment theory clinically
useful. This makes sense, given that attachment processes involve an affective-cognitive-
behavioral network that is geared toward reducing distress by achieving proximity to close
others. Indeed, findings stemming from attachment theory are often discussed in terms of their
clinical implications and applications.
Schuengel et al. (this issue) demonstrate that interest in the clinical implications of
attachment theory (i.e., attachment-related interventions, mental health outcomes) is gradually
increasing, as evident by a surge in citations of meta-analytic findings on these topics. At the
same time, Duschinsky et al.’s (this issue) sociological account of the attachment discourse
reveals significant differences in the meaning of attachment-related terms across research and
practice contexts. Taken together the findings put forward by Schuengel et al. and Duschinsky et
al. reveals a challenge for effective dissemination of health-care: Attachment knowledge is
increasingly applied to solve real-life problems (i.e., mental health issues), but attachment
discourse is not consolidated “enough” to be safely translated between academic disciplines
(e.g., from developmental science to psychotherapy research), and ultimately from academia to
clinical use.
In this short commentary, we take a clinical perspective to expand on this special issue’s
target papers in two ways. First, we propose that, despite an increase in citation impact of
clinically relevant attachment research (Schuengel et al., this issue), there are still core
theoretical and methodological questions left unanswered. These unanswered questions may be,
in part, due to discrepancies in attachment constructs across developmental stages and research
ATTACHMENT IN-HOUSE CLINICAL CONUNDRUMS 4
traditions (Duschinsky et al., this issue). Second, we suggest that core unsettled theoretical and
methodological issues may add to the difficulty in translating attachment research into practice.
These knowledge gaps limit the clinical utility of attachment theory and should be addressed via
engagement with adjunct academic disciplines.
If insights from attachment research are to be channeled toward bettering the wellbeing
of individuals and their families, then attachment scholars need to be first clear among
themselves regarding the conclusions stemming from the empirical findings. Only then can
attachment be responsibly disseminated within clinical practice. In other words, we first need to
do some “in-house cleaning” before trying to relay any unified message to clinical practitioners
and the public regarding what attachment can tell us about mental health and well-being.
An Umbrella Issue: Do All Bad Things Go Together?
In almost all academic domains outside of the developmental psychology school of
attachment research, and certainly in the discourse of non-academic clinicians, insecure
attachment representations are generally perceived as either a causal factor or a correlate of
psychopathological symptoms (Duschinsky et al., this issue). However, research from the past
four decades does not allow us to theoretically, empirically, and ethically justify such claims, at
least not when it comes to internalizing symptoms. Specifically, two meta-analyses examined the
link between attachment representations (as derived from the Adult Attachment Interview [AAI;
Main et al., 2003-2008]) and internalizing symptoms. Both concluded that insecure-preoccupied
(hereafter, hyperactivating), but not insecure-dismissing (hereafter, deactivating) individuals,
endorsed elevated depressive and anxiety symptoms relative to their securely attached
counterparts (Dagan et al., 2018, 2020). These results raise questions about the significance of
insecure attachment representations in the development and maintenance of internalizing
ATTACHMENT IN-HOUSE CLINICAL CONUNDRUMS 5
symptoms, suggesting that not all bad things (i.e., subtypes of insecure attachment
representations and internalizing symptoms) go together.
The importance of differentiating insecure attachment subtypes when predicting
developmental outcomes is by no means new. Building upon previous insights (e.g., Erickson et
al., 1985; see also Sroufe, this issue), we highlight three unsettled issues about the role of
insecure attachment in the emergence and maintenance of internalizing symptoms
1
. First, we
discuss our limited understanding of the mechanisms explaining the differential mental health
outcomes associated with each insecure attachment representation subtype (see Issue 1 below).
Second, we explore differences in meta-analytic associations between insecure attachment
representation subtypes and internalizing symptoms in adolescence and adulthood versus those
between insecure attachment pattern subtypes (as assessed via the Strange Situation Procedure;
SSP [Ainsworth et al., 1978]) and internalizing symptoms in childhood (see Issue 2 below).
Third, we consider that the pattern of associations between insecure attachment subtypes and
internalizing symptoms differ based on how attachment is assessed (i.e., AAI following the
developmental psychology tradition vs. self-report following the social psychology tradition; see
Issue 3 below). Echoing Schuengel et al. (this issue), we argue that moving attachment research
to the level of engagement- in this case, engagement with adjunct academic disciplines- is
essential in helping the attachment field better understand these “in-house” issues.
1
Of note, given the limited space, in this commentary we do not elaborate on attachment
disorganization; for an in-depth discussion on this attachment pattern, see Haltigan et al. (this
issue).
